Termes of Reference

UNICEFWCARO

TERMES OF REFERENCE

Title of Consultancy: Investment Case Study for Cholera prevention and control in Niger

Duty Station: Niger

Region: West and Central Africa Region (WCAR)

Level: P4

Planned Duration of Consultancy: 60 days between 1st of April and 30st of September 2016 80 days (from April to September 2016)

Contract Type: Consultancy - SSA Individual Contract

Closing Date: 18th March 2016

Submitted by: Child Survivor Development (CSD) – Water, Sanitation and Hygiene (WASH)

1.  Background and Context

Cholera is transmitted through food or water contaminated with toxigenic Vibrio cholerae. A 2012 review of cholera’s global burden estimated that 1.4 billion people are at risk for cholera, with 2.8 million cases and 91,000 related deaths in endemic regions annually (Ali 2012)[1]. The burden of cholera is disproportionately borne by the young, with children under five having the highest incidence of cholera and contributing almost half of the mortality (Ali 2012)1. UNICEF is committed to reduce under five mortality while the West Africa region has shown little progress up to now.

Cholera epidemics in West Africa regularly affect 14 countries. On average, 50 000 cases of cholera were registered in the region with a high case fatality rate above 3% (WHO standard: 1%) illustrating problems in early detection and in case management. Cholera epidemics are often associated with other humanitarian crises in the region such as floods, other epidemics, population displacement or armed conflict. This is currently the case in the area of the Lake Chad basin. Nigeria and Ghana are the most affected countries in the region despite their strong annual growth, highlighting striking inequalities in these two African giants. Cholera epidemics generally have a cross-border nature putting directly at risk neighboring countries which share borders with Nigeria and Ghana.

Effective cholera prevention and control interventions are well established. Cholera is preventable and can be controlled where access to clean water and sanitation facilities, and satisfactory hygienic conditions are ensured and sustained for the whole population. It is critical that governments and partners strongly engage on comprehensive strategies for cholera control, primarily ensuring sustainable access to clean water and sanitation infrastructures; and mobilize the corresponding resources as a long-term investment in high risk areas for the benefit of public health, economy and social welfare.

In 2011, the World Health Assembly 64.15[2] resolution “Cholera mechanisms for control and prevention” requested the WHO Director-General to revitalize the Global Task Force for Cholera Control (GTFCC). In 2013-2014 several technical sub-groups were created including a GTFCC Water, Sanitation and Hygiene (WASH) working group, which held its first meeting in New York in May 2015. Four main themes of WASH-focused cholera prevention and control were discussed during the meeting including efficiency of WASH interventions. At the end of the two days meeting, the subgroup that worked on “Efficiency of WASH interventions” identified “four needed outputs”: 1) An investment Case, 2) a toolkit to compare alternative program approaches, 3) case studies and 4) a sensitivity analysis. A key output is to prepare an « investment case for cholera control and prevention », that would allow a better informed decision making process for governments and donors on how investing in cholera control and prevention interventions. In addition, such an Investment Case would produce some needed evidence for advocacy purposes.

2.  Justification

Since 2009, the UNICEF West and Central Africa Regional Office (WCARO) has paid special attention to cholera issues in the region. Studies to understand the epidemiology of the disease and to feed risk reduction and response strategies were conducted in Guinea, Sierra Leone, Guinea Bissau (2009 - 2012), Nigeria, Cameroon, Chad (2010 - 2011), Niger (2013 - 2014), Ghana, Togo and Benin (2014). Since March 2012, UNICEF WCARO is engaged in the coordination of the cholera regional platform, which gathers major agencies and donors involved in the fight against this disease. Its objective is to improve cholera control and prevention in the region through the promotion of an integrated and targeted approach known as the “shield and sword strategy”. The main actions are the following:

·  Improving exchange of information and experiences in between countries including the diffusion of an epidemiological bulletin and of real time alerts;

·  Supporting countries for timely, evidence based and targeted interventions ahead and during cholera outbreaks;

·  Advocating toward donors and the WASH and Health stakeholders for long term solutions in cholera hotspots.

UNICEF WCARO through its regional project funded by ECHO and DFID is willing to increase development donor’s investments in cholera hotspot[3] to shift from recurrent humanitarian crisis to long term responses. One of the project objectives is to assist countries in planning and prioritizing for effective, efficient and sustainable interventions and to facilitate advocacy activities at regional and national levels for increased efforts from the WASH and Health sectors towards cholera elimination. To that end, a number of epidemiological and WASH studies have already been conducted in the region. The epidemiology of the disease is well known at regional, sub regional (set of countries affected by cross-border outbreak) and national levels including the identification of cholera hotspot. The next step for UNICEF in the region is to conduct a pilot investment case study and eventually to estimate the WASH investments needed for cholera prevention in the region by 2017/2018.

At the same time, the GTFCC is looking for an “Investment Case for Cholera Control and Prevention” document that will include:

·  The development of a common methodology to realize investment case studies at national level;

·  The completion of a number of case studies, i.e. applied “investment case study methodology” in priority countries, realized with accurate data directly taken in the country;

·  The elaboration of a toolkit and a methodological guide to allow replication of the exercise in other countries of interest upon request;

·  An estimation of the WASH investments needed for cholera prevention and control at global and/or regional level.

UNICEF WCARO is proposing to conduct a study to develop a methodology to realize an investment case at national level in close collaboration with the GTFCC and to complete a pilot case study in Niger. As per the requirement specified in the GTFCC concept note, countries that have already available epidemiological analysis with a robust description of priority geographical areas (hotspots) and populations and that have already identified the best suitable technical options for cholera prevention in the identified areas are eligible. The University of Kinshasa with the support of UNICEF has conducted two epidemiological studies in Niger in 2013/2014. A Cholera Epidemiology and Response factsheet produced by UNICEF WCARO in 2015 includes the identification of cholera hotspots. In addition, UNICEF will conduct in Niger and Chad between February and March 2016 a WASH assessment in the cholera hotspots to define the adequate long term responses and evaluate the funding needed to prevent cholera outbreaks.

In conclusion, there is a need to demonstrate that cholera prevention and control is possible, within a range of acceptable funding requirements and that the intervention will yield a benefit superior to the costs and that investing in cholera prevention and control is possible, affordable, and even cost-effective compared to the status quo and having to respond to cholera outbreaks on a regular basis. Moreover, the positive outcomes of investing in sustainable access to water and sanitation services go far beyond health positive outcomes of avoiding cholera cases.

3.  Purpose and Objective

The objective of the study is to develop a methodology to conduct an investment analysis case study for cholera prevention and control at national level and to apply this methodology to Niger as a pilot country. The whole process will be piloted by a Technical Committee composed of members of the GTFCC WG as specified below.

The current work will provide development partners in Niger including UNICEF country office with needed information and documentation to advocate for efficient and sustained WASH interventions in cholera hotspots through an analysis of the cost and benefit of control and prevention activities. In addition, it will raise awareness and hopefully mobilize donors, governments and partners to take a stronger engagement towards cholera elimination in Niger.

4.  Methodology and Technical Approach

As specified in the concept note developed on the “Investment Case for Cholera Control and Prevention” by the GTFCC, the whole process will be piloted by a Technical Committee (TC). The TC should be composed of a small group of GTFCC members as follows:

·  Epidemiologists (to review the available research works data on prioritization of areas / populations)

·  Public health specialists (for the part on strengthening surveillance / treatment)

·  OCV specialists (to assess the need, interest, feasibility of an OCV intervention)

·  Water and Sanitation specialists (to assess the type and feasibility of proposed WASH intervention)

·  Health economists (to pilot the economic evaluation process, define the methodology, etc.)

The TC will advise at different stages of the methodology and review the different outputs of the current study.

Step 1 – Inception report (2 days):

·  Write an inception report (in Microsoft Word), which will outline the proposed methodology, a timeframe with dates for reports and the travel arrangements to the field;

·  Submit and then review the draft report with comments and inputs from UNICEF supervisor before submission of a final version.

Step 2 - Investment case study methodology (15 days):

·  Review of publications on cost-benefit and cost-effectiveness of cholera and other diarrheal diseases control and prevention measures such as cross-border collaboration, case management, surveillance, OCV campaign, community mobilization and WASH interventions. The consultant will benefit from the literature review conducted in April-May 2014 by the sub-working group working on Efficiency of WASH intervention (GTFCC WASH-WG).

·  Propose criteria to consider and analyses to conduct for estimating cost and benefit of WASH development programs in cholera hotspots according to the context (urban, rural, riverside population, border areas etc.);

·  Propose criteria and analyses to conduct for estimating cost and effectiveness of WASH interventions in cholera hotspots compared and combined with other control and preventive measures (e.g. OCV);

·  Define a methodology to evaluate the cost-benefit and cost-effectiveness of WASH integrated programs and to realize “investment case study” at national level;

·  Submit and then review the draft report with comments and inputs from the Technical Committee and UNICEF supervisor before submission of a final version.

Step 3 - Desk-study covering (3 days):

The desk-study will cover the collection and review of background information as defined in the investment case methodology, including but not restricted to the following:

·  Information and data on cholera and diarrheal diseases burden: epidemiological studies, Niger Cholera Epidemiology and Response Factsheet, database of cases and deaths per hotspot, publication on cholera dynamics and risk factors in the study areas, latest DHS and latest MICS.

·  Information and data on WASH interventions: publication on efficiency of WASH intervention, ongoing or planned WASH projects in the study area and border areas of neighboring countries, WASH demographic data and studies defining technical options for cholera prevention in Niger (Cf. UNICEF WASH assessment conducted in February – March 2016).

·  Information on cholera control and prevention strategy: Regional Cholera Shield and Sword strategy, Niger Cholera Elimination plan, National WASH policy, UNICEF country strategy and report on UNICEF MICS, WHO position paper on OCV.

Step 4 - Field research (20 days):

·  With the support of the UNICEF Lake Chad Cholera specialist, collect missing background information to apply the investment case methodology in Niger including but not restricted to:

-  missing data to establish an estimation of the cost and benefit of WASH investment needed in the cholera hotspot according to the context (urban, rural, riverside population, cross-border etc.) and taking into account funded or planned WASH program to prevent cholera outbreak;

-  missing data related to the cost of other cholera control and prevention activities;

-  missing data related to the effectiveness of the implementation of cholera control and prevention activities (diarrheal cases in the study area, etc.).

·  Review the Cholera Elimination plan, UNICEF strategy and the WASH and Health national policies and assess their consistency;

·  Exchange with senior epidemiologist and key stakeholders at national, sub-regional and regional level regarding the cost-effectiveness of WASH intervention taking into account various implementation stages of WASH development program in border areas;

·  Discuss with donors and stakeholders about their interest and expectations for an investment case study for cholera prevention and control.

Step 5 - Analysis and interpretation of results (20 days):

·  Conduct an economic analysis presenting the costs-benefit and the cost-effectiveness of WASH intervention compared and combined to other control and prevention activities with support of the UNICEF Regional and the Lake Chad cholera specialists ;

·  Describe the prioritized interventions to be implemented and the population and geographic areas to be targeted to achieve the greatest impact over the long term taking into account the sub-regional dynamic of cholera outbreaks;

·  Write justification/rationale for sustainable approach based on WASH and Epidemiology considerations;

·  Write recommendations on how the results of the study can be best utilized at national level and mainstreamed into key national policy documents;

·  Review the methodology to realize “investment case study” at national level;

·  Submit and then review the draft report with comments and inputs from the Technical Committee and UNICEF supervisor before submission of a final draft.

5. Activities, Tasks, Outputs and Deliverables

The following will be expected:

1.  Deliverable 1: An inception report (in French, in Microsoft Word), which will outline the proposed methodology, a timeframe with dates for reports and the travel arrangements to the field.

2.  Deliverable 2: An investment case methodology report (in Microsoft Word) defining the criteria, analysis and the tools to conduct a cholera investment case study at national level (approx. 20 pages document in English – UNICEF WCARO will be in charge of translation to French further on).