Author Topic: Health Care Financing Study Consultant - Save the Children (Puntland)  (Read 19936 times)

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Save the Children has a long history of engagement in Somalia and in Somaliland stretching as far back as 1954. In more recent times (since 1992) Save the Children UK has maintained an operational office in Hiran Region in what is now called the Central South Zone of Somalia (CSS). Since 2000, both Save the Children Denmark and Save the Children UK have been working in Somaliland. In 2004, Save the Children UK established an office in Puntland State in response to the Tsunamis and continues to undertake programmes from this office while Save the Children Denmark in Puntland works through partners.
Closing date: 26 Jan 2010
Location: Somalia - Karkaar Region of Puntland State

1. Background

The collapse of the Siad Barre government in 1991 and the subsequent civil war that followed totally disrupted the Health system delivery in Somalia. The vast majority of children in Punt land, like the rest of larger Somalia did not have access to basic Health care services during this conflict period. In addition to the effects of the conflict, the country is also faced by perennial drought, as well as intermittent severe flooding especially in areas lying within Juba and Shabelle river basins.

The combined effect of all these problems is high levels of poverty. This has continued to undermine the country’s ability to provide quality Health care even in areas that have experienced relative peace in the recent past. However, in the states of Puntland and Somaliland, there has been deliberate and progressive effort to restore essential infrastructure and services including provision of Basic Health care services. But the governments’ capacity to effectively provide Health services is limited due to financial constraints.

1.1 The context of Punt land

Puntland state of Somalia has a regional administration and has relative peace and stability compared to the other parts of the country. The administration has a president, parliament and cabinet which provide security and governance including basic social services such education and health. The relative peace has enabled international agencies such as Save the Children (SC) to implement humanitarian and development work in the state.

Punt land’s Health sector has been improving for last couple of years because of compounded efforts of the ministry of Health and considerably support work of the international agencies including SC. Despite these efforts, the limited capacity of the MOH has one way or another hindered the provision of required standard of Health service to the children of Punt land.

1.2 Health Sector Context in Punt land

Like the rest of Somalia, data on the health status of the Punt land population is minimal and of varying quality. Recent studies report high mortality rates: Under 5 Child Mortality of 225 per 1,000; Infant Mortality of 133 per 1,000 live births; and Maternal Mortality of 1,600 per 100,000 live births. The 2006 MICS preliminary results show a dramatic decline in mortality for both infants and children under five: 96 and 156 per 1,000 live births respectively. However, the factors for this improvement are under analysis, as many other indicators of access to services declined during this period.

As stated in Punt land Facts and Figures (Ministry of Planning and International Cooperation 2006), the main causes of morbidity and mortality in children less than five years are Acute Respiratory Infections (ARI), Diarrhoea, Measles, Malaria and Malnutrition. Three out of every four children seen by health services are suffering from at least one of these conditions. In addition the EPI coverage of all eight recommended vaccinations by 1 year old is an alarmingly low 5% and preventable diseases such as measles and polio are disabling and killing children.

1.3 Save the Children (SC) Health Interventions in Puntland

The health sector is a key focal area for the Save the Children (SC) both globally and in Somalia. The organization has a long experience of implementing health projects with the overall aim of expanding both access to and the quality of health care available to the poorest and most marginalized populations in all countries where we operate.

In Puntland, Save the Children (SC) has been active in Karkar region since the Tsunami Response and Recovery Programme in 2005. The current programme has health, education and livelihoods components, which are closely interrelated.

At first, the health project was focused mostly on infrastructure rebuilding (construction of health centres and health posts, and supply of medicines and equipment for these), though the strategic direction has now shifted more to building capacity in the health sector at the political level, the academic level, the service level and the user level.
The current health project in Karkar region is funded by EC and benefits an estimated population of 130,000, of which about 70,620 are children. Of these children almost 29,000 are under 5 years of age. The project aims to improve access to quality health care for all 70,620 children in Karkaar region; though will specifically target the excluded rural, nomadic, and pastoral children and their carers, as well as children from poor minority groups, and the disabled.

To improve the quality of healthcare delivery, the project will provide training of trainers in the integrated management of childhood illness (IMCI), establish partnership with teaching institutions, and support the Ministry of Health (MoH) with training on health systems management, procurement, and health financing and setting up and managing health information systems.

Save the Children works with a right based approach, which puts special emphasis on promoting the themes of Convention on the Rights of the Child, the promotion of gender equality and empowerment of women. In the Somali context this means the action deals with harmful traditional practices like early marriages and female genital mutilation (both known to cause high infant and maternal mortality).

The project has in its ambit one component on health baseline in the 1st year of its work. This assessment is in relation to that component of the project and largely relevant to our long term health thematic program plan.

2. Purpose and Objectives of the Survey

2.1. Rationale

The overall intention of this research is to gain an insight in to the existing health financing mechanisms in Puntland. This research is driven by the premise that despite resource shortages in the health sector, the introduction of community cost-sharing and drug revolving fund is unlikely to increase the accessibility and affordability of public health care for the most vulnerable population in Puntland.

1. Cost-sharing (user fees) is the Ministry of Health official policy and there seems to be likely consensus among stakeholders to further develop and support this scheme. Save the Children research and advocacy will put pro-poor health financing back on the agenda, challenge the current policy and practice, and demonstrate an alternative health financing system.

The purpose of this research agenda (October – December 2009) is to explore the current health financing policy and practices in Puntland and develop a viable pro-poor health financing strategy for Puntland.

Provide evidence-based analysis of the impact of cost sharing on access to health services and health status of the community, particularly the most marginalized.

2.2. Objectives and Key Outputs:

This consultancy has two distinct objectives:

1. To conducts brisk national health accounts analysis.
2. To analyse the implementation of the community cost-sharing scheme, its impact on health system, community health, its management, waver off mechanisms and sustainability.
3. To design a viable pro-poor health care financing system for Puntland health ministry.
4. To analyse the community perceptions about various health financing mechanisms in the field.

2.3. Deliverables:

- Comprehensive document on current health financing situation and functioning of cost-sharing scheme in Puntland
- A pro-poor health financing system model

2.3. Specific Tasks (Study Scope)

Methodology :

The consultant will be responsible for the preparation of the study design and development of study instruments. S/he will have the overall responsibility to lead the field activities, data analysis and interpretation and report writing. It is expected that the consultant will come up with appropriate methods and tools to be used in the study which will be agreed with SC before application. The following methods and tools are suggested; NHA tools, FGDS tools, data sheath for health facility records.

The health program would send relevant literature to the consultant before the start of field work. These will include information on the health context of Somalia/Puntland, SC’s health TPP and individual health projects, and relevant past reports and surveys including Govt Health policy, Annual reports, Partners and Donors cluster survey reports, Save the Children health Reports. It is expected that the consultant will study the materials before coming to the field so as to gain a clear picture of the situation on the ground.

The consultant shall carry out the survey in a participatory manner, ensuring there is maximum involvement of SC staff, children and other stakeholders. S/he will always ensure to make necessary consultations and achieve consensus of opinion where needed, to have wide ownership of the process and outputs.

At a minimum the consultant will be expected to undertake the following:

1. Literature Review : This includes the following:
- Puntland Health project proposal
- Somalia Health Thematic Programme Plan
- Somalia Child Rights Situation Analysis, 2002-3
- Puntland Health Analysis, 2004-5
- Puntland health policy
- World bank health financing study for Somalia
- Other relevant documents
- One Million More Mobilising the African diaspora healthcare professionals for capacity building in Africa
- User Fee Position Paper
- Paying with their Lives The cost of illness for children in Africa
- An Unnecessary Evil? User fees of healthcare in low-income countries
- Cost of Coping with Illness Briefing Papers: East and Central Africa, Burundi, Ethiopia, Rwanda, Sudan, Tanzania, Uganda.
- Ethiopia - The never-ending cycle of poverty and illness: Can it be broken?
- Ethiopia - Final Evaluation of the Revised Waiver and Exemption Policy and Practice Pilot Project, Debresina Woreda, South Wollo. Jan 2004 – May 2005
II. Field visit to Hargeisa/Puntland , conduct analysis of health accounts, interview key stakeholders
III. Develop questionnaires and / or checklists to ensure all aspects of the health financing analysis, policy and practices. See Key Questions section below for guidance on the issues to be addressed.

IV. Conduct training of field team in data collection and FGDs.
V. Collate and analyse all data
VI. Conduct debrief for SC and MOHL
VII. Write 1st draft and share with SC
VIII. Revise the draft report and health financing model in the light of the SC team recommendations.
IX. Produce final report

2.4. Key Questions

1. thorough assessment of the impact of various policy mix on health care seeking behaviour:
a. What are the various health policy mix implemented in the Karkar region (i.e. existence and level of user charges and exemptions, qualification and presence of staff, perceived quality of care, existence of informal charges, presence of drugs, etc.)
b. What are the economic resources of the population, their consumption patterns and willingness to contribute to a health tax or pre-payment scheme?
c. What are the determinants of accessing health services in the area (special care will be given to understand the patterns for . socio-economic different groups)
2. Assessing the impact of an alternative financing strategy implemented in the Puntland:
a. What are the effects of a free access of services at the point of use, compared to user charges (the evaluation will take into account the differences of staff salaries between facilities)
b. What are the costs incurred (i) for the populations (by socio-economic group) and (ii) for the provider/follow-up survey using
c. What are the consequences on other aspects of health care provision (drug procurement, dual job-holding and motivation of health workers)

2.5. Timeframe

Save the Children is seeking to complete the whole exercise by February 25 2010. The consultant should start as soon as possible. A final report will be required within two weeks of the receipt of comments from Save the Children.

Activity Days Location

Consultant work
Design of checklists, interview schedule from home 2 Place of domicile
Travel to Nairobi 1
Briefing at Nairobi with Save the Children team 1 Nairobi
Travel to Hargeisa 1
Meeting with Ministry , SC field team, Directors etc 1 Hargeisa
Filed staff training 5 Hargeisa
Travel back to Nairobi and London 2
Data analysis 4 Nairobi/elsewhere
Initial report writing 5 Nairobi
Incorporation of comments and
submission of research and advocacy plan 3 Nairobi
Total International consultant time = 25 days inclusive of final report

Work by Save the Children team & local counterpart
Travel to Hergesa and staff meeting 1 Kakkar/Hergesa
Staff training 4 Hergesa
Community consultations,FGD 5 Kakkar /field
Health centre record review 8 Kakkar/field
Presentation / Debriefing by team leader 1 Hargeisa
Travel back to Puntland 1
Total national staff days 1 Nairobi
Travel back to Somali land 21
Total local team engagements 21 days

2.6. Management and Supervision

The consultant will report to the SC Program Director in Nairobi. Overall technical coordination and support will be provided by in house technical specialist who will be SC counterpart for the consultant.
and the day to day supervision will be made by the health coordinator Somalia along with her team.

2.7. Consultant Qualities

The person should hold a Masters Degree in health Economics, Developing Economics, or Public Health, with prior experience in healthcare financing issues and policy.
S/he should have skills with various research methodologies, particularly qualitative designs, NHA etc.
S/he should have the appropriate level of sensitivity to the children/ young population needs and be mindful of their basic rights.
Knowledge of the socio-economic and health development issues in relation to Puntland is desired.

2.8. Terms and Conditions

- Rate of pay of 500 Euro / day for maximum of 25 days, can be negotiated.
- Travel and visa / airport tax to and from home of domicile to Nairobi and into Puntland (Nairobi/ Hargeisa/ Nairobi), as well as travel within Puntland will be covered by Save the Children (this includes transport to/from airports)
- Modest accommodations will be provided by Save the Children - The consultant will be based in Save the Children guest houses during her/his stay in Nairobi and Puntland.
- The consultant shall be responsible for his/her food, refreshment.
Income tax and/or security implication as a result of a consultant being engaged in this piece of work
- The accompanying consultant contract will be drafted by Save the Children Somali land in order to activate the business international medical evacuation insurance coverage.
- Tax arrangements will be agreed in accordance with SC (UK) procedures – see accompanying contract
How to apply
Proposal Submission from Consultant
In response to these terms of reference, potential consultants are requested to submit a detailed proposal outlining how they propose to address the objectives. Approaches, other than that outlined above, are welcomed; however, consultant should justify the effectiveness of their various approaches. In addition to a detailed outline of the methodologies to be used, the proposal should include the following:
- Work approach
- The total costs of undertaking the work on a rate per daily basis
- Timescale
- Current CV
- References of previous employers for similar work.

Applications with non returnable copies of CVs, testimonials and 2 samples of previous work related to this assignment (baseline survey reports) should be submitted on or before 26th January 2010 and via email to and copied to Applications could also be submitted to SC offices in Nairobi and Hargeisa.
All applications should include the following:
- Cover letter (maximum 1 page)
- Technical proposal (max 5 pages). The proposal should include (i) brief explanation about the consultant with particular emphasis on previous experience in this kind of work (ii) understanding of TOR and the task to be accomplished (iii) proposed methodology, and (iv)draft work/implementation plan.

Reference Code: RW_7ZTAJ2-32

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