RFP Ref No. LRPS-2021-9172507: Conduct situation analysis including mapping of high-risk areas, service delivery points and modalities, partners and logistic supply in 4 City Corporations
TERMS OF REFERENCE FOR INSTITUTIONAL CONTRACT
Title of the assignment
Situation analysis including mapping of high-risk areas, service delivery points and modalities, partners and logistic supply in 4 City Corporations
Purpose
Conduct situation analysis including mapping of high-risk areas, service delivery points and modalities, partners in 4 City Corporations which will help to develop comprehensive micro plan for ensuring equitable services to all
Location
Dhaka North City Corporation, Dhaka South City Corporation, Chattogram City Corporation and Gazipur City Corporation
Estimated Duration
1st December 2021 – 31st March 2022 (4 months)
Reporting to Technical Supervisor of this assignment
Immunization Specialist, Health Section
1. Background
Bangladesh achieved some notable progress in the health sector, especially in reducing child mortality, but achievement in its Expanded Programme on Immunization (EPI) is remarkable and globally recognized as an example for developing countries. EPI has achieved and maintained neonatal tetanus elimination status since 2008, received the Polio Free Certificate along with 11 other countries of South East Asia in March 2014 and received GAVI Alliance Award in 2009 and 2012 for the outstanding performance in improving the child immunization status. Each year the country is vaccinating approximately 3.7 million targeted children against 10 deadly diseases. According to coverage survey 2019 shows 84% children are fully vaccinated with valid doses nationally, however inequities in vaccination coverage persist particularly between urban (79%) and rural (85%) coverage. Seven out of 12 City Corporations achieved less than 80 percent of FVC and around 1 per cent of children in urban areas have never been vaccinated. High internal migration in urban slum areas create challenges to track missed children or drop-out.
The Urban Local Bodies (ULB) City Corporations and Municipalities have the legal and administrative responsibility to provide Primary Health Care (PHC) and public health services for their residents however, due to competing demands for scarce resources at the ULB level and growing urban infrastructure needs, PHC and public health initiatives get limited priority within the municipal budget system and few resources are allocated for public health services. For the last two decades fundedby the Ministry of Local Government, Rural Development and Cooperation (MoLGRD&C), Asian Development Bank and USAID. These health service providers are dependent on contracts with donors or private funders and therefore sustainability of these services is a large concern. Other barriers for immunization coverage in urban areas are absence of PHC/ immunization sites in certain areas or insufficient number of sites per population, lack of proper coordination between service providing organizations (MoLGRD&C, MOHFW, NGOs) and other stakeholders in securing a high-quality vaccines supply and inadequate human resources support due to the lack of appropriate planning based on population size, attrition and high turnover.
UNICEF Bangladesh has received approval of Health System Strengthening (HSS) phase3 project of Gavi, the purpose of this project is to strengthen the immunization service delivery system and to improve coverage and equity among the most vulnerable populations. The project is targeted in 16 low performing districts and 4 City Corporations (CC). An assessment is proposed for four CC before the implementation of interventions to find out immunization service gap in terms of availability of services, unserved or underserved areas for vaccination, HR and resource constrain of implementing agencies and major challenges for immunization and Primary Health Care (PHC) services. The assessment will also work as a baseline for measuring progress of interventions and as a tool to develop an effective plan to cover the vulnerable population of urban areas and achieve equity in immunization coverage along with PHC.
2. Purpose, Objectives and Questions
Purpose
The purpose is to conduct a situation analysis including mapping of high-risk areas, service delivery points and modalities, major challenges and gaps in services and geographic areas in 4 City Corporations. The assessment will also explore strategy and solutions that can be taken to scale to improve immunization equity and coverage, including differences among various vulnerable groups (ethnic groups, slum dwellers, mobile, etc.). The assessment findings will be primarily used by the targeted CCs to develop plans for immunization service delivery including PHC with quality and accountability for ensuring equitable services to all. The intended secondary audience for these study’s findings will be the other City Corporations.
Objectives
The objectives are to conduct a situational assessment of the urban Primary Healthcare within four City Corporations (DNCC, DSCC, GCC & CCC), including:
- Analyse the existing policy & strategy documents for coverage and gaps
- Document the current management and health service delivery system through a stakeholder mapping
- Review existing service availability (immunization & PHC), including urban service delivery structures and service providers
- Identify underserved areas of these four CCs in terms of immunization and basic PHC with current coverage status (where are children/women missed for immunization/PHC)
- Identify the missed children, women, vulnerable groups through vulnerability profiling of population along with the analysis of immunization and PHC service status and healthcare seeking behaviour (Who are the children/women being missed for immunization, PHC)
- Identify barriers and enablers for implementation of immunization and PHC programs at supply and demand side, (disaggregated by vulnerable groups, vulnerable profile and/or demographics including at least ethnicity, gender, age and ability level) (Why are the children/women being missed for immunization or PHC)
- Understand the barriers and bottlenecks of demand generation for defined participant/audience groups to ensure consistent, continuous, repetitive communication to reach out hard-to-reach, high risk and ‘too-high-to-reach’ groups
- Suggest possible solutions and recommendations for Policy makers and Project Implementers
Overarching study questions
Throughout the assessment, the agency may explore the below potential study questions (but not limited to):
- What is the status of immunization services? (e.g. implementation strategy, organizations involved with their role and area, HR structure and status, coverage and completeness of services, completeness and correctness of HMIS, quality of EPI/yearly plans, planning process, component of PHC with availability, quality/status of monitoring/feedback/review meetings, etc.)
- Who are the the missed children, women, vulnerable groups? Why are they missed/vulnerable? Where are the unserved and underserved areas? Total population of vulnerable groups or un/underserved areas? Why are there no services or less services? What are the possible strategies to reach these groups with EPI and PHC services?
- What are the challenges to implement EPI services?
- What are the possible solutions to scale up of EPI in other urban areas? How can the findings from the assessment be used to sharpen the effective EPI planning process for City Corporation areas?
3. Description of Assignment
3.1 Scope of Work
The assessment will take place in Dhaka North City Corporation, Dhaka South City Corporation, Chattogram City Corporation and Gazi City Corporation, from December 2021 to March 2022. All public and private EPI and PHC service providers are within scope; the agency will further propose a sampling plan in the technical proposal and will be finalized in coordination with the technical supervision of UNICEF Health section and zonal offices, similar to all subsequent assessment activities. The agency will facilitate key workshops/meetings as necessary and will closely work Local Government Institutions (City Corporations) and Ministry of Health & Family Welfare.
A. Assessment of current immunization services (strategy, structure of EPI & PHC, % of coverage, service mapping), healthcare-seeking behaviour and challenges to delivery of quality EPI programme implementation
The agency will collect, analyze and present information from the qualitative and quantitative survey from policy makers, health managers, health services providers, local leaders, community leaders and beneficiaries, and from review of existing health facility admin registers and medical records. Desk review, field visits and interview will be conducted for refining the assessment. Quantitative and qualitative survey tools should be developed in the inception period and should be shared for review and tested before the fieldwork. Sampling of health facilities, service providers and communities should be done in consultation with UNICEF and GOB. For community analysis, a formative assessment would be necessary to review the acceptance, practice and barriers to immunization services. The agency will analyze demand side factors for successful current status of immunization services by service users. Social, religious, cultural and any other factors, which would insidiously or overtly hinder the initial and continuous uptake of services by the users should be the subject of assessment. Focus Group Discussion (FGD) in communities may be necessary for identifying barriers in community settings and finding practical solutions from the demand side. The agency will also use gender lens in this assessment to explore on gender issues including male involvement and differences in healthcare seeking behavior and access to health services among males/females. Quantitative and qualitative data collection tools for Health Facilities will be developed for service mapping along with interview with key informants and focus groups.
B. Vulnerability analysis to find out vulnerable groups along with unserved and underserved areas for immunization services and SBCC assessment to understand the barriers and bottlenecks of demand generation for different target audiences and challenges for programme implementation
The agency will conduct stakeholder analysis, including interviews with concerned local leaders, health managers, health services providers, community leaders and beneficiaries for better understanding of the identity of the missed children and women, the vulnerable groups, unserved areas and underserved areas with its contextual factors for implementing immunization services in CCs. Quantitative and qualitative data collection tools for Health Facilities, immunization and PHC services and communities will be developed for assessment of practice and observation, alongside interviews with key informants and discussions among focus groups. Specific population and area should be identified as per service unavailability or vulnerability from those targeted for interview and discussion. Also, the findings should bring out the barriers and bottlenecks of demand generation for defined participant/audience groups to ensure consistent, continuous, repetitive communication to reach hard-to-reach, high risk and ‘too-high-to-reach’ groups.
The identified barriers and bottlenecks will be used to support the process of refinement needed for successful adaptation of GOB’s implementation strategy. Literature review should include national policies and guidelines (Standard operating procedures), equity focus district evidence-based planning tool and study how bottlenecks were overcome in similar low-resourced settings.
C. Dissemination through national and sub-national workshops
The agency will compile all the assessment findings including current status of immunization and PHC services along with details of vulnerable groups, unserved and underserved areas and barriers and bottlenecks, and write and complete a report based on the assessment and study to print. The agency will compile CC/ward wise findings of the assessment and prepare presentation materials for each CC separately. One national and four CC level workshops shall be conducted. One compiled report will be submitted to UNICEF as the final deliverable. The agency will participate in the dissemination workshops of the assessment as presenter in coordination with UNICEF and MOHFW. The agency will ensure the active involvement of key stakeholders (e.g. EPI, PHC, Urban program implementers and policymakers) from government and development agencies as co-investigators or implementers.
3.2 Methodology
The agency will develop more specific methodologies for literature review, primary and secondary data collection and analysis, including desk review, interviews and field visit for health facilities and communities. During the inception phase, the agency will conduct an in-depth desk review of past evaluations, progress reports, programme documents, any other documentation and grey literature relating to the subject, and key implementation challenges. Based on the findings of the desk review, and review of secondary data, the agency will finalize primary data collection strategies including both quantitative and qualitative methods and analysis of data. Where applicable, this should include documented, detailed and replicable sampling plan by methodology. The agency will conduct site visits and observation for primary data collection. It should also undertake key informant interviews with the national stakeholders from policy makers to service providers to identify the barriers and enablers in the urban health systems. The qualitative study will include structured/semi-structured interviews covering social norms and policy, management, supply side bottlenecks, cultural practice and beliefs. In-depth interviews and focus group discussions with beneficiaries should identify the gaps and barriers to receiving health services, cultural beliefs, or behavioral patterns that may facilitate understanding and action, and provide an insight into knowledge and attitudes that are common or specific to the target populations.
The geographic areas for the assessment are DNCC, DSCC, Gazipur CC and Chattagram CC. The detailed assessment plan (e.g. assessment tools, teams, methodology) must be presented to UNICEF for clearance prior to field work (through an inception meeting/report). The tool(s) and other data collection instruments for desk and document review, institutional mapping and primary data collection shall be shared with UNICEF for technical inputs and clearance prior to their application. The assessment should employ the following combination of qualitative and quantitative data collection methods:
A. Desk Review
- Systematic desk review of key documents (e.g. CES, Urban health Strategy, disease surveillance reports, other evaluations, programme documents, presentations, intervention log frames, project proposals, HMIS, KABP quantitative and qualitative findings, etc.)
- Grey literature for mapping of existing services in the selected CC
B. Secondary Analysis of Existing Data
- Analysis of input, output and outcome data of CCs and others (both among program beneficiaries and non-beneficiaries, where possible)
- Use of real time HMIS data
- Disease surveillance reports
- Use of health facility administrative data and registers
- Use of project-wise M&E data of partner CSOs
C. Primary Data Collection
- Interviews with key decision-makers (approx. 20 persons) and end beneficiaries
- Potentially, surveys or other quantitative data collection methods
- Direct observation of facilities and community-based services and activities (Approximately 10 facilities from selected CC)
- Health Facility Assessment and exit client interviews
- Interviews and/or focus groups with key informants and community members (approx. 5 vulnerable groups, 10 un/underserved areas and 5 focus groups per CC, taking into consideration sex and age, missed children/women)
*Note there should be consideration for alternative methods of collection due to COVID-19 situation/ restrictions.
D. National and sub-national workshops review
- Advocacy and dissemination at national and CC levels
The agency will call out specific data quality assurances within each methodology to ensure the highest quality of data through collection, storage, entry, analysis, reporting, dissemination, and disposal. Similarly, the agency should specify the anticipated and realized limitations and mitigation/acceptance plans. While the agency is required to fully develop a study plan matrix in the inception report, mapping specific objectives to methods to data sources to proposed data analysis plan, the following list of indicators and information is necessary for inclusion:
- Physical mapping of health facilities and stakeholders by CC
- % of Population covered by each stakeholder by CC
- Mapping of organization providing health services by CC stating who, where, what & whom to cover
- List and mapping of geographical areas underserved for immunization services
- Current coverage status of immunization by CC
- Ward-wise table of services by type of service provider by stakeholder by CC
- # and mapping of vulnerable groups/population by CC, including missed children/women
- Current coverage status of immunization and healthcare seeking behavior of this population
- Causal analysis of vulnerability
- List the factors that hinder the initial and continuous uptake of services by the users by CC (Social, religious, cultural, etc.)
- Table of possible solutions and recommendations for Policy makers and Project Implementers
- Matrix of barriers and bottlenecks of demand generation for different audience groups
- Briefing note for Policy makers and Project Implementers on possible solutions and recommendations
3.3 Ethical and other considerations
This study will be held to the highest standards employed by UNICEF. This means, the agency will abide by the following:
- UNICEF Procedure for Ethical Standards in Research, Evaluation, Data Collection and Analysis
- UNICEF Strategic Guidance Note on Institutionalizing Ethical Practice for UNICEF Research
- UNEG Ethical Guidelines for UN Evaluations
The agency is expected to explain ethical considerations for the assessment, specifically spelling out how these above guidelines will be followed/met. Any specific ethical considerations or strategies necessary to prevent or avoid COVID-19 infection and spread should be addressed and detailed in the proposal. Further, ethical clearance must be obtained during the inception period, before any data collection with human subjects begins. The ethical clearance letter should be attached in the annexure of the final report. All data collected through this assignment, reports and dissemination materials are the intellectual properties of UNICEF and shall not be used for purposes other than those approved by the registered Institutional Review Board during the ethical clearance.
Additionally, the study will be human rights-based (including child rights) and gender sensitive. All applicable data will be disaggregated by sex, age, and ability level. The agency is advised to refer to the UNEG Guidance on Integrating Human Rights and Gender Equality in Evaluation, which is applicable to assessments like this one.
4. Deliverables
The table below outlines the main deliverables for this project. The agency should expand this and provide a detailed timeline for each work package, key activities (including review processes), and deliverable.
Deliverables
Items covered/Included
Time frame
Payment schedule
1
Inception report with assessment tools/ questionnaire/ methodology and plan
- Inception report including desk review, review of existing documents & data sources and specification of assessment tool/questionnaire, finalize primary data collection methodology and obtain ethical approval
- Detail implementation plan of assessment including person/facility/area
- Study plan matrix (including accompanying data analysis dummy tables)
5 weeks
30%
2
Draft assessment report
- Report on findings of the assessment and recommendation for implementation of EPI and PHC services
- Service delivery mapping, define vulnerable groups (incl missed children and women) (ethnic groups, mobile, slum dwellers etc), un- and underserved areas, barriers and bottlenecks of SBCC for each CC
10 weeks
40%
3
Dissemination workshop organization at national level and with 4 CCs, including the revised and final assessment form with all feedback incorporated
- Including at least one infographic and one presentation for national and for 4 CCs
- Facilitation including invitation of stakeholders
- Incorporate feedback from the workshops and finalize the assessment report
3 weeks
30%
5. Reporting requirements
- Inception report with tools within 5 weeks signing the contract;
- Initial draft report on assessment within 10 weeks of submission of Inception report;
- Final draft report on assessment within 13 weeks of submission of Inception report;
- Workshop materials, and infographics within 13 weeks of submission of inception report;
- All raw and analysed data and final data collection tools within 13 weeks of submission of inception report
6. Payment schedule
First payment: 30% upon clearance of inception report
Second payment: 40% upon finalization of assessment report (pre-workshops), as agreed with UNICEF
Final Payment: 30% final presentation at national workshop; submission of final report and all finalized materials
7. Qualification requirement of the company/institution/organization
- Agency and members of the team, including the leader, to have expertise and proven substantial experience of at least 10 years in research in public health
- Adequate knowledge and exposure to EPI, PHC and Urban health situation and programs in Bangladesh and the sub-continent
- Skills in quantitative and qualitative analysis and synthesis, knowledge of gap analysis/needs assessment methodologies, knowledge of methodologies and approaches with hard-to-reach populations
- Acknowledged Ethical Review Board (either internal or external) approval process of proposals
- Good report writing, presentation and verbal communication skills
Experience with UN or UNICEF an advantage