TORs: National Junior STTA – Research Associate (2 positions)

Technical Assistance Name: Strategic Review of the Global Health Initiatives Supported Interventions and Programmes in Pakistan and the Development of a Roadmap for Institutional Reforms 

Programme 

Evidence for Health (E4H) is a new Foreign, Commonwealth & Development Office (FCDO)-funded programme aimed at strengthening Pakistan's healthcare system, thereby decreasing the burden of illness, and saving lives. E4H (2023-2027) provides technical assistance (TA) to the Federal and Khyber Pakhtunkhwa (KP) governments and will subsequently operate in Punjab. The KP and Federal component is being implemented by Palladium along with Oxford Policy Management (OPM).

Through its flexible, embedded, and demand-driven model, E4H KP & Federal will support the government to achieve a resilient health system that is prepared for health emergencies, responsive to the latest evidence, and delivers equitable, quality, and efficient healthcare services. Specifically, E4H will deliver TA across three outputs:

Output 1: Strengthened integrated health security, with a focus on preparing and responding to health emergencies, including pandemics.

Output 2: Enhanced capacity for evidence-based decision-making to drive health sector performance and accountability.

Output 3: Improved implementation of Universal Health Coverage, with a focus on ending preventable deaths.

Background and Problem Statement

Pakistan is one of the largest recipients of global financing through Global Health Initiatives (GHIs), including the Global Fund to fight against AIDS, Tuberculosis (TB) and Malaria (GFATM-over $281 million from 2024-2026), the Global Alliance for Vaccines and Immunisations (GAVI-total disbursed funds as of October 2022: US$2.94 billion); the Global Polio Eradication Initiative (GPEI- plus over $155 million for the period 2023-25 from Islamic Development Bank, Agence Française de Développement (AFD) and Bill & Malinda Gates Foundation (BMGF)) and the Global Financing Facility (GFF-$82 million for the period 2022-27 under the World Bank’s National Health Support Programme). All of these provide a significant contribution to the health systems’ ability to prevent illnesses and manage health challenges, thus supporting the universal health coverage (UHC) and International Health Regulations (IHR) objectives.

Pakistan's economy faces considerable challenges stemming from a complex social, political, economic, and geopolitical landscape, particularly impacting public sector resources for health. The country's macroeconomic environment is currently facing challenges with low foreign reserves, disrupted supply chains of critical resources, and high inflation coupled with the sharp depreciation of the Pakistani Rupee. Furthermore, Pakistan's severe fiscal constraints have been exacerbated by the COVID-19 pandemic and the 2022 floods, which have had profound repercussions on the healthcare systems and essential health care services, especially for the poorest and vulnerable groups.

Given these economic and political challenges, coupled with significant public health threats, it has become critical to ensure that Pakistan's public and private health systems can adapt, respond, and remain resilient. To do this, specific areas of the health systems require reforms for the country’s progress against health-related Sustainable Development Goals (SDGs), especially the strengthening of integrated essential health services and health security core capacities, while using the Primary Health Care (PHC) approach. It is also important to understand the operating environment and effectiveness of GHI supported initiatives and programmes and develop a roadmap for institutional reforms. This will support maximising the value for money, impact, and sustainability of priority interventions and programmes.

In 2011, the 18^th Constitutional Amendment led to the devolution of various federal functions to the provinces. These included all vertical national PHC Programmes. However, the function of international coordination of some of the vertical PHC programmes implemented with support of GHI (GAVI, GFTAM and GPEI) were retained at the federal level, along with the function of IHR, as defined in the rules of business and federal legislative lists of the Constitution.

• GHI supported initiatives and programmes target large sections of the population: TB is a nation-wide problem; immunisation targets all children under 5 and women of reproductive age, and over 98% of the population lives in areas with some degree of malaria risk – 30% being in high-risk areas. This means there is some natural overlap in target populations in many areas for the interventions supported by GHI.
• By contrast, the HIV&AIDS epidemic is concentrated primarily among people who inject drugs and sex workers. The HIV&AIDS epidemic is described as fast-growing and is slowly spilling over into the general population, with the highest prevalence of people living with HIV in Punjab and Sindh.
• Over the medium term, malaria cases have been declining (until the recent floods). Immunisation coverage has increased gradually since 2012, and new vaccines have been added to the immunisation schedule, but coverage remains below target in many places. Pakistan persistently reports high Tuberculosis (TB) incidence. Performance in the area of reproductive, maternal, newborn and child health is comparatively better as indicated by a continuous rise in skilled birth attendance and institutional deliveries, but not for neonatal mortality and contraceptive usage.    
• Most preventive and promotive services are provided by the public sector, primarily through community outreach and PHC facilities. Public sector primary care facilities are designed to provide a range of prevention, promotion, case detection and treatment services. By contrast, private practitioners provide 70% of curative primary health care in Pakistan. There is some experience in the explicit contracting of private providers for TB care, for a relatively small share of immunisations, and HIV&AIDS care.
• Dependency on donor funding carries risks as the Overseas Development Assistance (ODA) is shrinking around the globe. Institutional capacities and dependency of external technical assistance and financial support is a major risk, which demands broader transformation and reforms. Furthermore, the current situation undermines true ownership due to some imbalances in power, resources, and capacity within the GHIs and the UN system.
• There are missed opportunities for collaboration and integration as most of the global investments remain in vertical silos. Verticality of these programmes leads to duplication of efforts and inefficient use of scarce resources, causing serious performance challenges and distortions within the health system by pulling scare resources across the health system through the incentives the programmes create.
• The GHI investments are expected to support the broader UHC and IHR agenda in Pakistan. Despite heavy global investment in infectious diseases, performance is not satisfactory. In the new Joint External Evaluation (JEE) tool, essential health services have been included as a new core capacity for IHR and performance is not satisfactory.      

Many of the global best practices are included in the National, Provincial, and Area specific evidence-informed Essential Packages of Health Services (EPHS), which act as policy frameworks for the provision of integrated essential health services. However, the verticality of GHI interventions and programmes is a major challenge for the delivery of integrated services at district and PHC levels. Integrated management is also interconnected, and it is essential to ensure value for money for the funds provided by the government, as well as the finances being provided by donors through GHI.

Specific Objectives

The overall objectives of the technical support will be:

1. To review and assess existing governance, coordination, management and implementation structures supported by GHIs, in order to identify barriers and gaps and suggest opportunities for improved governance through a well-coordinated structure that may bring more efficiency, effectiveness and improvement in service delivery, suggest steps for further devolution, integration, and sustainability of the investments.
2. To assess the relevance, coherence, effectiveness, efficiency, impact, and sustainability of the GHI interventions and programmesusing available evidence and a qualitative assessment.
   1. To appraise the extent to which the net benefits of the GHI supported interventions and programmes are continuing or are likely to continue. This includes an examination of the financial, economic, social, environmental, and institutional capacities of the systems needed to sustain net benefits over time. It further involves analyses of resilience, risks, and potential trade-offs.
   2. To conduct a donor and domestic resources mapping related to GHI supported interventions and programmes and assess with a priority to duplication of efforts and providing a holistic overview of their contribution for institutional strengthening, transition and sustainability including linkages with domestic funding.
   3. To feature clear recommendations on strategic, programmatic, health system and future institutional reforms, focusing on integration, devolution, coordination, and financing. This will inform decision makers on how to continue in the future, ensuring GHI supported programmatic success through evidence-informed integrated policymaking and reforms.

To provide a vision and roadmap for the evolution of reforms and activities to effectively, efficiently, equitably and sustainably delivery the GHI supported interventions and programmes through an integrated approach in line with national and international commitments and constitutional mandates.

Scope of Work

A team of consultants will be tasked with (1) designing the strategic review and assessment methodology, which should leverage the latest approaches for effective and compelling policy/strategy and programmatic review; (2) conducting a quick review of current GHI supported interventions and programmes on the methods agreed; and (3) using a participatory approach and the evidence generated to develop a roadmap for institutional reforms for the effective implementation of country-led GHI supported reforms on a sustainable basis.

The TA will analyse performance and progress of GHI supported initiatives and programmes against the Development Assistance Criteria (DAC) of evaluation. The team will work closely with the Ministry of National Health Services, Regulations, and Coordination (NHSR&C) and provincial/area Health Departments, as well as the managing layers of the GHI supported interventions and programmes at different levels. Listed below is a non-exhaustive list of the sequence of activities that the consultants will be expected to undertake.

• Perform a desk review of all the latest GHI related strategies since 2016 and action plans in the context of the country’s current political and socio-economic development. This will include a thorough assessment and understanding of the political economy in which the vertical programmes are being implemented or transferred to the recurrent budget.
• Conduct a stakeholder mapping at national, provincial, area and selected district levels and hold structured interviews, conduct qualitative research and consultations/ workshops for comprehensive assessment and planning.   
• Assess the overall progress made against the strategic areas and targets in the GHI supported plans and how this progress contributes to health outcomes as identified in relevant strategic documents such as commitments in the National Health Vision and provincial health strategies.
• Review the contribution of the GHIs in advancements made towards attaining health-related SDGs/ monitoring framework of strategies or identify the gaps that exist in the achievement of GHI related SDGs targets.
• Assess the alignment and integration of strategies and action plans for building stronger and more resilient health systems.
• Assess the programmes’ comparative strengths and advantages including their engagement and adjustments to respond to emerging needs and health emergencies. The consultants will be expected to take into account the adaptability of the GHI supported programmes in the context of climate-induced stresses on disease patterns, as well as the results that can directly be linked to the COVID-19 pandemic.
• Examine, analyse, and present epidemiological, health outcome and qualitative data from various sources (and interviews) of programmatic interventions in public and private sectors to identify major health systems challenges and risks, while considering cross cutting dimensions not limited to gender, equity and resilience.
• Appraise the extent to which the net benefits of the GHI supported interventions and programmes continue or are likely to continue. This includes an examination of the financial, economic, social, environmental, and institutional capacities of the systems needed to sustain net benefits over time. This involves analyses of resilience, risks and potential trade-offs.
• Conduct a donor and domestic resources mapping related to GHI supported interventions and programmes and assess with a priority to duplication of efforts and providing a holistic overview of their contribution to institutional strengthening, transition and sustainability including linkages with domestic funding.
• Document challenges and weaknesses of GHI plans and the effectiveness of their governance, coordination, procurement and supply chain mechanisms and collaboration with development partners, government institutions, private sector, and civil society organisations.
• Assess the extent to which the implementation of identified strategies contributed to promoting equal access and human rights-based approaches. In addition to gauging the progress against commitments laid out in SDG 3, the consultants will also be expected to focus on cross-cutting issues not limited to gender, equity and resilience.
• Identify best practices and lessons learned up till now from the implementation of GHI supported interventions and programmes.
• Develop clear recommendations on strategic areas and future institutional reforms, focusing on integration, coordination, and financing. This will inform decision makers on how to continue in the future, ensuring programmatic success through evidence-informed integrated policymaking on the control of infectious diseases.
• Develop a clear vision and roadmap for future institutional reforms related to coordination, integration, devolution, procurement, supply chain, information systems and financial sustainability etc. Options will be explored for joint strategic response while ensuring effectiveness, efficiency, equity and sustainable delivery of services through an integrated approach in line with national and international commitments and constitutional mandates.

The evaluation and roadmap planning exercise will be conducted across four provinces (Sindh, Punjab, KP, and Balochistan) and Federating Areas (Gilgit Baltistan, Islamabad and Azad Jammu & Kashmir) and will use a mixed quantitative and qualitative methods approach.

A focal point nominated by the Director General (Health) and other relevant staff of the M/o NHSR&C and Health Departments will be actively engaged, where possible, in the activity for capacity development regarding complex and holistic analyses and the development of a roadmap exercise.  

Timeline and LOE

Two Junior level Research Associates will work 60 working days each from February 2024 to June 2024.

Requirement 

• Postgraduate degree in public health.
• Minimum of 5-10 years' experience.
• Experience of data collection, collation, and analysis.
• Good writing and communication skills.
• Analysis and use of information; Working with others; Communicating with others.