REQUEST FOR PROPOSALS
RFP Title: Rapid Assessment of Community-Health Facility Linkages in Nigeria
Issued on: Thursday 26th May 2016
Proposal Deadline: Friday 24th June, 2016,
Submission Format: See directions (“Submission of Proposals”)
Send emails to:
Contact person: Bukola Ehimatie,
+234 (0) 803 650 2038
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Table of Contents
I. INTRODUCTION & BACKGROUND 3
II. OVERALL GOAL 5
III. ESTIMATED PERIOD OF PERFORMANCE 6
IV. SCOPE OF WORK & SPECIFIC TASKS 6
V. STUDY SETTING 8
VI. DELIVERABLES 9
VII. PROPOSAL GUIDELINES 9
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I. INTRODUCTION & BACKGROUND
In Nigeria, there have been several efforts to bring health care to the community and grass-root levels. The first attempt was with the establishment of the Basic Health service scheme which was implemented between 1975 and 1980. This scheme concentrated on the establishment of health facilities and the training of health care workers with little attention given to community participation, inter-sectoral cooperation or use of local technology (Obionu,2007). The health services, based on primary health care (PHC), include among other things: education concerning prevailing health problems and the methods of preventing and controlling them, promotion of food supply and proper nutrition, material and child care, including family planning immunization against the major infectious diseases, prevention and control of locally endemic and epidemic diseases and provision of essential drugs and supplies.
The provision of health care at PHC level is largely the responsibility of local governments with the support of state ministries of health. Furthermore, the enactment of the National Health Policy (1987) makes adequate provision for a comprehensive health care system, based on primary health care that is promotive, protective, preventive, restorative and rehabilitative to all citizens within the available resources so that individuals and communities are assured of productivity, social well-being and enjoyment of living thus ensuring universal access to health care for all. [Abdulraheem et al 2012].
Health care systems are often designed to encourage clients to seek care first at the primary level and then be referred, if necessary, to a higher level of care. If this reflects actual care seeking behavior, then health care costs for the clients and community members will be minimized. In many countries, however, clients/community members often bypass primary care facilities and seek care directly at referral care hospitals for illnesses that could be easily treated at the primary care facility. This can overburden the referral facility, and is often costlier for the clients and the health care system. [Kim et al, 2003; Menizibeya OW 2011].
Despite considerable investment over the years, available evidence suggests that health services throughout Nigeria are delivered through a weak health care system that is unable to provide basic, cost-effective services for the prevention or management of common health problems. The limited coverage of basic health services results from poor access to information and services and contributes significantly to poor health outcomes in Nigeria. Management of Health Services at the LGA and Ward levels are in disarray in most States.
With the over 36,000 health facilities in the country, and about 83% being primary health care centers, clinics and health posts; health access is still less than 50%. [Onwujekwe et al 2010]. The Primary Health Care System suffers from poor infrastructure and there are serious gaps in access to basic health services. Most public health facilities across the country are poorly equipped as indicated in findings from a 2001 survey of public PHC facilities reporting only 25% of health facilities with more than 25% of the minimum equipment package and 40% of PHCs with less than 40% of equipment. Materials and equipment for service delivery at the PHC facilities are hardly available or functional. Supply of essential drugs remains a major challenge to health care delivery at the PHC centers. Most health centres no longer have functional Drug Revolving Schemes resulting in shortage of critical medicines and commodities at point of service delivery. [NPHCDA 2015]. While it is observed that 45% of populace are living in urban and the remaining 55% in rural areas, yet about 70% of Nigerians access health services at private and 30% at government public health facilities. [Menizibeya OW 2011]
As the world moves back to Primary Health Care, community participation in the health system has risen to the fore as a fundamental principle, and is one of the underpinning values of primary health care outlined in the Alma Ata Declaration. However, for this paradigm shift to become a reality, communities in their different forms need to be empowered and recognized as agents of change and leaders in promoting their own well-being, rather than just targets of intervention.
Bearing the current status of PHC in mind and the drive for revitalization of the existing system, investigation into unravelling the factors acting as drivers of this deplorable state and those that can be useful in promoting service utilization and public confidence in the PHC need to be evaluated. Assessment should determine what strategies are working well and those underperforming with a means to proffering suitable recommendations.
Nigeria is currently implementing the Global Fund New Funding Model Grant, in which Association for Reproductive and Family Health (ARFH) is a Principal Recipient (PR) along with National Agency for the Control of AIDs (NACA), National Malaria Elimination Programmes (NMEP), Society for Family Health (SFH) and Institute of Human Virology (IHVN). In order to strengthen the Patient focused Health Referral Linkage system, it is important to assess referral pathways across health related services including HIV/AIDS, Tuberculosis, Malaria and Reproductive Maternal Newborn Child Health Services at the Community and Facility Levels. This consideration brings to bear programmatic and policy efforts geared toward strengthening integration and collaborative activities within the health system.
Despite the wide array of interventions being implemented at the health facilities and the communities in Nigeria, there is insufficient evidence on referral systems that can be scaled up and thus contribute meaningfully to restoration of public confidence in the primary healthcare system and support government in revitalization of the PHC agenda. In most cases, there may be anecdotal reports of success stories in program documents which need to be substantiated with robust quantitative and qualitative evaluation while taking in to consideration the interaction between the interventions and socio-economic, socio-cultural and demographic characteristics and other related factors that may serve as intervening variables or confounders.
ARFH in collaboration with the HIV, TB and Malaria Principal Recipients, FMOH and NPHCDA, has secured Global Fund approval to assess the community-facility referral systems with the aim of using the evaluation outcome to strengthen the referral systems in-country, which should in turn contribute to achieving the impact of GF and other health donors interventions and investments.
II. OVERALL GOAL
To determine opportunities, gaps and challenges that exist within the community and health facility interface.
The findings will provide basis for strengthening effective referral linkages between communities and health facilities in Nigeria that will contribute to restoration of public confidence in the healthcare system.
ARFH intends to engage the services of qualified and competent local consulting firm with experience in designing and conducting Rapid Assessment and Health Systems Evaluation. This organization should have experience in evaluating Health and Community Systems Strengthening Interventions. This Local consulting firm is expected to have two competent evaluation teams, with one team focusing on the design and conduct of rapid assessment of referral and linkage systems/pathways amongst facilities and diseases component (HIV/AIDS, TB, Malaria and Reproductive Health) and the other team focused on assessment of community-facility referral system. This Local firm is also expected to produce a quality evaluation report establishing the situation of referral systems in Nigeria. For the field work, data entry and data analysis process, the local consulting firm will ensure engagement of experienced epidemiologists and Sociologists in order to ensure quality of findings and report.
The Specific objectives:
Objectives of the community-health facility linkages assessment:
· To assess the existing community-health facility referral system in the country
· Determine barriers and enablers for the referral system in Nigeria
· Assess the operational capacity of the referral system with respect to human resource availability, health products availability, access and utilization including functionality of laboratory equipment
· Determine a cost effective referral model that can be adopted to improve community-health facility referral linkages and outcomes
III. ESTIMATED PERIOD OF PERFORMANCE
JULY TO NOVEMBER, 2016
IV. SCOPE OF WORK & SPECIFIC TASKS
The extent to which the evaluation team and the consultant will work will be largely dependent of the final protocol however; the following will be taking into consideration:
1. Desk review of existing literatures, project documents and report of assessments of the referral system, health system and the primary health care services in the country, review of relevant referral linkages and health service delivery policy documents, guidelines and protocols/procedures etc
2. Description of the existing referral networks/pathways and services between the community and public and private health facilities as well as inter facility referrals especially public/private interphase and how they are inter-linked
3. Analysis of current and past interventions aimed at promoting increased service uptake at PHCs by community members either through government support of donor-driven interventions
4. Highlight possible contributory factors mitigating against effective and functional referral system and
5. Elucidate innovative strategies and interventions that can be used to revamp the failing health system and make referral system functional and effective for the benefit of all.
6. The focus of assessment is aimed at evaluating the functionality of the referral pathway between various disease programmes at the PHC levels including but not limited to Malaria, HIV/AIDS (HCT, PMTCT), Tuberculosis, MNCH, ANC etc. services.
In general, the overall scope of the evaluation will encompass assessment of referral pathways across health related services including HIV/AIDS, Tuberculosis, Malaria and sexual and reproductive health services at the community and health facility levels. This consideration brings to bear programmatic and policy efforts geared toward strengthening integration and collaborative activities within the health system.
Specifically, the Rapid Assessment Assignment scope will also involve:
· Development of the Assessment protocol-evaluation design and methodology for the Community-Facility Referral Systems Assessment
· Development of tools to carry out the Rapid Assessment.
· Provision of the software to be used for data entry
· Training of the field workers
· Training of the data entry clerks
· Conduct of field work
· Data analysis
· Presentation of data to the stakeholders
· Presentation of Assessment findings
· Preparation and submission of the Assessment Report
The specific research questions to be addressed during the evaluation:
Essentially the Survey Consultant will seek to answer the broader question about exactly what the effectiveness of referral linkages exist between community and health facilities and the impact of this on the burden of disease in Nigeria.
Within the broader question, and with respect to the outlined objectives above, the following will be areas of focus for the work of the Survey Consultant:
1. Describe the epidemiology of the community-health facility referral linkages, demographics, socio-economic characteristics of general population, clients at the community and those attending the health facility, describe health-seeking behaviour, awareness of the availability of health services and its quality
2. Describe the documentation practices including linkages, feedback mechanism, policies, protocol and directory
3. What services are often being referred for?
4. Who are the beneficiaries of this referral?
5. Are there existing feedback mechanism following the initiation of referral process?
6. Describe the models of referral linkages that exists: Inter-facility referral, community-health facility referrals, and Intra-facility referral linkages
7. What factors necessitates bypassing of the referral system/linkages?
a. What are the barriers to effective referral?
b. Socio-cultural, access/hard to reach,
c. Attitude of the health worker
d. Additional cost for service uptake, user fees, service charge, etc
e. Indirect costs: transport, etc.
8. Are the required resources available for effective referral system?
9. How many days and hours/day is the health facility opened?
10. Assess patient-provider interaction and quality of care/services available at the health facility
11. Describe the operations and mechanisms that either promotes or otherwise hamper the effective referral linkage
12. Where does the health facility get referral from?
13. Where does the health facility refer patients to?
14. What services are available at the health facilities?
15. What services are available at the community levels?
16. Are there existing protocols or procedures for establishing and completing referral?
17. How regular are services available to clients?
18. Are drugs, consumables (methylated spirit, gloves, etc.), laboratory equipment and reagents available?
19. Are drugs, consumables (methylated spirit, gloves, etc.), laboratory equipment and reagents for fee-paying or donor supported services?
20. How many health workers are available? What are the cadres?
In addition, the consultant shall assist ARFH in obtaining ethical approval from the NHREC for the study prior to data collection.
V. STUDY SETTING
This is a cross-sectional study design with mixed-methodology and will adopt both qualitative and quantitative research methodologies. Consequently, careful measures will be undertaken to make appropriate selection of study sites. We expect that the consultancy will propose an appropriate tailored study design and sampling frame that will generate adequate statistical power to make meaningful inferences for the selected states, with respect to community-health facility referral linkages in Nigeria.
Target Population
The study is expected to consider community members residing in localities where active community-based interventions have taken place. The study targets or respondents may or may not have directly benefitted from any donor supported intervention. Similarly, the community based organizations and health facilities within the selected LGAs and States will constitute significant portions of the study respondents.
In particular youths, adult women and men of reproductive age group in the communities where TB, HIV, Malaria, Family planning and MNCH interventions have been implemented, will form the study population for the quantitative component. For the qualitative study, patients, community members, community leaders, Community Based Organizations (CBOs) focal persons, and health facility focal persons will be study participants.