Consultant: Cost-Effectiveness and Sustainability study

1. BACKGROUND

Almost eight years since the outbreak of war in Syria, Lebanon continues to host the highest ‎per capita number of Syrian refugees anywhere. The additional population has strained ‎essential services, limiting access for both refugees and vulnerable Lebanese. As part of ‎efforts to meet urgent needs, International Medical Corps UK (IMC) with identified consortium partners, Première ‎Urgence-Aide Médicale Internationale (PU-AMI) and Fundación Promoción Social de la Cultura ‎‎(FPSC) have been implementing the REBAHS project (Reducing Economic Barriers to Accessing Health and Mental Health services) in Lebanon funded by the EU MADAD Trust Fund. The overall objective of the project to improve access to quality primary health care, community health, and mental health ‎services for Syrian refugees and other vulnerable populations in Beirut and Mount Lebanon, ‎Akkar, Tripoli, Bekaa, and the South. Additionally, the project aims for improving the quality of service provision through the Primary Healthcare system strengthening which includes capacity building of staff and providing necessary supplies such as equipment and medication, and quality improvement plan tailored to each facility, with progress measured and reflected in ‎incentives paid to each facility monthly. ‎

Health Services

Through adopting a Flat Fee Model (FFM),‎ IMC/PU-AMI support 52 PHCCs (30 PHCCs supported by IMC and 22 by PU-AMI) in Akkar, ‎Bekaa, Beirut, and Mount Lebanon, the South, and Tripoli, to provide affordable quality primary ‎healthcare services for refugees and vulnerable Lebanese. Under this flat fee ‎model (FFM) patients will pay a subsidized consultation fee of 3,000 LBP and will receive all ‎medically necessary imaging, diagnostic, and laboratory tests for free, as well as free ‎medications on the Ministry of Public Health’s (Essential Medication List).

Capacity Building

In the past period, IMC/PU-AMI have conducted several capacity building activities for health facility staff at PHCCs. The topics were selected based on needs identified by the PHC management and IMC/PU-AMI, in ‎coordination with the MoPH and other health actors, in order to avoid duplication of activities. ‎The MoPH collected and coordinated the plans for all health training practices conducted nationwide and ‎IMC/PU-AMI determined training topics based on discussions with the MoPH and an annual ‎comprehensive needs assessment of each supported health facility and according to regular ‎supervision visits. As such, training topics at the start of the where IMC/PU-AMI have worked with the PHCCs to identify the most urgent needs‎.

Promote quality improvement at PHCCs

As part of comprehensive quality assessments to be conducted every quarter, IMC/PU-‎AMI continued to utilize a standard PHC assessment tool and medical record assessment ‎tool already developed and utilized by IMC based on MoPH and WHO guidelines, in order to ‎identify areas in need of improvement. IMC/PU-AMI monitored and provided support for ‎the implementation of improvement plans through regular visits by health officers, pharmacists ‎and medical advisors, who will provide technical support, as well as oversight. Health officers ‎will record gaps and improvements related to the quality of service provision and facility ‎management at each clinic.

Community Health

As a complement to clinic-based services, community health outreach and education activities ‎implemented by IMC and PU-AMI will help in the early detection and prevention of health-‎illnesses and complications as well as decrease the need to seek additional health care services ‎and further financial spending on health. ‎

IMC and PU-AMI’s Community Health Education (CHE) Program adopts a complementary, ‎community-driven approach, with a focus on building capacity of a trained cadre of Community ‎Health Workers (CHWs), made up of both men and women hired from within the local refugee ‎communities. CHWs encourage health-seeking behavior and raise awareness on fundamental rights ‎and critical health topics among refugees living in Informal Tented Settlements (ITS) and ‎Collective Shelters within the catchment area of PHCCs. Through field level coordination with ‎other national and international service providers, the CHWs and other community-health ‎education staff members are trained to identify people in need and refer them to the ‎appropriate services in various sectors, including mental health, protection, GBV, WASH, ‎primary health care, reproductive health, shelter. ‎

Mental Health

Through the REBAHS project, IMC has further expanded its mental health program through ‎support of nine mental health case management teams based in Community Mental Health ‎Centers (CMHC) all over Lebanon.  These CMHCs are located within PHCCs with some established within another community center. Furthermore, FPS continued to ‎provide MHPSS services through the CMHC at Zahle SDC in central Bekaa.‎ The community mental health teams consist of case managers, psychotherapists, and ‎psychiatrists. The FPS team also includes a nurse, whose role is to assist case managers ‎during their outreach and provision of psychotropic medication and psychoeducation for ‎beneficiaries unable to access the center.  The salaries of all the aforementioned staff are covered by both IMC and FPS respectively, allowing all MHPSS services at the centers to be provided free of charge to beneficiaries accessing these centers. In addition, psychotropic medications are procured through IMC funds, based on the essential list of medication provided by the Ministry of Public Health (MoPH) and that follows the World Health Organization’s (WHO) guidelines. Although FPS does not procure medications, FPS receives psychotropic medications from those already procured by IMC, as well as from the Ministry of Public Health (MoPH). As a result, psychotropic medications distributed to the centers are also provided free of charge at both IMC and FPS supported centers. CMHCs provide space for the provision of case management services, including ‎services for moderate to severe mental health cases. Once stabilized, the clients can be ‎referred back to the target PHCCs for follow up and continuous treatment at the PHCC level. ‎This initiative has not only expanded services at the community level to vulnerable refugees and host ‎populations but will also create a sustainable system for the provision of appropriate MHPSS ‎services by integrating the services into PHCCs.

2. PURPOSE & OBJECTIVE

The overall objective of the consultancy is to assess and evaluate the REBAHS project cost calculation effectiveness, the decreased dependency on Secondary Healthcare service due to quality Primary Healthcare service provision, and the impact of IMC's primary healthcare system strengthening activities which also includes sustainability.

THE ASSIGNMENT CONSISTS OF FOUR WORK STREAMS

Work Stream 1a – Developing Cost Forecasting Models for Primary Health Care-Based Support Packages for Services: A model will be developed that would allow IMC (and its partners) to simulate and forecast potential cost of services for selected packages in selected center, regions or nationally. The model will include an information input interface that requires certain indicators related to coverage packages and sociodemographic informartion of target population. The model will generate cost estimates with different scenarios based on the input information and modifiable metrics. The outcome of this work stream will provide IMC (and partners) with valuable cost information for evidence-based budgeting for services.

Work Stream 1b – Developing Cost Forecasting Models for Primary Health Care-Based Support Packages for Infrastructural Support: The above-mentioned model can have an add-on section that would also do budget forecast for infrastructural support, including equipment and capacity buliding. The input interface for the section will be based on a thorough baseline assessment conducted to targeted primary health care centers. The outcome of this work stream will provide IMC (and partners) with modifiable levels of infrastructural investments in targets centers, regions and nationally for evidence-based budgeting.

Work Stream 2 – Evaluating REBAHS System Strengthening Components and Potential for Sustainability: This work stream will focus on the effect that the REBAHS system strengthening components, specifically infratrsucture and capacity building, had on supported primary health care centers. The assessment will include capacity levels, range of services, enhanced capacity among others. In addition, the assessment will explore the potential for a supported center to sustain the level and range of services in a post-REBAHS phase. It will also attempt to identify areas categorized by sustainable with no, limited or modifiable support, with the nature of needed maintained support. The outcome of this work stream will be very valuable in constructing a comprehensive view of the benefit of this REBAHS component and identfying factors to support an ongoing level and range of services.

Work Stream 3 – Return on Investment Analysis of the REBAHS project: A ROI analysis will be conducted that is based on enhanced financial access provided to REBAHS beneficiaries (investment) at the primary health care level and its effect on reduced utilization of secondary, tertiary and other services (return). A sensitivity analysis will accompany the ROI analysis. The outcome of this work stream will serve to inform the donor, as well as policy makers in Lebanon (and beyond), on the utility of the REBAHS project, in terms of ROI and less pressures on already stretched health care infrastructure.

3. KEY TASKS

The assignment involves the participatory preparation and finalization of the tasks. For the assignment, it is expected that the consultant will ensure participation at ‎different levels including partners, IMC, and other relevant stakeholders. ‎

The following specific tasks are to be carried out:‎

‎1.‎    Contact with IMC and partners’ teams to:‎

o    Gather expectations for the processes and outcomes of the study

o    Review available resources for carrying out the assignment

o    Ensure common understanding on the ToR

‎2.‎    Desk review of the project’s key documents including but not limited to:‎

o    Project proposal and logical framework

o    Financial documents that include budgets, calculation sheets, projections, PHCC historical data

o    Review project standard operating procedures and conduct inception ‎meetings with project stakeholders

o    Inception Report

‎3.‎    Develop in consultation with IMC and partners a first draft Inception Report for implementation (in English) including:‎

‎3.1 Methodology, along with the suggested data collection methods and tools ‎

‎3.2 Detailed implementation plan ‎

‎3.3 Tools and templates for data analysis and reporting

‎3.4 Data entry system and analysis plan

‎3.5 Study plan for relevant review of secondary data, reports, studies, surveys.

‎4.‎    Review and finalize the Inception report for implementation based on feedback ‎collected from programme teams‎

‎4.3‎    Field manual for enumerators in English and Arabic

‎4.4‎    Final tools and templates for data collection, analysis and reporting (in both English and Arabic)‎

‎4.5‎    Final data entry and analysis plan (in English)‎

‎5.‎    Recruit, train, and manage the enumerators and data entry staff

‎6.‎    Data collection in selected PHCCs

‎7.‎    Data entry, cleaning, and analysis

‎8.‎    Render first draft report to IMC and partners for comments

‎9.‎    Finalize the  report within ten working days of receiving comments.‎

4. THE EXPECTED OUTPUT OF THE CONSULTANCY

Deliverables:

• Inception report including the proposed methodology, sample size, team composition and detailed implementation plan.
• Qualitative and quantitative data collection tools
• Qualitative and quantitative data along with summary tables and statistics
• PowerPoint presentation reflecting the findings
• A clear and concise, well-written report containing lists and tables, and facts and figures demonstrating findings per component.
• Finalized tool for budget calculation for both Mental Health and Health
• Final workshop with all partners on the findings of the assessment (cost for workshop venue to be covered by IMC)

Required Format for the assessment report:

The final assessment report will be submitted to IMC and should not exceed 30 – 35 pages (without the annexes). The final assessment report should be produced in English and must include at least the following:

• Cover page
• Table of contents
• List of abbreviation
• Executive Summary that should include major findings of  assessment including indicator table, conclusions and recommendations;
• The objectives of the assessment
• A description and justification of the methodology used, timing of assessment and challenges / limitations of the analysis
• A presentation of results and the analysis
• Challenges, conclusions, recommendations
• Annexes

Report annexes should include:

• The terms of reference for the assessment
• The data collection tools
• Budget calculation tools
• The sampling table along with the list of locations covered under the assessment
• The composition of the assessment team
• List of documents and bibliography

5. LOGISTICS

The consultants will be responsible for logistical arrangements such as transportation, communication, translation, management of data collection, and other related tasks. IMC programme teams will provide limited support on tasks related to coordination and scheduling at field level where necessary.

6. TIMELINE

IMC is expecting the completion of the consultancy tasks as described in this ToR over a maximum period of 2.5 months starting upon contract signature.

7. General Conditions of the consultancy

• The consultant will agree to abide by International Medical Corps’ code of conduct, and Child Safeguarding policy requirements.  The consultant will be orientated to these policies before engaging in data collection.
• Final payment to the consultant will be dependent on the completion of all deliverables.
• Consideration of Ethics: The consultant will ensure that written consent is obtained from all participants in the study.

8. Intellectual property rights:

All documentation including data related to the assignment shall remain the sole and exclusive property of IMC.