Assessment Of Referral Mechanism – Primary To Secondary Health Care Including Emocnc

Terms of Reference (ToRs) Assessment of referral mechanism – Primary to secondary health care including EmOCNC   United Nations Population Fund Ministry of Public Health Lebanon    Background   Referral health care may be defined as care that cannot be provided at Primary Health Care level (PHC). PHC refers to health care provided in the community for people making an initial approach to a medical practitioner for advice or treatment. If medical conditions cannot be managed at the PHC facility level, referral for emergency or essential medical, obstetric and surgical care to the nearest appropriate secondary or tertiary health care facility is required. In many situations, emergency referral is also required to treat life threatening and lifesaving conditions. PHC policy will neither be understood nor accepted by beneficiaries without a proper system to access care for more complex cases, hence, the humanitarian, political and economic importance of referral health care should not be underestimated. Referral systems must take into account local demographic characteristics and burden of diseases as well as the level of development of the country’s health system. Factors that must be considered include issues related to co-payment, specifics related to various diagnostic and treatment algorithms, and treatment of chronic diseases (e.g. diabetes, kidney insufficiency, cancers). The availability, capacity and cost of existing country referral facilities are crucial. Various elements for referral should be in place such as timing, complexity of the condition, decision making, clarity of information, necessary logistical measures, etc.  Patients requiring health care not available at the PHC level are therefore referred to a higher level of care which can be divided into secondary and tertiary health care. Secondary health care is an intermediate level of health care that includes diagnosis and treatment performed in a hospital or health center having advanced services through specialized personnel, equipment, laboratory facilities, bed facilities, etc. Tertiary health care is more specialized medical care for patients who are usually referred from secondary care centers. It includes subspecialty expertise in surgery and internal medicine, diagnostic modalities, therapeutic modalities for treating advanced and/or potentially fatal diseases among others.   Emergency Obstetric and Newborn Care (EmOCNC) can be divided into basic and comprehensive obstetric care. Basic EmOCNC is critical to reducing maternal and neonatal death and can be provided with skilled staff in health centers, large or small. Comprehensive EmOCNC is typically delivered in hospitals. However, the types of upper levels of care are usually defined by the Ministry of Health of each country in terms of specialization of the services provided, staff profiles and complementary examinations.    Continuum of care is a concept involving an integrated system of care that guides and tracks patients over time through a comprehensive array of health services spanning all levels of intensity of care. In general there is a need to define the roles and to coordinate activities among the various health sub-systems to reduce duplication and waste of the limited resources and to standardize and improve the quality of health care in Lebanon.   In 2009, the Lebanese Ministry of Public Health (MOPH) launched the PHC accreditation program to expand and improve quality across the continuum of care.[1] Secondary and tertiary health care facilities in Lebanon are mostly private and cost is a significant barrier to accessing quality health care specifically for the poorest Lebanese and other vulnerable populations including the Syrian refugees. Accordingly, MOPH has ensured equal access to Syrians through its existing infrastructure at all levels of healthcare; which has further imposed a huge burden on the secondary and tertiary health care facilities specifically.   In parallel, UNHCR has been applying a cost sharing modality consisting of absorbing 75% of the fee for service for Syrian refugees at selected MOPH primary health care PHC centers in addition to providing support to secondary and tertiary health care. In 2014, UNHCR provided financial support to 55,566 cases for secondary and/or tertiary care services. Most of the referrals – about 55% - were for obstetric care, of which 36% of obstetric referrals resulted in a C‐section.   One of the existing referral mechanism established in collaboration with the MoPH and that has been serving vulnerable communities is the Makassed Communal Health Care Bureau (MCHCB). MCHCB was established in 1983 with the aim to provide medical and preventive health services. Working across six centers currently and a hospital, MCHCB in addition to standard PHC services provide services for normal deliveries at center level (Wadi Khaled) and hospital level, stabilization of difficult deliveries and safe transportation to a contracting hospital at the account of the center, guarantee access to all new born who need admission to a contracting hospital and provision of needed vaccination for children. During Syrian crisis Makassed has been providing a continuum of care to Lebanese and Syrians population at primary & secondary health care level.   Moreover in September 2014, through the support of MOPH, MCHBCB also replicated the above mentioned “Mother and Child Health Care” initiative, aiming to provide quality primary healthcare services to hundreds of mothers and children in three Lebanese target areas: Beirut, Bekaa and the North. The aim of the initiative is to alleviate the impact of the Syrian crisis on Lebanon by strengthening the public healthcare system’s capacity to provide full healthcare services for non-insured pregnant women living in the selected areas, including antenatal and delivery services in addition to child healthcare and vaccination for children up to twenty four months of age through: -     Empowering primary health care centers operating in the catchment area of each hospital and enable them  provide Prenatal care for pregnant and ensure a well-baby development   -     Putting in place a well-established referral system between the hospital and its satellite health care centers   Availability of data on the continuum of care across the referral care from PHC centers through the array of secondary and tertiary health services is limited in Lebanon. Various studies have been launched to assess the quality of services at both PHC and hospital level (2007 & 2009 respectively)[2].               Goals and Objectives   The purpose of this assessment is to contribute to the improvement of quality, efficient, timely and sustained referral mechanism from primary health care to secondary level including for emergency obstetric and newborn care (EmOCNC).  As such, this assessment will allow the identification of critical gaps that would require enhancement and strengthening within the existing health referral mechanism   More specifically, the key objectives of this assessment will aim at providing the following information in relation to continuum of care across the referral care from PHCCs through the array of secondary health services in Lebanon:     Knowledge & perception of the service providers at the primary and secondary health care levels about the existing referral mechanism including minimal operational standards, related statistics and service provision. Knowledge & perception of the beneficiaries at the primary and secondary health care levels about the existing referral mechanism in place in terms of quality, efficiency, timeliness, etc. Availability of any other existing operational referral care system (Makassed organization) with details on its functional processes & effectiveness pertaining to referral care.   Tasks description Under the guidance of UNFPA office and MoPH, a consultant will be contracted to carry out the following tasks:   Carry out any existing relevant literature review in regards to referral care in general and to MOPH Lebanon in particular (MoPH standards and policies on referral, accreditation guidelines and operational standards by MoPH, MCH initiative report by Makassed/MoPH) Develop a detailed timeline for the consultancy/assessment as agreed with UNFPA/MOPH. Conduct two facilitative meetings with UNFPA/MOPH at the beginning and end of assignment. Conduct one interview with MoPH nominated representative regarding referral mechanism from primary to secondary health care including for EmOCNC. Conduct five interviews with MoPH PHC - Universal Health Coverage Centers[3] (UHC) representatives and conduct five interviews with referral hospital representatives. Conduct four interviews with beneficiaries at each UHC & hospital. . Conduct one interview with private NGO (Makassed) representative Conduct four interviews with beneficiaries at Makassed PHC & its referral hospital regarding referral including for EmOCNC. Develop two tools (interview questionnaires) for the proposed assessment. Conduct field visits as required to selected areas for the proposed assessment. Consolidate the data collected and provide detailed analysis as part of final draft report. Ensure timely delivery of a comprehensive final report based on UNFPA’s feedback. Methodology The methodology will consist of the following: Conduct meetings with stakeholders (with MOPH, WHO and UNHCR) as needed. Identify and select five UHCs and referral hospitals based on selection criteria (to be discussed with UNFPA and the Ministry of Public Health). Within each UHC & hospital the target groups will consist of one  service providers (i.e. representative) Four beneficiaries per UHC & hospital. Semi structured questionnaires shall be applied for the service providers Semi structured questionnaire shall be applied for beneficiaries. Expected Outcome The consultant shall deliver a comprehensive assessment report in English (30-40 pages excluding annexes and references) based on the objectives and requirements set forth in the Terms of Reference. The report will constitute the final outcome of this consultancy and suggested to consist of the following sections (the final structure of the report will be discussed and agreed upon between the consultant and UNFPA): Overview and background of the assessment; Methodology, data collection procedures, and data analysis plan; Findings and discussion including challenges, lessons learned, and suggestions for scaling up; Conclusion and recommendations; List of annexes (if any); References   The consultant will also prepare and share a brief Power Point in English on the assessment (i.e. methodology, results and recommendations) as well as and take part in a one meeting for sharing the results of the assessment.   Duration of Assignment The assessment should be concluded within two months from the signing of the contract. UNFPA responsibilities Review the TORs and clarify the deliverables Provide consultant with necessary and relevant documents Facilitate consultant’s contact with the main stakeholders (MoPH, UNFPA, Makassed, other) Participate in the meetings where feasible  Suggest mitigation and approaches for overcoming any bottlenecks  Provide input on the data collection tools, data collected, draft report and the power point presentation. Qualifications Advanced University degree (MPH/MS) in public health/social and/or development sciences or other related areas with previous work experience and considerable skills in survey design, analysis and report writing; Strong background understanding of Lebanese health system; Strong background in health and/or Maternal and Reproductive Health; Good  knowledge in humanitarian contexts and familiarity with humanitarian related resources and material; Excellent interpersonal skills and ability to establish effective and working relations with other stakeholders; and Excellent written and spoken communication skills in Arabic and English. HOW TO APPLY Interested candidates may apply online by providing: (1)   a P-11 Form (click to download), and (2)   a most updated CV, and (3)   a cover letter mentioning the relevance of past/current experience with the requirements of the consultancy.   The above documents must be sent to the following email address: info-lebanon@unfpa.org by no later than September 23, 2015 Candidates who fail to submit the required documents above will not be considered for review. Only those applicants in whom UNFPA has expressed interest shall be contacted within a maximum of 5 working days following closure date.   [1] MoPH strategic plan 2007 [2] Health Reform in Lebanon: Key Achievements at a Glance   http://www.moph.gov.lb/Media/Documents/dg08014.pdf [3] Universal health coverage centers (UHCs) – are MoPH PHCcs that are currently being upgraded and accredited to provide a range of preventive and curative services for vulnerable Lebanese populations.