Term of Reference

Understanding barriers to acces health and nutrition services for children less than 5, Rwanda

Background

In Rwanda, tremendous progress has been made in improving child survival. The under-five mortality rate has declined by two thirds since 1990 (from 152 deaths per 1,000 live births in 1990 to 50 deaths per 1,000 live births in 2014/15). In spite of this rapidly declining rate of reduction in mortality, the current figures are still unacceptably high and is estimated that, approximately 20,000 children under the age of five continue to die annually from diseases like diarrhoea, acute respiratory infection, malaria and neonatal causes. Additional efforts are needed to further reduce mortality among children and mothers.

The Government has achieved this reduction by strengthening both facility and community level health systems.  As a result, 91% of all deliveries were conducted in health facilities and 93% of children aged 12-23 months have received all basic vaccines. Though these achievements are commendable, there are substantial gaps like, 81% of newborns have not received postnatal care in the first 2 days after birth, over one-third of children estimated with severe acute malnutrition did not receive appropriate treatment , and considerable proportion of children under age 5 who had symptoms of acute respiratory illness (46%), diarrhoea (56%), and fever (51%) have not received advice or treatment from a qualified provider. Only 55% of children under 15 years of age living with HIV were on antiretroviral therapy.  In order to increase the coverage for these interventions it is essential to understand the barriers that prevent access to health services.

Access is more than simply the opportunity to use healthcare services.  It is a multidimensional concept based on the interaction between healthcare systems and individuals, households and the community.  Access can be seen to have several core dimensions: availability; affordability; approachability; appropriateness; and acceptability.  While Rwanda’s health system has progressively improved in various of these dimensions, it is important to understand the barriers that still impair access to health services so that appropriate policies and strategies can be identified to address them. This assignment will focus on understanding the barriers to access health and nutrition services for children less than 5 years of age.

Objectives, Purpose & Expected results

The primary objective is to understand the barriers for children under 5 years of age and their care givers to access health care services for various health and nutrition interventions.

The purpose of this assignment is to design, collect data, analyse data, make qualitative follow-up and write a report to address the objective defined above. The end product will be a final report that is approved by Ministry of Health (MoH).

Description of the assignment

This assignment will focus on the perspective of children under 5 years of age and their care givers as recipients/targets of health care services for accessing preventive and curative interventions for various childhood illnesses including malnutrition. As noted above, the assignment will look at access to health care from the dimensions of availability, affordability, approachability, appropriateness and acceptability. Availability is the degree of fit between suitable healthcare services and providers being at the right place and at the right time, and the prevailing needs of the population.  Affordability is the degree of fit between the full and accumulative costs to the individual using a service, and that individual’s ability or capacity to pay in the context of their household budget.  Approachability is the degree of fit between the healthcare services and providers in place, and the identification or recognition of such services by individuals, households and communities who may require them.  Appropriateness is the degree of fit between both the content (quality) and delivery of services, and the expectations of individuals, households and communities who may seek care.  Acceptability is the degree of fit between the mutual expectations of the provider and (potential) patient, and an individual’s, household’s and community’s attitude towards the healthcare system.

This assignment will identify challenges, objective barriers and potential enablers for accessing quality health and nutrition services for all the dimensions listed above. The assignment should include a framework that captures information about the characteristics of the children and their caregivers (age, sex, education, economic category, urban or rural, etc.), the nature of the child’s/mother’s health or nutrition problem (e.g. acute respiratory infection, diarrhoea, malaria, severe acute malnutrition, neonatal illness, etc.), interventions that need to be provided to every child or caregiver (e.g. immunization, vitamin A, deworming, growth monitoring, screening for malnutrition, education on infant and young child nutrition, antenatal care, iron and folic acid during pregnancy ,etc.), and the types of health service provider (e.g. community health worker, health post, health centre, district hospital, etc.).

The methodology of the assignment encompasses a quantitative component (desk review of data and the household survey) and two qualitative components: (1) a qualitative assessment of healthcare workers in some target areas and basic health facility assessment; and (2) post-survey focus group discussions in target communities to better understand what the survey results revealed.

The sample of communities/households is tentatively expected to be taken from one cell in each of five provinces of the country and their nearest health facilities (health post/health centre/hospitals). The assignment should offer guidance on the sampling. The assignment does not aim to be nationally or regionally representative but illustrative. Household questionnaires should require no more than 45 minutes to administer.

Some of the key clinical conditions or interventions that need to be considered for assessment are:

-Children under 5 with diarrhoea

-Children under 5 with malaria

-Children under 5 with acute respiratory infections

-Children under 5 for 2 doses of Vitamin A and deworming

-Children under 5 with severe acute malnutrition

-Children under 2 for growth monitoring and screening for malnutrition

-Children under 2 for education on infant and young child nutrition and seeking health care

-Children under 2 for full immunization

-Children below 28 days for neonatal illnesses (preterm babies, neonatal jaundice, neonatal asphyxia, etc.)

-Children below 28 days for postnatal care

-Children under 15 with HIV

-Pregnant women for early ANC

-Pregnant women for 4 or more ANC

-Pregnant and lactating women for iron & folic acid

This assignment will be carried out through a desk review, a household survey, qualitative assessment of health workers, post-survey discussions with target communities, and discussions with UNICEF, MOH and other key partners.

 The main tasks involved are:

•Discuss and confirm the scope of the assignment with UNICEF and MOH. This particularly includes the purpose of the study and the structure/content of the Deliverables (see below).

•Review relevant documents, other related health research and documents from Rwanda, and examples of similar research from other countries and the research tools used to inform the development of the design.

•Draft the design (see Deliverable 1) and agree with UNICEF and MOH before moving on.

•Develop tools and protocols for desk review, household survey, and qualitative assessments among healthcare workers and target communities (see Deliverable 2).

•Conduct a desk review of available quantitative and qualitative data from Rwanda, including data from DHS and health management and information system (HMIS).

•Conduct a household survey from one cell in each of four provinces and city of Kigali.

•Conduct qualitative assessment of healthcare workers, basic health facility assessment and post-survey focus group discussions in target communities.

•Analyse the data and provide a draft report for initial feedback from UNICEF and MOH (see Deliverable 3).

•Share a revised draft report with UNICEF, MOH and partners, revise based on feedback, and validate the findings through a consultative forum and produce a final report that is approved by MOH (see Deliverable 4)

Deliverables

There are four Deliverables associated with the assignment:

Deliverable 1: Inception report that includes the design approved by appropriate forums within MOH, including review/feedback

Deliverable 2: Agreed instrument protocol for field work and data collection that include tools and protocols for quantitative and qualitative data collection and analysis approved by appropriate forums within MOH, including review/feedback

Deliverable 3: Draft final report on finding and recommendations and summary presentation

Deliverable 4: Final report approved by appropriate forums within MOH, after validation and incorporating feedback

Deliverable 1: The design overview can be a fairly short document (e.g. 5 pages) presenting a snapshot (narratively and/or diagrammatically) of the study including objectives, key research variables/questions, comments on methodology and proposed sample (options), timeline and points for decision/agreement before moving to other deliverables. This may be revised through discussions with UNICEF, MOH and partners. The design will need to be approved by the appropriate forums within MOH (Technical Working Groups/Steering Committee).

Deliverable 2: Based on approved design, tools and protocols for quantitative and qualitative data collection and analysis need to be developed. The tools and protocols should translate all of the methods in the design into specific data collection and analysis instruments to be used as part of the assessment. These tools and protocols for desk review, household survey (including questionnaire), and qualitative data collection, and analysis may be revised based on discussions with UNICEF, MOH and partners. They need to be approved by the appropriate forums within MOH (Technical Working Groups/Steering Committee).

Deliverable 3: After completion of data collection and analysis as per the design (deliverable 1) a draft report and a summary in the form of powerpoint presentation will be produced. As a minimum, the draft report and the presentation should consist of the following, unless otherwise agreed between UNICEF and MOH in writing:

•Executive summary

•Background

•Methodology

•Findings

oAvailability

oAffordability

oApproachability

oAppropriateness

oAcceptability

•Analysis and discussion

•Conclusions and recommendations with a focus on improving implementation

•Attachments including TOR, tools and protocols

Deliverable 4: Based on feedback from UNICEF, MOH and partners, approval/validation from the appropriate forums within MOH (Technical Working Groups/Steering Committee) a final report will be submitted. The final report should include, progress reports and minutes of meetings, mission reports, technical reports, training material, presentation material, workshop/training evaluation reports, and other relevant reports. The database should also be submitted along with the final report.

The write up of all deliverables above should be in clear language so that they can be easily understood, avoiding long sentences, jargon, abbreviations and technical terms to the extent possible, and should as necessary define the terms used. As appropriate, the deliverables must also contain tables, charts, diagrams or other visual materials to illustrate.

Reporting requirements

List the reports to be prepared during the assignment as well as deadlines for submission; it includes requirements such as contents, number of copies, language, who should receive the reports and whether they should be submitted electronically (specify the file format; e.g. "pdf"), in hard copy, or both.

Potential types of reports are:

• Inception Report
• Progress Reports and Minutes of Meetings
• Mission Reports
• Technical Reports
• Draft and Final Report
• Training material
• Presentation material
• Workshop/training evaluation report

Location and Duration

The following is an indicative timeframe, spread over roughly 4 months; deadlines will be specified in the contract. The contract is expected to be signed in June 2018 with the aim to complete the entire assignment by end of September 2018. The tentative timeframe for various components will be given in the final selected bid document with respect to four Months period. The various components will include but not limited to signing contract, discussions with UNICEF, MOH and document review; design submitted to UNICEF and MOH and agreed; tools and protocols developed and agreed; desk review and field work of survey; initial tabulation available and tools for qualitative analysis developed; Qualitative field work conducted; draft report submitted for review; all deliverables finalised based on comments from MOH and UNICEF.

Qualification requirements

UNICEF anticipates hiring an institution consultant with the following qualifications:

Mandatory Qualifications - required in order to be evaluated

Minimum 3 years experience in designing and conducting surveys on barriers to access services and analysis in developing countries. 

Desired qualifications

• Experience with barriers to access services and analysis among children under 5 years of age.
• Experience with barriers to access services and analysis in Rwanda will be an added value.
• Capacity with a professional team able to carry out the scope of work with similar complexity
• Demonstrable experience producing similar documents
• All team members should have excellent English writing/communication skills. The team members’ composition should take into consideration, according to the specific areas of intervention, the necessity of communicating in Kinyarwanda. 
• The Team members proposed by the institution should include the following:

• Team Leader should have 10 years’ minimum experience in coordinating and participation in similar assignments
• Public Health expertise with minimum of 10 years’ experience in works like this in Rwanda
• Research expertise, both quantitative and qualitative, with at least a basic understanding of statistical and sampling techniques, including interview and focus group discussion experience
• Data analysis expertise with a minimum of 10 years of experience, preferably in health
• Data collection expertise with at least five years’ experience
• Other than surveyors, all team members should hold at least Masters’ degrees
• Strong writing skills in English with a clear, straightforward writing style
• Familiarity with academic research on health issues in Low and Middle Income Countries, such as morbidity/mortality and access to services
• Exceptional analytical, quantitative and summarising skills
• Hands-on experience with the implementation capacities and constraints of governments in developing countries, particularly Low and Middle Income Countries in Africa
• Experience with WHO, UNICEF or other international health bodies

The Firm must be aware of the conditions of each site/region of intervention. In some circumstances, particular logistic arrangements are required.

Therefore, in presenting proposals, bidders should take these elements into serious consideration. UNICEF is not responsible for any unexpected additional cost or arrangement required during the implementation of the assignment.

Evaluation process and methods

Separate Technical and Financial proposals should be submitted in sealed envelopes. A two-stage procedure shall be utilized in evaluating proposals, with evaluation of the technical proposal being completed prior to any financial proposal being compared. A 80/20 assessment model for the technical and financial proposal respectively will be adapted. Bidders must score a minimum of 64 points on the Technical Proposal and meet the Mandatory Qualifications to be considered technically compliant for the component, and for the Financial Proposals to be opened.

The criterion to be used for the evaluation of proposals is outlined in the below :

1.Technical proposal:

a) Narrative proposal of maximum 10 pages including at least: Firm expertise and experience, Proposed approach and methodology including proposed timeframe for each deliverable, Proposed team structure/responsibilities and expertise/experience. The technical proposal should include a staffing structure, including details of days per team member articulated against a workplan of activities.

b)Annexes: Workplan of scheduled activities and CVs of all team members can be included as Annexes, in addition to the maximum 10 pages of narrative.

2.Financial proposal:

a.      All bidders must submit a stand-alone budget for: a) Staffing by team member, b) Direct Costs, and c) Indirect Costs.   

TECHNICAL EVALUATION

  OVERALL RESPONSE & METHODOLOGY

Max score

MAX 40

MIN 28

Understanding of scope, objectives and completeness of response

MAX 10

Quality of the proposed approach and methodology

MAX 20

Quality of proposed implementation plan, i.e. how the bidder will undertake and staff each task, and time-schedules, risk assessment

MAX 10

2.PROPOSED TEAM and ORGANISATIONAL CAPACITY

MAX 40

MIN 28

Leadership Skills: In Team Leader, Relevant leadership/management experience, skills and qualifications (Team leader should also hold one of the technical skills. Team Leader role will be scored separately from technical skills, below.)

MAX 10

Technical expertise: public health/research expertise on survey design and data collection; Relevant experience, skills & qualifications

MAX 10

Technical expertise: public health / research expertise on analysis and report writing; Relevant experience, skills & qualifications

MAX 10

Organization of the team, roles & responsibilities and presence in Rwanda

MAX 10

TOTAL MARKS FOR TECHNICAL COMPONENT A

MAX 80

MIN 56

3.      FINANCIAL PROPOSAL – Full points are allocated to the lowest priced proposal that meets the minimum score on the technical proposal. The financial scores of the other proposals will be in inverse proportion to the lowest price.

MAX 20

MIN: N/A

TOTAL MARKS 100

Financial Proposal Format:

                          FINANCIAL PROPOSAL FORMAT (IN EXCEL SHEET)

Deliverable; Payment proportion;Cost

Deliverable 1: 20%; COST

Deliverable 2: 25%; COST

Deliverable 3: 30%; COST

Deliverable 4: 25%; COST

Administrative issues

• Interviews if necessary indicating for which experts/position (in general, the evaluation of experts is conducted on the basis of their CVs).
• Whenever possible, bidder should be requested to provide an all-inclusive cost in the financial proposal.  Bidder should be reminded to factor in all cost implications for the required service / assignment
• When travel is expected as part of the assignment, it shall be clearly specified (e.g. location, duration, number of journeys …etc.) in the TOR.   Bidder shall be required to include the estimate cost of travel in the financial proposal.  It is essential to clarify in the TOR that i) travel cost shall be calculated based on economy class travel, regardless of the length of travel and ii) costs for accommodation, meals and incidentals shall not exceed applicable daily subsistence allowance (DSA) rates, as promulgated by the International Civil Service Commission (ICSC).
• Unexpected travels shall also be treated as above.

Project management

 UNICEF will issue the contract and pay the institution, based on the payment schedule mentioned below and after the approval of the deliverables by MOH and UNICEF. UNICEF’s Health Specialist - in collaboration with MOH - will manage the contract and be the focal point for all contractual matters.

The institution will be responsible for all logistical arrangements associated with this contract. UNICEF / MOH will provide a letter of support to facilitate obtaining visa and for the purpose of field visits where needed (for quality assurance). Other expenses such as international and local travels, visas, banking/cash services, or office space and equipment (including computers and photocopiers) shall be under the responsibility of the institution.

For all contractual issues, the institution will report to UNICEF. For technical issues, the institution will work directly with the technical team, led by UNICEF and MOH. All deliverables must be approved by MOH and UNICEF in order to be considered final.

The institution is expected to use his or her own equipment, including computers. UNICEF premises will be available for the meetings and collecting inputs from other partners.

The institution shall not make use of any unpublished or confidential information, made known in the course of performing duties under the terms of this agreement, without written authorization from MOH/UNICEF. The products of this assignment are not the property of the institution and cannot be shared without the permission of MOH/UNICEF. The institution shall respect the habits and customs of the local population and abstain from interfering in the country's political affairs.

The institution shall abide by and be governed by UNICEF Procedure on Ethical Standards in Research, Evaluation and Data Collection and Analysis which can be accessed here: https://www.unicef.org/supply/files/ATTACHMENT_IV-UNICEF_Procedure_for_Ethical_Standards.PDF

Payment Schedule

Deliverable

Payment proportion

Deliverable 1: 20%

Deliverable 2: 25%

Deliverable 3: 30%

Deliverable 4: 25%

HOW TO APPLY:

Qualified institutions shall submit their offers Technical and Financial in separate files to the following email: [email protected]

The deadline for submission is 15 June 2018, 5pm Kigali time.