Médecins Sans Frontières
Start date: Early April 2024
Duration: Final report to be submitted by July 2024 (date TBD)
Requirements: Interested applicants should submit 1) a technical proposal, 2) A financial proposal, 3) CV(s), and 4) a previous (relevant) work sample
Deadline to apply: 2359hrs CET on March 26, 2024
Apply to: [email protected] BEIDE
Note: We value quality over quantity. Providing only the requested and necessary documentation should prove your interest, capacity, and competency in the best possible manner. The evaluation will require a site visit to the project, which will be planned during the initiation phase, through discussions with the project, the Consultation consultation group, and the SEU.
–> Download the ToR for more information via our website**:** https://evaluation.msf.org/call-proposal-evaluation-decentralization-component-through-mentoring-msf-ocbs-project-beira. <–
BACKGROUND
Mozambique’s health care system was after its independence in 1975 considered by the WHO as a best-case model for other developing countries.[1] A civil war in the mid-90s has slowed down its progress, and today’s health care service provision is experiencing severe challenges. Limited medical supply, understaffed health care facilities, poor motivation of health care workers, and a lack of adequate training reflect barriers to establish quality health services within the local health structures.[2] The COVID COVID-19 pandemic has worsened the situation and burdened the already fragile health system.[3] The country has increased its internal funding of health expenditure. In 2019, 79% of health expenses were financed internally, the rest (21%) was funded by external sources.[4] Nevertheless, poor governance and management, resource mobilization[5] as well as gaps in documentation of the use of health funding[6], are further influencing a low level of quality health care.
Mozambique has the second highest number of people living with HIV (PLHIV) in Sub-Saharan Africa.[7] 12.4% of the adult population (15-49 years) was living with the virus in 2022.[8] HIV is the leading cause of mortality and morbidity in the country.[9]CD4 testing was introduced in Mozambique in 2003, a Test-and and-Treat approach was adopted in 2016 and the routinely identification of Advanced HIV Disease (AHD) in patients was finally established in 2022. Based on an internal assessment from the Ministerio de Saude de Mozambique (MISAU) in 2022, 25% of PLHIV newly initiated on Antiretroviral Therapy (ART) were AHD patients.[10] This is in line with the global estimations of people with AHD in need of specialized services, as studies have estimated that over 30% of PLHIV in low- to middle-income settings initiating Antiretroviral therapy (ART) have a CD4 cell count lower than 200 cells/mm3.[11]
The country’s HIV prevalence among Key Vulnerable Population (KVP), (Female Sex Workers (FSW), Injectable Drug Users (IDUs), Prisoners, and Men who have Sex with Men (MSM)) tend to be higher compared to the general population (GP). 19% of new HIV infections occur among FSW, clients of female sex workers, and partners of sex workers[12], 5% among MSM[13].
Sofala province lies in the middle of the country and shows a HIV prevalence higher than the national level of 13.2%. Beira town is the capital of and largest city in Sofala province with an estimated population of 719 719,806 inhabitants in 2022 and an HIV prevalence of 13.4%.[14] 84 84,890 PLHIV were on ART in 2020.[15]
In terms of the KVP in Beira, MISAU estimated the HIV prevalence around 24% among FSW[16] and 9.1% among MSM[17]. From 2014 until August 2023 MSF had 7,080 KVP enrolled and followed up, with a self-assessed overall HIV prevalence of 21.4%. The HIV prevalence among FSW was 39.1%, among MSM 9%, and among transgender groups (TG) 29%.[18] HIV services for KVP remain largely inadequate and they face access barriers to health services, for MSM particularly due to stigma and discrimination.
MSF History in Beira
In 2014, MSF started working in Beira as part of “the corridor project”. This project offered a contextualized and comprehensive package of care to KVP along a major transport corridor running through Mozambique, Malawi, and Zimbabwe. KVP targeted in this project included FSW, MSM and workers workers-in in-mobility (i.e. truck drivers i.a). In 2015, MSF started to intervene in two primary Health Centers (HC), ) – Munhava and Ponta Gea, – supporting MISAU in the implementation of specific HIV HIV-related activities including routine Viral Load (VL) monitoring and pharmacy management, targeting KVP. In 2017, the corridor project evolved to deliver a quality and tailored package of HIV prevention and treatment, as well as Sexual and Reproductive Health (SRH) services, to KVP. The corridor project was handed over to FHI360 due to the low feasibility to follow the target population crossing borders, and therefore attain continuity of care. ThoughHowever, MSF continued to work with KVP in Beira on at community level.
In 2018, MSF activities were reoriented with the overall objective to reduce morbidity, mortality, and incidence of HIV among KVP in Beira (including FSW, youth at risk, MSM, and TG) as well as the general population with AHD. The intervention areas of this new project focused on AHD-, TB-, SRH-, KVP KVP-friendly services on three levels: (1) Community, (2) Munhava and Ponta Gea HC, and (3) Beira Central Hospital (BCH).
MSF has been working alongside MISAU to ensure replicability of the activities, experience and skills sharing, intending to influence sustainability of the intervention’s outcomes. MSF activities in Mozambique, specifically MSF protocols and tools have influenced the national guidelines on KVP services, sexual and reproductive health (SRH) including safe abortion care (SAC), and AHD care that were finalized in 2020.[19]
In 2021, MSF concluded that it was not viable to keep a traditional clinic-centered approach for HIV. It was decided to widen MSF support to primary health care level but apply a less hands-on approach. Under the main objective to expand and improve access to health services on primary health care level for KVP, SRH and AHD patients, the project was in 2021 again restructured into now two main components:
- Decentralization component including the support to 10 HCs focusing on KVP KVP-friendly services, SRH and AHD services., and
- (2) Vertical AHD services provided at BCH and Munhava HC.
The targeted population also includes the general population, assuming increased capacity of healthcare staff impacts the general population of Beira.
In 2022, MISAU started to implement the new guidelines in BCH and Munhava HC with support from MSF and the ambition to later expand to other HC in Beira. MISAU’s plan to roll out the new guidelines on primary health care level did experience difficulties and has not yet been finalized. MISAU further requested MSF to help with the reactivation and improvement of the national tutoring system.
Decentralization Component of The Project
The decentralization component of the project aims primarily at sharing technical experience, empowering the HC staff, and improving their awareness about the impact the services have on the patient’s life. MSF does not provide direct medical services but focuses on capacity building as well as punctual support in logistics and medical supply in 10 selected HC in Beira town (Nhaconjo, Chingussura, Inhamizua, Ponta-Gea, Macurungo, Manga Loforte, Mascarenhas, Cerâmica, Nhangau, and Marrocanhe). AHD consultation per month varied between 10 to 80 in 2023, between the different HC. From 2022 to mid-2023, a total of 6 346 women received SRH services.[20] KP KP-specific data about service use are not available so far.
Mentoring Program
Capacity building has been a central element in all components of the project with the aim of achieving continuity of quality services. Nevertheless, little success in influencing health worker’s skills and performance has been observed before the reorientation towards decentralization. Current evidence points strongly towards the need for teaching and learning to happen in the workplace to be effective, far more than in a classroom setting. Clinical mentoring programs are designed to this educational approach. MSF therefore decided to develop a proper mentoring program including training, mentoring, and supervision of health care workers, aiming to influence knowledge, skills, and attitude while using a staff-oriented, adult-learning approach.
The mentoring program consists of training packages on KVP KVP-friendly, SRH, and AHD services and was implemented stepwise from May 2021 to September 2023 in all 10 HC. The program spanned over 6 months in each HC, passing 5 five phases, and targeted mainly clinical and patient support health care staff. Since its start, about 150 health care staff were fully involved in the program, becoming so-called mentees.
The 5 five phases include a pre-mentoring phase (2-4 weeks) to assess needs and assess resources. A training phase (3-5 days) then transmits specific training packages on SRH, KVP, AHD and additionally on laboratory. The mentoring phase (4 – -14 weeks) consists of a daily companionship of the mentees to support the implementation of the gained knowledge and to create a learning environment. In the follow-up phase (3-6 months) mentees are continuously supervised through the conduction of weekly case discussion, monthly feedback sessions and support by phone if needed. Finally, in the replication phase prospective mentors are selected within the mentees, to attend a training training-of of-trainer workshop. These mentors will then start the replication.
[FIGURE MISSING – PLEASE SEE IN TERMS OF REFERENCE]
With the end of the mentoring program, the decentralization component of the project will have completed its activities by mid-2024. On-demand support for the 10 HCs will continue and collaboration with community actors will be maintained. MSF will further support MISAU in the implementation of the AHD, SRH and KVP guidelines on primary health care level.
PURPOSE AND INTENDED USE
PURPOSE. The evaluation will assess the overall results of the decentralization component with a specific focus on the mentoring program. It should further document lessons learned and elaborate recommendations for other decentralization initiatives through mentoring in MSF contexts.
INTENDED USE. The evaluation findings will be used by MSF and possibly other actors (iee.g. MISAU) to inform decentralization efforts in MSF contexts. The evaluation process and its recommendations will further provide guidance for possible adaptations of Beira project’s strategy.
EVALUATION QUESTIONS
1. To what extent is decentralization through mentoring relevant and appropriate?
- Was the decentralization component appropriately responding to the needs of the target population?
- How was the decentralization component aligned with priorities of relevant stakeholders?
- Which opportunities could have improved appropriateness of the decentralization component?
2. To what extent was decentralization through mentoring effective?
- What were the expected results of the decentralization component?
- To what extent was improved knowledge, skills, and attitude of the targeted healthcare staff achieved? In what way were expected patient’s health outcomes achieved?
- How could the decentralization component have increased its effectiveness?
3. To what extent has decentralization through mentoring influenced larger contributions (impact), perceived by different stakeholders?
- What unforeseen positive or negative consequences did the decentralization component influence?
- How could a wider positive (systemic) change have been increased?
4. To what extent is decentralization through mentoring coherent within its broader context?
- In what ways were synergies with local resources and interventions considered and interlinkages (internal and external) established?
- What could have improved coherence?
5. To what extent is decentralization through mentoring replicable?
- In what ways was replicability of the project’s component considered in its implementation?
- To what extent is the decentralization component replicable by MISAU?
- To what extent is the decentralization component replicable by MSF?
EXPECTED DELIVERABLES
1. Inception Report
Based on conducting initial document review and preliminary interviews, the inception report should include a detailed evaluation proposal, including methodology and analysis.
2. Development of a Theory of Change
This is advised to be done in parallel with or before the finalization of the inception report. It should provide a visual on the causal links and assumptions of the project’s elements in relation to its main objectives.
3. Draft Evaluation Report
The report should answer the evaluation questions addressing the set objectives and intended use of the evaluation. It should include analysis, findings, and conclusions and, where applicable, lessons learned and recommendations.
4. Working Session
As part of the report writing process, the evaluator will present the findings, collect attendances´ feedback and will facilitate discussion on lessons learned with the attendance of commissioner and consultation group members in one or more working sessions.
5. Final Evaluation Report
The final report should consider comments and feedback received during the working session.
6. Dissemination
To be defined in a separate dissemination plan, can include presentations, learning sessions, meaning-sensemaking exercises, or other communication materials with partners, communities, or patients.
We expect the evaluator(s) to be flexible in considering additional deliveries that might be necessary to successfully proceed in the evaluation process. Each deliverable is reviewed by the SEU and approved by the Evaluation Commissioner.
TOOLS AND METHODOLOGY PROPOSED
In addition to the initial evaluation proposal submitted as part of the application, a detailed evaluation protocol will be prepared by the reviewers during the initial phase, following access to the documentation and initial discussions with the evaluation consultation Consultation group Group (CG). The initial report will include a detailed explanation of the proposed methods and their rationale based on validated theories. It will be reviewed and validated as part of the creation phase in coordination with the SEU.
RECOMMENDED DATA SOURCES
- Routinely collected medical data (raw and aggregated data from MSF, ECHO or MISAU).
- MSF and OCB strategic and project documents (project descriptions, logical frameworks, operational strategies, annual reports, capitalization reports, evaluations, research and similar).
- National, regional, and global strategies, thematic documentation, and guidelines.
- External literature, research, and documentation.
PRACTICAL IMPLEMENTATION OF THE EVALUATION
Number of evaluators: TBD
Timing of the evaluation: March – July 2024
The SEU engages a Consultation Group (CG) in this assessment process with the goal of increasing understanding, buy-in, process learning, and the quality and utility of the evaluation. The CG is headed by a commissioner. They contribute to the finalization of this ToR.
PROFILE/REQUIREMENTS FOR EVALUATOR(S)
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Requirements:
- Proven evaluation competencies;
- Degree in public health, health service management, epidemiology, or related area;
- Experience in HIV patient care, service provision or similar;
- Experience in capacity building, mentoring or similar educational approaches; and
- Fluency in Portuguese, and English.
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Assets:
- Experience and/or understanding of MSF.
- Experience in Southern Africa region, specifically Mozambique.
- Expertise in Advanced HIV Disease service management/provision.
- Experience working with Key Vulnerable Population (FSW, MSM, or others).
- Expertise in SRH service management/provision.
- Expertise in participatory approaches.
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[1] Pfeiffer 2003. International NGOs and primary health care in Mozambique: the need for a new model of collaboration. Social Science and Medicine.
[2] Giardo 2020. Health, development, and institutional factors: The Mozambique case. Health, development, and institutional factors: The Mozambique case (econstor.eu)
[3] MSF Beira project document 2022 – 2024.
[4] UNICEF 2019. Budget Brief: Health Mozambique 2019.
[5] PEPFAR 2016. Health financing profile Mozambique.
[6] UNICEF 2019. Budget Brief: Health Mozambique 2019.
[7] WHO 2022. The Global Health Observatory 2022. HIV – Number of people (all ages) living with HIV (who.int)
[8] INSIDA 2022. National HIV survey 2021 – Summary Sheet. 53059_14_INSIDA_Summary-sheet-Web.pdf (columbia.edu)
[9] CDC Factsheet. CDC in Mozambique
[10] CQUIN 7th Annual Meeting 2023. Analysis of Advanced HIV Disease eligibility through CD4 test differences in Mozambique. PowerPoint Presentation (columbia.edu)
[11]Ford N et al. 2018. Guideline Development Group for Managing Advanced HIV Disease and Rapid Initiation of Antiretroviral Therapy. Managing Advanced HIV Disease in a Public Health Approach. Clin Infect Dis. 2018 Mar 4;66(suppl_2): S106-SS110. doi: 10.1093/cid/cix1139
Carmona S, et al 2018. Persistent High Burden of Advanced HIV Disease Among Patients Seeking Care in South Africa’s National HIV Program: Data from a Nationwide Laboratory Cohort. Clin Infect Dis. 2018 Mar 4;66(suppl_2): S111-S117. doi: 10.1093/cid/ciy045
[12] MISAU 2012. Inquérito Integrado Biológico e Comportamental entre Mulheres Trabalhadoras de Sexo. Mozambique
[13] MISAU 2011. Inquérito Integrado Biológico e Comportamental entre Homens que Fazem Sexo com Homens, Moçambique
[14] MSF Project Identity Card. Beira Mozambique
[15] MISAU 2023. Relatorio semestral das Actividades Relacionadas ao HIV/SIDA. Relatorio Semestral_HIV_2023_FINAL.pdf
[16] MISAU 2012. Inquérito Integrado Biológico e Comportamental entre Mulheres Trabalhadoras de Sexo. Mozambique
[17] MISAU 2011. Inquérito Integrado Biológico e Comportamental entre Homens que Fazem Sexo com Homens, Moçambique
[18] MSF internal documentation
[19] MISAU 2022. Guião de manejo do paciente com doença avançada por HIV.
[20] MSF Beira project document 2023
How to apply
The application should consist of a technical proposal, a budget proposal, CV(s), and a previous work sample. The proposal should include a reflection on how adherence to ethical standards for evaluations will be considered throughout the evaluation. In addition, the evaluator(s) should consider and address the sensitivity of the topic at hand in the methodology as well as be reflected in the team set-up. Offers should include a separate quotation for the complete services, stated in Euros (EUR). The budget should present a consultancy fee according to the number of expected working days over the entire period, both in totality and as a daily fee. Travel costs, if any, do not need to be included as the SEU will arrange and cover these. Do note that MSF does not pay any per diem.
Applications will be evaluated based on whether the submitted proposal captures an understanding of the main deliverables as per this ToR, a methodology relevant to achieving the results foreseen, and the overall capacity of the evaluator(s) to carry out the work (i.e. inclusion of proposed evaluators’ CVs, reference to previous work, certification et cetera).
Interested teams or individuals should apply to [email protected] referencing BEIDE no later than 23:59hrs CET on March 26th, 2024. We would appreciate the necessary documents being submitted as separate attachments (proposal, budget, CV, work sample and such). Please include your contact details in your CV. Please indicate in your email application on which platform you saw this vacancy.
MSF is committed to applying responsible data protection principles in all its activities, including assessments, respecting both humanitarian principles and the European GDPR. During the assessment process, you will potentially have access, collection, storage, analysis, and possibly disposal of MSF’s and its patients’ sensitive and personal data and information (SPDI). Please take particular note of the SEU’s ethical guidelines when preparing your proposal, taking into account the tools and solutions you will use, how you will work to mitigate any data incidents, and how you will dispose of the data collected once the evaluation is complete.
Deadline: 26 Mar 2024