Background

The Global Fund is the main financier of programs that fight AIDS, TB and Malaria. It works in close collaboration with other bilateral and multilateral organizations to supplement existing efforts in dealing with the three diseases. Since its inception, through the disease specific grants, the Global Fund has also supported building of resilient and sustainable systems for health (RSSH), including the community systems.

To date, the Global Fund has invested US$ 1.8 billion in Zimbabwe. During the previous funding cycle (2014-2018) US$ 95.6 million of the Global Fund funds was allocated to the RSSH, of which the Health Worker Retention Scheme (HWRS) share amounted to US$ 49.4 million, which includes support to the community health workers. 

The current allocation for the period 2018-2020 amounts to US$ 502 million, out of which the RSSH component share is US$ 48.7 million. US$ 34 million has been earmarked for the health worker retention and US$ 10 million already  disbursed for year one (2018) under the historically agreed  implementation structure, and pending the clarification on the future of the scheme in light of the Results Based Financing approach by the Government of Zimbabwe, and health sector in particular.

The total domestic allocation for public for health is US$ 408 million for the current financial year (January-December 2018). The Ministry of Health and Child Care allocation stands at 8% of the total Government budget of US$ 5.1 billion, which is below the Abuja Declaration target of 15%. It is worth noting, however, that a very small portion of the total domestic allocation has been actually received by the Ministry of Health and Child Care due to country’s fiscal constraints.

Health Worker Retention Scheme

During the period 2006-2009, Zimbabwe experienced unprecedented economic downturn and hyperinflation that lead to high attrition of workforce to other countries across all sectors. Low salaries for public sector employees and economic hardship were the main reasons behind the attrition in the health sector. This was a major risk that would have affected the quality of health services and achievement of results for Global Fund supported programs. To mitigate against the rapid loss of health workforce, and to cushion the selected critical cadres from low remuneration, the public health workers in Zimbabwe have since 2009 been receiving allowances under the Health Workers Retention Scheme funded by partners through the Health Development Fund as well as direct contributions through the Global Fund.

At the start of the scheme in 2008, an exit plan was agreed between the Global Fund and the Government of Zimbabwe stipulating that:

the Global Fund contribution to the HWRS would be reduced by 25% annually starting in 2011 and ending in December 2013, to be commensurate to the Government of Zimbabwe annual increase in wages for the same cadres; and

Health cadres to be supported under the HWRS should be capped at 18,860 staff for the Global Fund support.

The HWRS was a collaborative initiative implemented by Ministry of Health and Child Care, with support from the Global Fund and donors in the Health Development Fund. The Global Fund and the Health Development Fund partners(HDF) respectively funded the staff allowances and salaries for full time posts up to approx. 7% and 5% of the overall package designed for grades C5 (nurses, clinical officers, etc.) and above. Over the years, the Global Fund share in the HWRS gradually increased in relation to other funders.

Although a sustainability plan detailing the transition modalities for HWRS was drafted and submitted to the Global Fund in 2014, the Government was unable to increase civil service wages which had already represented 85% of the national budget before the launch of the Global Fund New Funding Model in 2015. The critical driver behind the continuation of support has been the lack of fiscal space to absorb the HWRS. In 2016, the employment costs accounted for more than 60% of the total government allocation in the health sector. Consequently, the burden of program spending mainly fell on development partners and personal out-of-pocket payments.

In addition to the allowances, salaries and other incentives financed jointly by the Government of Zimbabwe, World Bank and HDF, under the Results Based Financing modality the staff in health facilities have been receiving 25%  of payments made to the rural health centers and hospitals as performance incentives in those geographical areas where RBF has been piloted.

With the Results Based Financing having already been adopted and implemented by the Ministry of Health and Child Care, the Global Fund has remained the sole financer of the HWRS, which is a position that puts into question the relevance of the scheme in the current context, its operational effectiveness, impact and sustainability of the concept.

Human Resources for Health (HRH) Strategic Plan 2017-2020

The Government of Zimbabwe is currently implementing the National Health Strategy (2016-2020) – “Equity and Quality of Health: Leaving No One Behind”, setting out the strategic direction for the health sector over the next five years in order to attain this vision. The document builds on the previous (2009-2013) strategy and its extension in (2014-2015) by addressing the existing gaps and consolidating the gains achieved through a comprehensive response to the burden of diseases and strengthening of the health systems to deliver quality health services to all Zimbabweans during the previous strategic periods.

Internal and external stakeholders participated in the development of the current Human Resource for Health Strategic Plan 2017-2020 that complements the National Health Strategy (2016-2020) by ensuring that the health sector has adequate human resources to attain the set objectives. The intention of the Human Resource for Health Strategic Plan 2017-2020 is to provide a framework to both develop and retain human resources essential for the delivery of quality health services. The Human Resources for Health Strategic Plan (2017-2020) also marks the beginning of a more structured and systematic response to the challenges faced by the health sector.

The Human Resources for Health Strategic Plan 2017-2020, however, falls short in providing a comprehensive analysis of evolving and current situation with regards to the human resources for health and is non-specific on the impact of the Health Workers Retention Scheme. Importantly, the Human Resources for Health Strategic Plan has no clear strategic direction how the staff retention will be best addressed until 2020.

Results Based Financing

In 2011, the Government of Zimbabwe in collaboration with the World Bank piloted the Results-Based Financing modality (RBF) for health in two districts. In 2012 and 2014 respectively, the RBF was scaled up first to 16 districts and then to 42 districts through the Health Transition Fund financing. The RBF modality initially targeted only maternal health indications.

The RBF is increasingly being promoted by the leading global actors as a way to effectively increase performance in terms of service quality, service utilization and to improve staff motivation so that the Universal Health Coverage can be achieved.

Since 2014, Crown Agents have been implementing RBF in partnership with the Ministry of Health and Child Care in 42 rural districts covering 830 health facilities and an estimated catchment area population of 6.6 million. Supported by the World Bank, CORDAID is implementing RBF in 18 districts. At the beginning of 2018 fiscal year, the Government of Zimbabwe expanded RBF to remaining districts thus ensuring that there is nationwide coverage of RBF. Moreover, the Ministry of Health and Child Care is working on expanding the RBF scope to all conditions including Malaria, TB and HIV/AIDS. The expansion has been achieved using the Ministry’s own Health Levy Funds (US$16 million). Under its Health Financing Policy, the Ministry of Health and Child Care made clear their intention to transition from the HWRS to RBF by 2020. Meanwhile, the partners support to HWRS in 18 districts was discontinued in 2018. The Global Fund was called upon on several occasions by the Health Development Fund partners to join the RBF, while the Ministry of Health and Child Care has so far preferred to keep the proportion of its current Global Fund allocation (2018-2020) with HWRS and until the planned full transition to RBF.

The RBF modality monitors and assesses the performance of rural health facilities on selected sixteen maternal, neonatal and child health indicators based on the counter-verified District Health Information System (DHIS2) data, quarterly client satisfaction surveys scores conducted by community based organizations as well as the District Health Executive quality of care scores. The performance results are used to process invoices and pay performance subsidies to clinics. RBF in Zimbabwe focused on the following three components:

• Results-based contracting
• Management and capacity building
• Monitoring and documentation

There are currently two HR incentive/retention systems operating in parallel due to the expansion RBF to all districts of Zimbabwe. The health workers within the band of C5 and above are effectively receiving incentives both from the traditional HWRS and through RBF.

The RBF evaluation reports show a mixed picture with some indicators showing incremental impact in some health facilities and not in others. The impact on staff satisfaction is also mixed and the findings are inconclusive if and how the RBF safeguards the retention of health workforce. Moreover, all the RBF pilots were done with the HWRS already in place, therefore the study results were not specific whether the retention was attributable to RBF or the combination of the two schemes.

Duties and Responsibilities

UNDP wishes to engage the services of a partnership/ consortium of two consultants who will  work jointly  to carry out the  review of the Health Workers Retention Scheme. The team leader will be responsible for submitting the proposal and should assign/select a partner to work on this assignment. The proposal should include the CV’s of each team member.  It is expected that the partnership of consultants/company makes use of relevant international expertise.

The consultants will agree on how to deliver on the shared deliverables based on their areas of strengths and expertise.  The consultants will be health systems strengthening experts with strong focus in the  following areas :  1) Health Financing   and  2) Human Resources for Health

The two consultants will work jointly to produce the final output:  A report detailing issues affecting Health Workers Retention Scheme (HWRS) and Results Based Financing (RBF), outlining today’s status quo and benchmarking competitiveness of remuneration, dynamics and feasible options for Global Fund implementation approach and prioritization for next funding cycle. This will require an agreement between the two consultants on the division of labor for the following tasks:

1. Undertake in-depth analysis of the current status of the human resources for health in terms of macro-economic situation, remuneration, retention and the risk of catastrophic attrition, i.e. is HRH retention still the problem in Zimbabwe;
2. Undertake technical analysis of the RBF scheme by mapping those operational issues that are directly linked to incentives provided to human resources for health retention, i.e.:
   • What are the indicators in the RBF framework?
   • How does performance link to health workers incentives?
3. Provide a comparative analysis of the implementation of the HWRS and RBF models:-
   • Which approach is more relevant under the prevailing macro-economic and health system issues?
   • Are the approaches targeting the appropriate cadres?
   • Are there any remaining gaps in both models, i.e. technical, operational, etc.?
4. Provide practical recommendations to the Global Fund on the following:
   • The most appropriate and impactful modality of funding the human resources for health interventions within the current funding cycle (2019/20)
   • Priorities of the Global Fund support to human resources for health in the next funding cycle (2021-2023) by focusing on both the value for money and sustainability

Expected Outputs

A report detailing issues affecting HRH retention, outlining today’s status quo in terms of HRH remuneration across all categories for the purposes of HRH retention and benchmarking competitiveness of remuneration, RBF dynamics and possible options for Global Fund implementation approach and prioritization for next funding cycle

List of Reference Documents

To be provided after the inception dialogue on the review approach with the Country Team

List of Key Informants

To be provided after the inception dialogue on the review approach with the Country Team

Timeline and Deliverables (Joint Deliverables)

The assignment will start in June 2019   and is expected to complete in 6 weeks with the submission of the draft report. Travel to Zimbabwe is envisaged during the period of 1-2 weeks. The Global Fund plans to share the report with the Government of Zimbabwe and partners by September 2019 .

Documents to be submitted when submitting Proposal:

Interested individual consultants must submit the following documents/information to demonstrate their qualifications. Please group them into one (1) single PDF document as the application only allows to upload maximum one document

1. Personal CV or P11, indicating all experience from similar projects, as well as the contact details (email and telephone number) of the Candidate and at least three (3) professional references;

2. Proposal:

   (i) Explaining why they are the most suitable for the work

   (ii) Provide a brief methodology on how they will approach and conduct the work

3. Letter of Confirmation of Interest and Availability and Financial Proposal that indicates the daily rate/fee of the candidate, in US dollars, using the template provided in Annex III (http://procurement-notices.undp.org/view_notice.cfm?notice_id=56244).

Evaluation of Proposal

Evaluation of the proposal shall be done based on cumulative analysis:

When using this weighted scoring method, the award of the contract should be made to the individual consultant whose offer has been evaluated and determined as:

a) responsive/compliant/acceptable, and

b) Having received the highest score out of a pre-determined set of weighted technical and financial criteria specific to the solicitation.

* Technical Criteria weight; [70%]

* Financial Criteria weight; [30%]

Only candidates obtaining a minimum of 70% point would be considered for the Financial Evaluation. The Technical evaluation will be done as per summary below:

Technical (70%):

• Expertise of the Individual Contractor/Lead Consultant (30%);
• Methodology, Its Appropriateness to the Condition and Timeliness of the Implementation Plan (50%);
• Qualification of Key Supporting Personnel (20%);

Competencies

Core competencies:

• Demonstrates integrity by modeling the UN’s values and ethical standards;
• Promotes the vision, mission, and strategic goals of UNDP;
• Displays cultural, gender, religion, race, nationality and age sensitivity and adaptability;
• Communications and networking skills;
• Ability to work effectively as part of a team;
• Strong interpersonal and negotiating skills, sound judgment and discretion.

Technical/Functional competencies:

• Evidence of practical experience in health systems strengthening, health systems performance assessments, with strong focus on healthcare financing and human resources for health in low/middle-income countries
• Practical experience in organization management, strategic planning of associations and  public organizations at the national and regional level;
• Excellent public speaking and presentation skills.

Required Skills and Experience

The assignment requires  a team of  two experts  covering the following areas:-

• Health Financing
• Human Resources for Health.

 One proposal will be submitted by the Team leader  and the   qualifications and experiences of the  team members  should complement each other   to cover both areas of the assignment .

 Academic Qualifications:  of each team member

• Graduate level training (Masters level) in public health, international health, healthcare management, Economics,  Human Resources or relevant areas

Experience of the team:

• Each team member should have at least 7 years of practical experience as a technical specialist, adviser or consultant.
• African experience is essential, Zimbabwe experience desirable;
• Evidence of previous experience working on the Global Fund related issues;
• A solid experience in the areas of economic development, poverty analysis, development and planning, strategic planning of the projects focused on economic development through providing evidence-based policy advice;
• Experience in formulating development strategies and policies;
• Experience in working in complex, multi-partner environment.

Language:

• Fluency in written and spoken English is required for this consultancy.