Terms of Reference for the development of Somali Health Sector Strategic Plan/s – Phase II (2017-21)

Background Somalia is one of the most fragile states in the world with one of the most complex and protracted conflicts. Across all dimensions of human development, the country has suffered severe consequences from conflict, as reflected in the indices developed by the global Human Development Report. The fragility of the country over the past two and half decades resulted in weakening of the health sector, its systems and personnel with a subsequent focus on emergency response interventions to recurrent crises. Earlier, to review and address the challenges in the Somali health sector, a high level forum (HLF) was held in Nairobi, on 15 June 2015, chaired by UN Resident Coordinator/ Humanitarian Coordinator. The high level forum was co-chaired by the three Ministers of Health and attended by donors, UN agencies and NGOs. In this HLF on the Somali health sector, it was decided to:
Undertake a comprehensive review of the health sector in Somalia by September 2015 taking into consideration already undertaken studies and analysis;
Utilize evidence from the review and in consultation with all partners design an architecture of the next phase of health sector implementations (HSSPs);
Enhance conversations between humanitarian and development health partners and agree on a framework to working together and create improved synergies.
The WHO office responded to the above request by fielding a high level mission to review the Somali health sector in September 2015 along with the involvement of other stakeholders. Based on the findings and recommendations of the mission, the next phase of the development of Somali HSSP/s will start in 2016. Somali Health Context • The burden of diseases (BoD) is heavily dominated by communicable diseases, reproductive health and under-nutrition issues whereas issues related to non-communicable diseases and mental illnesses are also on the rise. The Somali health situation is one of the worst in the world and the country is unable to achieve its Millennium Development Goals (MDGs) on health and nutrition by end 2015 . • > 610,000 malaria cases in 2014. Tuberculosis is highly prevalent with 30,000 new cases every year, of which fewer than half are detected. Malaria is endemic in some parts and HIV epidemic growing with a prevalence rate of about 1% with higher prevalence among the high risk groups . • 70% of Somalis do not have access to safe water supply or sanitation. Half of the population practice open defecation – in rural areas this is as high as 83%. Diarrheal diseases accounts for majority of deaths among children along with respiratory infections. • Life expectancy is estimated to be 53 and 56 years respectively for male and females. 1 in 7 children dies before fifth birthday whereas a woman dies every 2 hours during pregnancy / childbirth. • One out of 18 women has a lifetime risk of death during pregnancy. The country has one of the highest total fertility rate (6.7) in the world with unmet need for birth spacing at 26%. • 98% women experience female genital mutilation/ cutting, leading to serious obstetrical and gynaecological complications. • 202,600 acutely malnourished children in the country whereas 60% of children <5 and 50% of women suffer from anaemia. • One in three Somalis suffer from some form of mental health problem due to longstanding conflict, unemployment and socioeconomic stress. • 201
4 estimates indicate that there are approximately 6,000 doctors, nurses and midwives . The WHO minimum threshold for health worker- population ratio states that there should have been around 30,000 health workers to achieve health MDGs. • Health financing for Somalia has been extremely limited as Somali macroeconomic performance is poor. Resources for the health sector are mainly out-of-pocket or through donors’ funding. Somali diaspora contribute in the health sector significantly but information is not documented.
Nevertheless, a new environment is emerging in the Somali health sector. Security gains in parts of Somalia have created space to engage in development strategies and the building of governmental structures and processes. The legitimacy of the authorities is critical for successful implementation of the Somali Health Policy, Health Sector Strategic Plans (HSSPs) and the Essential Package of Health Services (EPHS). The Health Sector Strategic Plans (HSSPs 2013-16) – with an annual cost of $75-80 million – are ending in December 2016. It is important to develop next phase of strategic plans for the Somali health sector beyond 2016 to ensure continuity. New HSSPs need to be aligned with the National Development Plans and IPRSP to ensure the health sector benefits from cross sectoral reforms. True public expenditure in health is very low9 (less than 5% of total health expenditure through public system). The challenge is how to ensure more commitment from the Somali authorities, at least to reflect recurrent (starting with salaries) health expenditure in the public budget. Key bilateral donors in the health sector are United Kingdom, Sweden, Japan, Finland, United States, Italy, Australia and Switzerland and their support increased from minimum of $30 million in 2011 to more than $68 million in 2014 (plus additional support for nutrition, polio, measles, etc). Annual support from Global initiatives (GFATM and GAVI) varied from a minimum of $19 million to $40 million during 2011 to 2014. Core funding from UN agencies for health is approximately $9 million per annum. Humanitarian funding (including CHF and CERF) was at the level of $15.6 million in 2014. Turkey is a new non-traditional donor with commitment of $59.6 million for health infrastructure development in 2014 . Qatar and Saudi Arabia are among the donors supporting the Somali health sector in close collaboration with health authorities.

Objectives The main objective of this consultancy is to review the status of Somali Health Sector and produce the next generation of Somali Health Sector Strategic Plan/s (HSSPs) – Phase II (2017-21), while aligning the same with the Somali National Development Plans – NDPs (under development), Somali Health Policy, Sustainable Development Goals (SDGs) and Somali Humanitarian (health and nutrition) Plans. The specific objectives are: i) To carry out the situation analysis and programming while ensuring coherence of different policies, strategies and plans;
ii) To describe the process through which plan/s have been developed;
iii) To develop financing, auditing and accountability arrangements;
iv) To develop implementation and management arrangements; and v) To outline results, monitoring, review mechanisms
Recipients a) The primary recipients of the assistance will be the Somali leadership and health authorities b) The secondary recipients will be the women, children, families, general population, health care providers, policy makers, opinion leaders, implementing partners, donors, UN agencies and development partners
Expected Outputs WHO Somalia will identify a team of experts/ consultancy firm to develop the Somali HSSP/s in consultation with all stakeholders. The following key outputs are expected: • An inception report to be agreed with the Health Sector Committee (HSC) including Health and Nutrition clusters, clearly defining the process of the consultations and timelines • Brief reports of consultations/ workshops carried out with the stakeholders to design the plan/s • Somali Health Sector Strategic Plans covering the essential ingredients of a sound plan, fully aligned to the Somali Health Policy, Somali Humanitarian Plans for health and nutrition, Sustainable Development Goals (SDGs) and National Development Plans and following the principles of the Somali Compact/ New Deal
• A presentation on the HSSP/s, to be delivered in a plenary of stakeholders, HSC, Health and nutrition cluster and Health Advisory Board (HAB)
Scope of Work A design team consisting of experts and with support of the Somali health authorities, UN agencies (WHO, UNICEF and UNFPA) and donors and NGOs will ensure the following essential characteristics in the new HSSP/s: 1: Situation Analysis and Programming: • The situation analysis is based on a comprehensive analysis of health determinants and health outcome trends within the Somali epidemiological, political, socio-economic and institutional context. • The analysis uses disaggregated data to describe progress towards health policy objectives with a focus on health care, universal health coverage to improve equity, service delivery to make health systems people-centred, public policies to promote health of communities, and leadership to make health authorities more empowered and trusted. • Defining impact, outcome, outputs and sub-outputs which are specific, achievable, measurable, realistic and time bound. • Planned strategies and interventions addressing health priorities, equitable access, quality and health outcomes across all population especially vulnerable groups. Especially for service delivery, the plan/s should clearly outline the needs at regional level.
• The plan/s identifies key systems issues that impact on sustainability, including equity, financial, human resource and technical sustainability gaps and constraints. • The plan/s describes short and long term strategies to meet technical assistance requirements for its implementation. • Contingencies plans for emergency/humanitarian health needs (natural or manmade disasters and emerging / re-emerging diseases) at all levels. • The plan/s includes a risk assessment of potential barriers to successful implementation. 2: Process: • A multi-partner mechanism ensuring the lead of the authorities and the participation of all stakeholders providing inputs systematically and regularly during design and implementation. • Ensuring that all needed sectoral and multi-sectoral policies and legislations under the spirit of ‘health in all policies’ are in place. • The plan/s notes the need for regulatory and legislative framework and strategy to ensure enforcement. • Political commitment is evidenced by increasing the proportion of government’s financing for the health sector. • Political discussions in the cabinet and parliament, agreements and endorsement of the key policies, strategies and budget. • The new HSSP/s and other sub-sectoral strategies and plans are consistent with each other with overarching policy objectives of the Somali health policy and national level goals and targets. 3: Financing, Auditing and Accountability: • The HSSP/s are accompanied by a sound expenditure framework with costed plan (both recurrent and investment financing). • Revenue projections are based upon explicit assumptions, include all sources of finance (local and external) and account for any foreseen uncertainties. • The HSSP/s ensures systems that avoid catastrophic health care expenditure and impoverishment from results of seeking care. • Costing and budget estimates for scaling up equitable services on sound analysis. • Financial plans have transparent criteria governing allocation of funds across programmes including non-state actors. • Financial management systems meet national and international standards as well as produces reports appropriate for decision making, oversight and analysis. • Sufficient staff capacity and competencies to ensure efficient disbursements and identify fund flow bottlenecks and resolve them. • There is an effective fiduciary process, as evidenced by routine internal and external audits (following international standards) of financing, procurement and resource management. • The system assures performance is routinely assessed against ‘value for money’. • A committee/ mechanism credibly investigate alleged irregularities and appropriate sanctions are applied. • How internal and external funds will be channelled, managed and reported on. With guidance on how to manage fiscal space constraints to scaling up. 4: Implementation and Management: • Roles and responsibilities of implementing partners for each strategy and intervention. • Each objective has measurable annual milestones to assess progress towards implementation. • The framework of service delivery is defined and identifies equitable allocation of resources, including plans for referrals and supportive supervision. • Prioritized, human resource needs are identified including level, skill mix, training, supervision and incentives with plan to solve problems. • Constraints to logistics, information and management systems and creditable actions to resolve them. • Procurement and supply management policies and systems in place to assure universal access to safe, effective and good quality essential medicines and commodities. • Internal and multi-stakeholders governance arrangements that specify management, oversight, coordination and reporting mechanism. • The HSSPs include a description of accountability, oversight, enforcement and reporting mechanism. 5: Results, Monitoring and Review: • The HSSPs have a detailed performance based framework for monitoring and evaluation (M&E) that include valid and collectable input, output, outcome and impact indicators. • M&E of implementation uses HMIS, surveys, resource allocation data and other epidemiological data disaggregated by major determinants of health. • The plan/s have description of information flows and gaps, sources, methodologies & processes. • Critical gaps and weaknesses in the M&E plan are identified with an explicit costed strategy to overcome these. • A multi-partner review mechanism inputs systematically and regularly into assessing sector performance. • The plan/s detail credible multi-stakeholders mechanisms to provide routine feedback on performance to sub-national and non-state providers. • The M&E plan detail how results from performance analysis will formally be incorporated into future decision making including resource allocation and disbursements.
Methodology To achieve the desired outputs, it is envisaged that: • The design team will take account of analytical work on education, gender, governance, political economy, security, conflict, social exclusion etc.
• In particular, the design team will take account of the Somali health policy, discussions related to the national development plans and critical health system components/ building blocks. The design team will consider the findings and recommendations of the WHO’s ‘Review report of the Somali Health Sector’ in September 2015 and other analytical work.
• The design team will also need to review and understand current donors, UN agencies, public and private sector resources that support the health sector.
• The design team will review policies, plans and programme specific documents, reports, reviews and other relevant information through a desk review. • The design team will convene a series of consultations/ workshops with different tiers of Somali authorities, health officials (including regional and district health teams), donors, UN agencies, implementing partners, non-state actors, beneficiaries and other stakeholders. WHO zonal offices along with UNICEF and UNFPA offices and Somali health authorities will organize workshops. • The design team will subsequently produce a draft HSSP/s and presentation to share findings with stakeholders in a joint meeting of Health Sector Committee and Health and Nutrition clusters. • Comments and views will be received in 2 weeks and the same will be incorporated in the draft plan/s. The final version will be presented in the HAB for endorsement of the Health Sector Strategic Plan/s – phase II (2017-2021).
Timing The assignment will commence no later than January 15, 2016.
Inception Phase: The duration of the Inception Phase will be 2-3 weeks from the date of contract signing. The inception report will be based on the literature, desk review and meetings with key stakeholders as required. The report will be finalized and presented in the joint HSC & health and nutrition clusters meeting for endorsement. Further deliverables of the Implementation Phase will be identified and agreed during the Inception meeting. The inception report (not more than 15 pages) will include the areas listed below: • Work plan with clear roles and responsibilities, budget details and timelines for the design phase of HSSP/s;
• Governance mechanisms for the design phase and endorsement phase of the HSSP/s. • TOR for any short work to be commissioned during the design phase; • Communication plan for disseminating findings, strategies and plan/s. • Gantt chart.

Design phase: The design team will be responsible for producing the draft HSSP/s in consultation with all stakeholders within a period of 40 days. The tasks expected during the design phase include, but are not limited to, the following: • Carry out consultations with all stakeholders including regional and district stakeholders and beneficiaries (especially women, youth and marginalized groups) in all Somali zones. • Maintain the record of all consultations/ workshops and database of persons met. • Ensure completion of short TA work required for the development of HSSP/s on time. • Co-ordinating with Somali health authorities, health and nutrition cluster, relevant partners (donors and UN) to ensure synergies and maximising effectiveness of inputs and minimising transaction costs for partners. • Present the draft HSSP/s with the HSC and health and nutrition clusters and invite further comments/ views within 7 days.

Endorsement phase: After incorporating comments from the HSC, health and nutrition clusters and other stakeholders, the design team will finalize the plan in 10 days and will present the same in the HAB meeting for endorsement. Another presentation to the HSC/ health and nutrition clusters may be required just before the HAB meeting.

The following timelines are proposed (the final timeline will be as per the agreed Inception report): • 15 January 2016: Signing of contract and start of the Inception phase • 4 February: Share the inception report with HSC/ health and nutrition cluster • 8 February: Meeting of the HSC to review and endorse the inception report • 9 February: Start of the design phase • 9 February to 20 March: Complete all consultations/ workshops with all stakeholders. • 23 March: Share draft HSSP/s with the HSC and health and nutrition cluster • 28 March: Joint meeting of the HSC and health and nutrition cluster to review the draft HSSP/s • 28 March to 4 April: Stakeholders to share comments and views with the design team • 8 April: Incorporate all comments and share the next draft of the HSSP/s with HSC/ health and nutrition cluster • 12 April: Present revised HSSP/s to the HSC/ health and nutrition cluster • 15 April 2016: Present final HSSP/s to the HAB for endorsement
The final plan should not exceed 40 pages and should include foreword of 1 page, executive summary of maximum 2 pages including strategic priorities and implementation arrangement, as well as appendices.

Expertise: WHO Somalia wishes to secure the services of an experienced firm to carry out the work of the development of Somali HSSP/s – Phase II (2017-21). WHO will fund and support the successful bidder to operate mechanisms for the development of Somali HSSP/s. In order to deliver the services, the successful bidder will be responsible for sourcing international and national consultants’ inputs. The successful firm must have a strong core team with experience of similar work in developing and fragile countries, good knowledge of the Somali context and a track record of delivering in challenging situations. The organisation must demonstrate their capacity in the following areas: • Comprehensive understanding of latest international health policies, working practices – in particular demand creation and delivery of health services to the poor to reduce inequalities and improve public health; • The ability to develop and apply innovative ideas and solutions; • The ability to communicate clearly and effectively with a wide range of contacts and skills to managing partnerships and engage with senior politicians, government officials, development partners and other stakeholders in an inclusive way; • The strategic health planning, health financing and M&E capacity; • The ability to assess risks and suggest mitigation measures; The firm will share CVs of the team members/ consultants with WHO/ assessment team from different constituencies, in the proposal to ensure that the correct skill mix is identified. In case, for any valid reason, WHO/ assessment team is not satisfied with the skills or performance of any team member, the supplier will change the team member.
Reporting and Management The WHO Somalia office will deal with the contractual issues whereas on technical matters, the design team will be responsible to the HSC/ health and nutrition cluster. At Zonal/ State level, the Director General of Health will be the focal points for the activity. 3. Responsibilities of Ministries of Health and WHO • DGs (Health) will nominate a focal point at MoH to be in touch with design team about processes.
• The MoH focal points and WHO office will collect all relevant documents on health system development, service provision, policies and strategies to be shared with the design team.
• The MoH focal points and WHO office will identify and arrange field visits to health centres, hospitals, clinics, offices, etc. in the rural and urban areas. • The MoH focal points and WHO staff will provide assistance in translation during interviews if needed, approaching sample care providers.
• The MoH focal points and WHO office will prepare list of stakeholders and managers to be interviewed including high level officials and make sure their availability during the visits. • WHO office will be responsible for all travel arrangements including tickets, per diem, venue booking, security clearance, internal travel etc. for the participants invited in the workshops.
Security The firm will be responsible for the safety and well-being of their personnel affected by their activities under this contract, including appropriate security arrangements. WHO will share available information with the firm on security status and developments in-country where appropriate. The security situation is volatile and subject to change at short notice. The supplier should be comfortable working in such an environment and should be capable of delivering the contract.

HOW TO APPLY:
Send your proposal including technical and financial details to:

recruitment@nbo.emro.who.int