TORs: National Junior STTA – Research Associate

      Establishing an Effective and Sustainable Training System for the Primary & Secondary Healthcare Department, Government of Punjab

Programme

Evidence for Health (E4H) is a Foreign, Commonwealth & Development Office (FCDO)-funded programme aimed at strengthening Pakistan's healthcare system, thereby decreasing the burden of illness and saving lives. E4H provides technical assistance (TA) to the Federal, Khyber Pakhtunkhwa (KP), and Punjab governments, and is being implemented by Palladium along with Oxford Policy Management (OPM).

Through its flexible, embedded, and demand-driven model, E4H supports the government to achieve a resilient health system that is prepared for health emergencies, responsive to the latest evidence, and delivers equitable, quality, and efficient healthcare services. Specifically, E4H delivers TA across three outputs:
Output 1: Strengthened integrated health security, with a focus on preparing and responding to health emergencies, including pandemics.
Output 2: Strengthened evidence-based decision-making to drive health sector performance and accountability.
Output 3: Improved implementation of Universal Health Coverage, with a focus on ending preventable deaths.

Background and Problem Statement

The Primary and Secondary Healthcare Department (P&SHD) has an infrastructure for continuous professional development in the form of the Provincial Health Development Centre (PHDC) and 33 District Health Development Centres (DHDCs) across Punjab province. This setup has been used for decades to deliver post-induction, promotion, and refresher training for its employees. These trainings are conducted self-help, and budgets are insufficient to provide for basic training needs.

Furthermore, training is typically planned either in conjunction with the hiring phase when management is obligated to ensure that new hires complete post-induction training as a regulatory requirement or in cases where management fails to fulfil the regulatory requirement and consequently, officials of certain categories may be deprived of due promotions. In other cases, only during outbreaks of diseases when higher authorities are vigilant do management ensure these trainings are held, which consequently fails to deliver the intended impact on service delivery in the long term.

P&SHD has recently improved the physical infrastructure of DHDC training facilities by revamping training halls, libraries, and offices and providing training-related furniture and equipment. However, the training regime lacks training needs assessment, module development process, criteria for resource person selection, monitoring, and feedback mechanism.

The following is a non-exhaustive list of challenges in the current training system that our team identified in their discussions with Department officials.

• DHDCs across Punjab carry out training for several categories of service delivery providers. Still, the absence of a leadership role by PHDC in conducting these trainings affects the consistency of the skill set being imparted.
• The trainings are scheduled to fulfil a formality to secure confirmation of the job or promotion rather than to use it as an opportunity to familiarise the employee with job requirements for which s/he has been hired or is about to be promoted.
• A systematic approach is absent in analysing data already collected to ascertain long and short-term changes required in content development or training methodology.
• There is no institutional mechanism to develop training modules. The best-case scenario is that presentations prepared by someone in the past, which may contain outdated content and methodologies, are being used to deliver these trainings.
• There is no framework to select and engage the best resource persons available in the catchment area of the PHDC. The Programme Director of PHDC conducts these trainings single-handedly or engages resource persons based on institutional memory.
• The absence of an M&E framework leads to collusion between trainers and trainees, which often results in just marking attendance and getting partial payments in cases where a training allowance is promised.
• The absence of a coordination framework between DGHS, HISDU, and PHDC hinders vital information sharing for mutual benefit and ultimately improves health service delivery. 

Objective

The TA workstream aims to collaborate with the P&SHD in designing, implementing, and evaluating a standardised, effective, and sustainable training system for health sector professionals across Punjab province. This system will enhance the capacity and performance of healthcare providers at both the provincial and district levels, ensuring the delivery of high-quality clinical and non-clinical training for continuous professional development.

Scope of Work and Methodology

The methodology proposed in this section is non-exhaustive and iterative. It provides a general overview of the minimum required depth of activities that should be undertaken for this engagement. The TA will be implemented in three phases, with deliverables aligned to each phase to ensure clear milestones and accountability.

Phase-I (July 2024 to August 2024)

The first phase will include a comprehensive understanding of Punjab’s requirements, international best practices, and Pakistan’s international commitments. 

• A review of the EPHS for Punjab. This document defines the core services that should be provided across the province. By analysing this package, the team will identify the training requirements associated with each service and assess the availability and the requirement to update any—if dated—of current training programmes and guidelines. These have already been listed in the EPHS document.
• An examination of the National Health Support Program (NHSP) project, funded by the World Bank.The NHSP project specifies Disbursement Linked Results (DLRs) related to training, which must be achieved to secure World Bank funding. DLI 2 and DLI 10 (specific to Punjab) are some of the relevant NHSP conditions for fund disbursement. Annexure 2 of the TORs sets out details from the NHSP.
• An assessment of the Minimum Service Delivery Standards (MSDS), which set benchmarks for service delivery that healthcare facilities must meet. The team will understand the training necessary to meet these standards by studying the MSDS.
• A general review of several other national policies and strategies, which include but are not limited to the NHV; the HRH Vision; and the Joint External Evaluation (JEE) recommendations.
• A review of international best practices, such as WHO's Digital Education for Building HRH Capacity, which explores digital strategies for capacity building in the health workforce. The team will also examine WHO's Working for Health initiative outlines global strategies for developing the health workforce and the Core Competencies for Public Health Professionals framework. 

Phase II (August 2024 to October 2024)

The second phase will establish a baseline understanding of the current training landscape. The team is expected to undertake the following activities at a minimum:

• Identify and build consensus around key critical areas that require continuous building capacity throughout TA delivery.
• Establish a clear understanding of current training systems, requirements, and ongoing initiatives in Punjab through a series of activities including but not limited to:

•  Literature review and synthesis of existing training regime design and its implementation, reports of development partners, Performance Audit Reports, Audit Paras, and other relevant components. The team will also conduct an in-depth review of the provincial training strategy, training requirements of service rules, and training needs of upcoming health sector interventions.
• Furthermore, an assessment of the training facilities based on agreed parameters, such as accessibility, affiliation, allocated budgets, and infrastructure adequacy, also needs to be conducted under this TA.
• Engage a wide range of stakeholders, including PHDC, DHDCs, HISDU, DGHS, project directors of vertical programmes, healthcare professionals, trainers, trainees and development partners, to get a clear overview of past efforts. The team will also map the partners and implementing agencies supporting the P&SHD existing training systems. The team is expected to develop a list of critical questions, with well-defined prompts to steer Key Informant Interviews (KIIs) and other consultations to adequately assess the current state of training needs and available resources to address those needs. Annexure 3 of the TORs outlines the current DHDC training programmes.
• Assess the findings and recommendations of a similar TA that E4H delivered in Khyber Pakhtunkhwa (KP) to develop sustainable trainingsystems. This review is essential because it will ensure that the Punjab team uses resources optimally with minimal duplication of efforts. The EPHS for KP and Punjab have similarities and training identified in the KP TA, which can be replicated in Punjab with minor alterations. These should be documented and referenced where applicable, including the amendments made or required for Punjab’s context.

The proposed activities outlined in Phase II are expected to culminate in developing a comprehensive report detailing the current training regime, its challenges, and recommendations.

Phase III (November 2024 to January 2025)

Building on the work completed in Phases I and II, Phase III will focus on the detailed development and initial implementation of the standardised training framework.

• Utilising what was learned from the training needs assessment conducted in Phases I and II, categorise the clinical or non-clinical training. This classification will be based on:
• A detailed assessment of current workforce competencies and future needs identified in Phase II.
• Comparison of training requirements with the availability of training centres analysed in Phase II.
• Examination of different PC-Is, including allocated funds for training initiatives, to ensure alignment with government priorities and financial sustainability. 
• Develop a prioritised action plan to align training initiatives with government priorities and address identified gaps in workforce competencies. Develop the training system and supporting guidelines by: 
• Engaging relevant stakeholders (e.g., professional associations, academic institutions) identified in Phase II to refine guidelines for the training suggested by the EPHS.
• Reviewing and synthesising training materials collected in Phase I and creating a holistic training curriculum for each course, including learning objectives, goals, content, duration, and references.
• Finalising the TORs for a comprehensive training system within the P&SHD. The TORs, developed based on stakeholder feedback from Phase II, will outline roles and responsibilities, decision-making processes, and mechanisms for coordination and collaboration among stakeholders.
• Identifying master trainers from the P&SHD or clinical trainers from the Specialised Healthcare & Medical Education Department for each training course, based on criteria established in Phase II.
• Incorporating provisions for supportive supervision, a monitoring checklist, affiliation, certification, and necessary items for skill labs, as identified in the infrastructure assessment in Phase II.
• Obtaining endorsement for the system from teaching organisations such as the Post Graduate Medical Institute, Institute of Public Health, and University of Health Sciences, based on initial consultations in Phase II.
• Outlining linkages to the monitoring centre to gauge the timely implementation of the training calendar and achieving desired learning outcomes, as highlighted in Phase II.
• The training system should also outline details of clear linkages to the monitoring centre to gauge the timely implementation of the training calendar and the achievement of desired learning outcomes. 
• Develop an implementation plan:
• A comprehensive and actionable plan outlining strategies, resource allocation, and technical support to the Department, ensuring the training system’s sustainable implementation.
• The implementation plan will include a detailed timeline for the rollout of the training system. This comprehensive district-level DHDC training calendar prioritises equity. It addresses the specific needs of underserved areas (like South Punjab), as well as a resource mobilisation plan to ensure financial sustainability.
• Work closely with the P&SHD to oversee the progress and efficacy of the training initiatives to integrate the new training system successfully.
• The consultants are expected to devise a well-thought-out exit strategy to ensure the training regime stays in place post-funding from FCDO and the E4H programme. This will include strategies for securing ongoing financial and technical support, building local capacity, and institutionalising the training processes.
• Disseminate progress and achievements to relevant stakeholders. 

• Embedded Support:
• The team is also expected to provide embedded support to the P&SHD. The support should be defined in the inception report to outline what the Department can expect regarding ongoing assistance.
• The details of the embedded support's extent, duration and breadth will be further elaborated. At this stage, we envision the embedded support to include—among other things—working closely within departmental units, such as PHDC, to participate in daily operations and decision-making processes directly.
• This hands-on approach will ensure tailored, practical solutions for training cycle-related activities and operationalisation of the training regime. Depending on the department's requirements, the consultants may be asked to conduct capacity-building sessions as well.

Timeline and LOE
The level of effort for the role is 80 working days, from Jul 2024 to - Jan 2025. 

Requirements:

Educational Background
Bachelors in Economics, Epidemiology/Public Health, Management Sciences or a related field; Master's degree preferred

Technical expertise

• Ability to produce clear and concise research reports, articles and policy briefs.
• Understanding of various training systems, curricula, and institutions in Punjab
• Proficiency in data management and analysis software (e.g., SPSS, STATA, R) and experience with qualitative data analysis tools (e.g., NVivo). Proficient in writing research proposals, scientific articles, reports, and presentations
• Ability to conduct thorough literature reviews to identify gaps in current knowledge. 

Competencies

• Experience establishing data-driven insights to support evidence-based decision-making and program adjustment.
• Ability to visualise data findings through graphs, charts, and other visual aids for effective communication.
• Robust qualitative, quantitative and policy analysis skills.
• Effective communication and collaboration with team members, presenting research findings and discussing technical concepts with technical and non-technical experts.

Deliverables/KPIs

• Support the team in developing an inception report clearly defining the methodology and work plan.
• Conduct literature reviews and synthesise findings to inform the development of the inception report and training needs assessment. Assist in developing the training framework and implementation plan, including data collection tools, data analysis plans, and monitoring and evaluation indicators. Support the team in writing reports, developing visuals for data illustration, interpreting graphs/charts, and maintaining project documentationProvide regular progress reports and a final comprehensive report detailing the achievements, lessons learned, and recommendations for the future.