TORs: National Senior STTA – Governance Expert

Technical Assistance Name: Establishing and operationalising a Coordination and Governance Mechanism to oversee the National Action Plan for Health Security (NAPHS) recommendation in 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 (2023-2027) provides technical assistance (TA) to Punjab and also to the Federal and Khyber Pakhtunkhwa (KP) governments. The Punjab component is being implemented by Palladium along with Oxford Policy Management (OPM).

Through its flexible, embedded, and demand-driven model, E4H Punjab will support 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 will deliver 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.

E4H-Punjab works in partnership with the Punjab Department of Health (DOH).

Background and Problem Statement

Pakistan ranks as the eighth most vulnerable country in the world to long-term climate risk by the Global Climate Risk Index (2022). Punjab, with 52.6% of the population and 25% of the country's geographic area, is envisioned to adopt a leading role in ensuring climate-resilient health security.  Unlike the other provinces, in Punjab, health is a subject of two provincial departments. While health security and compliance with International Health Regulations (IHR) is predominantly the role of the Primary & Secondary Healthcare Department (P&SHD), the Specialised Health and Medical Education Department (SH&MED) is mandated to contribute towards natural or man-made emergency responses. 

In the last two decades (2000-2019), the province has been documented to be undergoing an epidemiological transition. The share of communicable diseases, along with maternal and perinatal nutrition, has been reduced from 65% to 49.9%, while the share of non-communicable diseases (NCDs) has increased from 29.9% to 43.7%. Such transition presents significant challenges in adherence to required IHR core capacities, particularly for P&SHD.

Punjab has seven dedicated vertical programmes targeting diseases such as Hepatitis, Tuberculosis (TB), AIDS, and Malaria; an Expanded Programme on Immunisation (EPI), Integrated Reproductive Maternal New-born Child Health & Nutrition (IRMNCH&N), NCD, and Communicable Disease Control & Epidemics Prevention Control (CDC & EPC). All these programs have a significant field presence, with an anticipated steady stream of Government funding set to move to the recurrent side of the budget in either 2024 or 2025. Alongside two Bio Safety Level-3 Labs and World Health Organization (WHO)-certified Drug Testing Laboratories, the province is well-equipped to lead in IHR compliance and the execution of the NAPHS 2024-2028 recommendations. However, without a formally notified one-health-related coordination body, the P&SHD Department faces significant governance and coordination challenges due to systemic fragmentation. Efforts towards intersectoral coordination, crucial for a 'one-health approach', face impediments in addressing complex health determinants through collaborative intra- and inter-departmental policies and programmes. Therefore, there is a pressing need to formalise a coordination mechanism in Punjab that is focused on IHR and aligns with the NAPHS 2024-28 recommendations.

While the province has made strides in IHR, critical gaps remain that hinder effective health security and response. These gaps, exacerbated by climate change, inadequate intersectoral coordination, and the evolving disease burden, necessitate targeted interventions. The following problem statements list specific areas where focused effort is required to bridge these gaps. The P&SHD and the E4H team recognise the urgency of addressing such interconnected challenges to build a more responsive and integrated health security landscape in Punjab.

Enhanced preparedness for climate-induced health challenges: Punjab faces escalating climate change impacts, including floods, heatwaves, smog, and droughts, exacerbating public health vulnerabilities. Historical outbreaks of diseases such as dengue, Congo fever, typhoid, and diphtheria, notably aggravated by the COVID-19 pandemic, underscore the need for strengthening outbreak preparedness and response mechanisms, particularly in the aftermath of natural disasters.

Strengthening intersectoral coordination for IHR: The P&SHD, despite being the lead agency for IHR compliance, confronts challenges in furthering intersectoral coordination essential for the 'One Health Approach.' The absence of formalised decision-making and crisis response frameworks, especially in collaboration with the SH&MED, leads to fragmented health interventions and underutilised data from longstanding vertical programs, impacting policy development and response efficiency.

Addressing NCDs amidst resource constraints: With NCDs rising, the allocation of resources to the NCD programme remains disproportionately low compared to communicable disease programmes. This misalignment does not reflect the shifting health burden, impeding effective management of NCD prevention.

Data utilisation for evidence-based making decision-making: Existing health screening programmes, including those targeting vulnerable groups like transgender individuals and jail inmates, generate valuable data that is currently not maximised for disease pattern analysis and informed decision-making. This limitation highlights the need for comprehensive data integration and analysis capabilities to guide health strategies and interventions.

Alignment of governance mechanisms with national health security objectives: The National Action Plan for Health Security (NAPHS) 2024-28 calls for major reforms in coordination mechanisms to align provincial IHR-related governance with national frameworks. This necessitates an intensive push to overhaul Punjab's health governance structures to enhance national health security and compliance with IHR.

Objective

The specific objectives of the Punjab TA are to:

• Assess the existing IHR/health security arrangements at the provincial and district level of the P&SHD and propose and operationalise a unified governance mechanism to address inefficiencies in Punjab and make it more efficient and responsive.

Scope of Work and Methodology

As a part of this TA assignment, the team will cover the following scope of work:

• A comprehensive literature review is proposed, including but not limited to the following resources. Through the literature review, the TA team will explore various facets of the health security situation in Punjab.  It will identify the gaps in the core competencies required for IHR implementation and develop pragmatic solutions to address them.
  • JEE Report 2023
  • Calamity Act 1958
  • Health Security Financial Assessment Report 2021
  • Minutes of Meeting of IHR Annual meeting
  • National Action Plan for Health Security 2017-23
  • Pakistan National Health Vision 2015-2025
  • National TB Control Guidelines 2019
  • National Guidelines Infection prevention and control (2020)
  • National Immunization Policy 2022
  • National Strategic Framework for Anti-Microbial Resistance 2015
  • Contingency Plan (for dengue, monsoon, heat waves etc.)
  • Provincial Comprehensive EPI Reviews Reports
  • Essential Package of Health Services documents (Generic & Provincial)
  • One-Health Joint Plan of Action 2022-2026
  • Punjab Health Sector Strategy, 2019-2028
  • Pakistan Crisis Response Plan 2023-2025
  • IDSRS
  • UK Flemming Fund support for AMR
  • Essential Package of Health Service
  • Risk Communication and Community Engagement Strategy, Punjab, 2021
  • Punjab Environmental Protection Act-1997 (amended in 2012)
  • Notification of Tehsil Health Emergency Response Committee (TERC) P&SHD 19-05-2020.
  • Notification of District Health Emergency Response Committee (DERC)
  • Framework of Action towards Climate Resilient Health Systems in Pakistan
  • PC-Is of relevant programmes like TB and HIV/AIDS control programmes and documents on COVID-19 preparedness and response, including other relevant documents that emerge during the TA.
• After completing the desk review, the TA team will conduct consultative sessions with the M/o NHSR&C, the NIH, and the relevant officers of P&SHD, livestock, agriculture, environment, and Public Health Labs in Punjab, along with other relevant government departments considering the multisectoral prevent, detect and respond mandate of IHR.
• The TA team will map the support from development partners for the P&SHD's IHR core capacities, ensuring their inclusion in the governance framework. Key partnerships include the UK Health Security Agency's (UKHSA's) support for the Integrated Disease Surveillance and Response (IDSR), USAID's support for the Global Health Security Agenda (GHSA), and other WHO collaborations.
• After detailed consultations, the team will quickly evaluate governance mechanisms under the IHR, covering Biosafety, Biosecurity, Food Safety, Zoonotic Diseases, AMR, Immunization, Laboratory Systems, Surveillance, Human Resources, Emergency Management, and Infection Control. The objective is to improve governance through enhanced accountability, transparency, rule of law, efficiency, equity, and inclusiveness, aiming for a more effective, cooperative, and fair health security system.
• Furthermore, the team will identify opportunities for supporting and enhancing IHR capacities through Global Health Initiatives contributions.
• The TA team will then formulate and propose a governance mechanism designed to effectively implement NAPHS recommendations, provincial policies, and activities about the operational provincial plan, ensuring an integrated, resilient health system in Punjab that can manage health risks from disasters, outbreaks, and climate change, while clearly defining the roles, responsibilities, and functions of involved forums for optimal functionality and effectiveness.
• The draft governance mechanism will be finalised after obtaining feedback from relevant stakeholders in a consultative session.
• Following the approval, the team will support the P&SHD in organising the first meeting of the governance mechanism at the provincial level and in selected districts.
• The team will also determine the resource requirements at provincial and district levels for implementing agreed actions and activities under NAPHS 2024-28.
• Additionally, they will thoroughly analyse the current and anticipated domestic and external support required to implement the NAPHS 2024-28.

Deliverables

The consultant responsible for this assignment is expected to work diligently towards completing the deliverables outlined in the project scope.

• Comprehensive literature review summarising key findings related to health security, governance structures, and challenges.
• Detailed report on stakeholder consultative meetings, incorporating valuable input from relevant departments and development partners.
• Leadership in developing a governance mechanism for health security, finalised after thorough consultations with relevant public sector stakeholders and donors/development partners.
• Formulation of SOPs, guidelines, and M&E linkages to support the effective implementation of the governance mechanism.
• Evidence of embedded support for the CDC & EPC in the P&SHD to facilitate the convening of the first meeting of the governance and coordination mechanism and its relevant documentation.

Timeline and LOE

The level of effort for the role is 40 working days, from March 2024 to May 2024

Requirements

Technical Expertise:

• Comprehensive knowledge of health governance structures and mechanisms, specifically in the context of health security and emergency response.
• Proficient in designing, implementing, and managing surveillance programs to monitor the emergence and spread of infectious diseases.
• Extensive experience in planning and executing strategies for responding to health emergencies, including pandemics and natural disasters.
• Familiarity with the IHR 2005, encompassing practical implementation at both national and provincial levels.
• In-depth understanding of climate-resilient health systems, emphasising the integration of health security measures in response to climate change.
• Proficiency in conducting thorough literature reviews, analysing policy documents, evaluating data, and synthesising information to inform strategy development and support decision-making during health emergencies.

Competencies:

• Proficient in devising frameworks, analysing disease patterns, tracking outbreaks, and conducting epidemiological investigations to comprehend the spread of infectious diseases and their determinants, including developing effective control/response strategies.
• Demonstrated leadership skills to conduct stakeholder consultative meetings involving various government agencies and departments, non-governmental organisations, and international partners, facilitating focused discussions on complex health governance issues.
• Strong analytical and problem-solving abilities to identify gaps and propose practical solutions.
• Expertise in public health policy development and advocacy, enabling the influence of decision-makers, shaping health security policies, and soliciting the allocation of resources for preparedness and response efforts.
• Effective communication skills to clearly convey recommendations and governance mechanisms to diverse stakeholders.
• Proven experience in designing and implementing monitoring and evaluation structures that carry inter and intra-sectoral linkages for seamless governance operations.