TORs: National Mid-Senior STTA – Research Associate

Development of a Policy Brief for Provincial Health Accounts for the Primary and Secondary Healthcare Department 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 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

Health systems worldwide are continuing to evolve in response to a multitude of factors, including improvements in medical technology and knowledge, increased information about health and health services and creating greater access to them, changes in health policy priorities to meet shifting disease and demographic patterns, new organisational methods, and more complex financing mechanisms. Health accounts must also adapt to these developments and anticipate future trends.

The Organisation for Economic Cooperation and Development developed the System of Health Accounts (SHA) to meet the increasing demand of policymakers and analysts to describe healthcare systems from an expenditure perspective for international and national purposes. It includes an “integrated and comprehensive methodology for tracking health expenditure through uniform accounts comparable across countries. The framework focuses on final consumption and tracks resource flows through the health system—from its sources (funding sources, financial arrangements), patterns of provision (providers and factors of provision), and through to its use (health care functions, diseases/programmes.

Stemming from SHA are the National Health Accounts (NHA), a macroeconomic accounting framework for revealing a country’s aggregated expenditures on health. NHA provides a detailed functional (e.g., preventive vs. curative services allocation and expenditure) and objective classification (e.g., salaries, medicines, equipment, and buildings) of financial data into different sources (federal ministry, provincial government, state-owned enterprises, private insurance plans, and households).

NHA Pakistan comprises the health expenditures for the four provinces (Punjab, Sindh, Khyber-Pakhtunkhwa (KP) and Baluchistan) as well as federal health expenditures. It shows health expenditure for and of Pakistani citizens and residents as well as spending by external agencies, like bilateral donor agencies and UN offices, on inputs to health care in Pakistan. Although it is recommended in the SHA that the NHA use the accrual method in accounting for expenditures, the data situation in Pakistan currently does not allow

for the application of the accrual method. Therefore, the figures presented for Pakistan’s NHA are cash-based. The province-wise breakdown of health expenditures is called Regional Health Accounts or Provincial Health Accounts (PHA), sub-accounts of the NHA and track health expenses for a specific regional section of the health system. Like the NHA, the sub-accounts measure the expenditures by financing sources, financing agents, health care providers and functions, which show the flow of resources by constructing matrices.

However, the use of NHA and PHA is quite limited for informed policymaking and investment decisions, particularly at the provincial level. This is mostly due to the complexity of the data presented and limited awareness of its existence.

Nevertheless, with increasing investments in Punjab's healthcare sector, mainly through initiatives like the Sehat Sahulat Programme, outsourcing of service contracts for health facilities, and implementation of Universal Health Coverage (UHC) packages, there is a growing need to present health expenditures in a more understandable format for policymakers to make effective, evidence-informed decisions.  

Objective

1. Perform a comprehensive trend analysis of recent rounds of the Punjab Health Accounts/NHA
2. Based on the analysis, develop a comprehensive policy brief that can be used to inform decision-making in the Primary and Secondary Health Department (P&SHD).
3. Collaborate with the P&SHD to identify key stakeholders who will be the primary users of the policy brief so that it can be tailored to the needs and interests of its intended audience.

Scope of Work and Methodology

• The team is expected to plan and conduct initial meetings with key focal points within the Department. The initial mapping of stakeholders should perform the function of a rapid assessment of the current financial flow mechanisms within the P&SHD. Department officials that are directly concerned include all officials in the Development Finance & Reforms unit, the administrative unit, the vertical programmes, the DGHS, the Technical Unit, and HISDU. Please note that this is a non-exhaustive list, and it is the prerogative of the consulting team to ensure that they first map out all relevant stakeholders and all direct and indirect users of financial data so that the policy brief can be structured in a way that proves useful to different use cases.
• Determine if raw data from the NHA specific to Punjab is needed from the Pakistan Bureau of Statistics (PBS). If so, request the P&SHD to facilitate the acquisition of this critical data for the policy brief.

Checkpoint 1: The E4H project team received an inception slide deck with stakeholders identified, financial flows mapped, and key informant interview (KII) prompts developed.

Conduct a rapid literature review to collect insights and create a better understanding of peer-reviewed academic research relevant to NHA/PHA/financial flow analyses and policy briefs.

• The team is expected to conduct a quick but structured literature review with a well-defined review protocol. At a minimum, the protocol must include clearly identified research questions and inclusion/exclusion criteria as a consistent method for extracting and presenting findings.
• The team will then develop an outline for the policy brief based on the findings of the literature review and the conclusions drawn from the KIIs conducted during step 1 of the TA. The team is also expected to share the structure and outline of the policy brief with key officials from the P&SHD and the E4H technical backstopping team to ensure 360 feedback. 

Checkpoint 2: A short three/four-page report presenting literature review findings, the proposed structure of the policy brief, key recommendations, expectations identified during KIIs, and consultations with department officials.

1. With the help of all the data reviewed, the literature examined, and the consultations conducted—the team will develop the first draft of the policy brief according to the outline and priorities identified in the earlier stages of the assignment.

• The team is expected to incorporate schematic diagrams to represent key findings and analyses visually. These visuals should help convey complex information in an accessible and engaging manner.
• The team will share the first draft with the E4H technical backstopping team and present it to identified focal persons within the P&SHD to incorporate any necessary feedback.

Checkpoint 3: A pre-final draft of the policy brief that is expected to go through minor tweaks, formatting and a final technical review. The draft should be accompanied by a detailed email indicating where all requested amendments and review changes have been incorporated and how all comments have been addressed. However, the STTA team may wish to alternatively put detailed comments within the document to show all the aforementioned amendments instead of an accompanying email.

Finalise the policy brief by incorporating stakeholder feedback and addressing comments or concerns. Ensure the document is agreed upon by the P&SHD and ready for dissemination or presentation, effectively communicating its findings and recommendations to its intended audience, mainly the P&SHD.

Checkpoint 4: Final report draft, approved by the P&SHD, the E4H QA team, and FCDO. The final slide deck will present findings to key focal persons within the P&SHD to share findings and recommendations for the policy brief. 

Timeline and LOE
The level of effort for the role is 32 working days, from July 2024 – Sep 2024. 

Requirements: 

Technical expertise

• Expertise in conducting thorough literature reviews and synthesis, consolidating information from diverse sources to inform research and identify knowledge gaps.
• Strong writing skills to prepare clear and concise reports, documents, and findings that effectively present research results and recommendations.
• Ability to generate meaningful insights from collected data.
• Proficiency in managing research projects, including planning, organising, and coordinating research activities and meeting project timelines and objectives. 

Competencies

• The ability to advocate for policy changes or improvements based on research findings, translating research outcomes into actionable policy recommendations.
• Competence in collaborating across disciplines to address complex issues effectively.
• Skill in developing and implementing health communication strategies to convey research findings. 

Deliverables/KPIs

• Develop a draft of the policy brief with all requested amendments and review changes approved by the P&SHD, the E4H QA team, and FCDO.
• Finalise the policy brief by incorporating stakeholder feedback and addressing comments or concerns. Ensure the document is agreed upon by the P&SHD and ready for dissemination.
• Prepare a final slide deck to present findings to key focal persons within the P&SHD.