PDS No: 9

Form 5A3 Comments and Suggestions on the Terms of Reference and on Services and Facilities to be provided by the Clients

1. On the Terms of Reference

The consultant has carefully gone through the project’s well-defined objectives, enabling them to fully comprehend the monitoring challenges and connect the impact evaluation assignment criteria and the project implementation methods.

• Including the estimated cost clearly shows the project’s financial aspects. It is commendable that the government has undertaken and implemented the project entirely on its budget.

• The Top outlines the consultant’s responsibilities with an illustrative explanation, which has helped develop a relevant study methodology and work plan.

• The specific mention of the submission schedule for the Inception report, one draft report, and the final report have clarified the logistical requirements.

• The Proposal Data Sheet (PDS) has facilitated the client’s expectations.

1. Comments on Service and Facility

• The Proposal Data Sheet (PDS) outlines the types of facilities the client will provide, both in terms of general provisions and specific field-related facilities, setting clear expectations for the project’s operational support.
• The Terms of Reference (ToR) details the required team composition, project duration, study coverage area, and expected respondents, enabling the formation of a competitive team customized to the project’s needs.
• Logistic support from the client, including DGHS support, Necessary documents, and knowledge sharing is explicitly articulated in the ToR
• The Consultant has conducted a thorough review of the client-provided items and outlined suggestions for enhancing administrative and local support to maximize research effectiveness, as detailed in the preceding analysis of the ToR.
• Request for administrative and local support from the client aims to streamline project operations and facilitate fieldwork for the consulting team, fostering an environment conducive to achieving project objectives efficiently.

.

Form 5A4 Description of Approach, Methodology and work Plan for Performing the Assignment

5A4. Technical Approach and Methodology

5A4.1 Introduction

Directorate General of Health Services (DGHS), is a Bangladesh government body responsible for overseeing the public health system, developing health policies, coordinating services, implementing programs, regulating facilities, and monitoring health outcomes. The proposed research on “Facilitators, barriers and potentials solution to access and delivery of quality care for major non communicable disease (NCD) through NCD corners in Bangladesh “” is for improvement of  NCD corners and NCD treatment facilities  in Bangladesh.

( Mixed method study) Exit interview

5A4.2 Rationale:

Non-communicable diseases (NCDs) is a vital public health crisis, claiming 41 million lives in 2021 alone, with a staggering 71% of all deaths worldwide attributed to NCDs. Particularly alarming is the disproportionate impact on low- and middle-income countries (LMICs), where 77% of these deaths occur. Bangladesh, too, grapples with the rapid escalation of NCDs, now responsible for approximately 68% of mortality and 64% of the disease burden in the country. In response, the Government of Bangladesh has initiated significant efforts to address this burden, notably through the establishment of NCD corners in primary healthcare facilities since 2012. Starting as a pilot program in three Upazila Health Complexes (UHCs) in the south-western districts, these corners aimed to provide specialized care for prevalent NCDs. Expanding this successful initiative to 300 UHCs nationwide underscores the government’s commitment to tackling NCDs. However, despite these efforts, there remains a lack of comprehensive understanding regarding the facilitators, barriers, and quality of care offered by NCD corners. Therefore, this study seeks to bridge this gap by conducting a comprehensive assessment of the factors influencing the provision of quality care through NCD corners. The objective is to qualitatively and quantitatively assess facilitators, barriers, and identify potential solutions to improve access and delivery of quality care for NCDs across Bangladesh.

5A4.3 Objective of the study:

General Objective: “Qualitatively and quantitatively assess the facilitators, barriers, and identify potential solutions to improve access and delivery of quality care for non-communicable diseases (NCDs) through NCD Corners in Bangladesh.

5A4.4 Specific objectives:

1. Assess the facilitators’ contribution to the provision of quality services for major NCDs, including facility readiness, diagnostic services, and the availability of NCD-related medicines.
2. Evaluate the knowledge and attitudes of service providers towards the NCD management standard module, utilization, and referral system.
3. Identify barriers and limitations hindering the delivery of quality care for major NCDs, in terms of capacity, training, human resources and logistics, workload, and physical space for rendering services.
4. Identify potential solutions to address existing barriers and limitations through in-depth interviews with policymakers, specialists, and service providers

Expected Outcomes

1. Comprehensive assessment of facilitators influencing the provision of quality services for major NCDs.
2. Evaluation report of service providers’ knowledge and attitudes towards NCD service delivery.
3. Identified barriers and limitations were affecting the delivery of quality care for major NCDs through the NCD corner.
4. Recommendations for potential solutions to overcome identified barriers and limitations for ensuring quality NCD services through NCD corners.

Scope of services, tasks (Components) and expected Deliverables

The study will address the following issues:

1. Assessment of facilitators for quality services for major NCDs, including facility readiness, diagnostic services, and availability of medicines.
2. Evaluation of service providers’ knowledge regarding NCD management models, utilization, and the referral system, along with their attitudes towards service delivery.
3. Identification of barriers and limitations, encompassing knowledge gaps, capacity issues, training deficiencies, inadequacy of human and material resources, workload, and physical space constraints.

Expected Deliverables

1. Detailed report on facilitators contributing to quality NCD services through NCD Corner.
2. Comprehensive analysis of service providers’ knowledge and attitudes towards NCD service delivery.
3. In depth analysis on barriers and limitations hindering the delivery of quality care for major NCDs through the NCD corner.
4. Recommendations for potential solutions are based on in-depth interviews with policymakers, specialists, and service providers.

Research Questions:

• What specific aspects of facility readiness, such as equipment availability and infrastructure maintenance, influence the quality of NCD care provided in NCD Corners?
• How do diagnostic services in NCD Corners, including the availability of tests and their accuracy, impact the effectiveness of NCD management?
• What factors determine the accessibility and reliability of NCD-related medicines in NCD Corners, and how do these factors affect patient outcomes?
• To what extent are service providers in NCD Corners familiar with the NCD management standard module, and how does this knowledge influence their practice?
• What are the attitudes of service providers towards the utilization of the NCD management standard module, and how do these attitudes affect its implementation?
• How effectively do service providers in NCD Corners utilize the referral system for patients requiring specialized NCD care, and what factors contribute to or hinder its effectiveness?
• What are the primary barriers to capacity building among service providers in NCD Corners, and how do these barriers impact the delivery of quality care?
• What training programs are currently available for service providers in NCD Corners, and how do these programs address the specific needs of NCD management?
• What are the key challenges related to human resource management in NCD Corners, and how do these challenges affect service delivery?
• How do logistical constraints, such as supply chain issues and equipment maintenance, impede the delivery of quality care for major NCDs in NCD Corners, and what strategies can be implemented to address these constraints?

Duration of the Assignment:

The assignment duration will be ………… from the date of signing the contract.

Geographical area of the study:

This study will be conducted all over the Bangladesh NCD corners. It will be divided into eight divisional areas in Bangladesh.

1. Dhaka Division
2. Chittagong division
3. Rajshahi Division
4. Rangpur division
5. Khulna division
6. Sylhet division
7. Barisal division
8. Mymensingh division

Proposed Methodology

The general approach of the study is based on mixed methodologies with both quantitative and qualitative research methods. The study design, including the selection of data collection methods and tools, sampling approaches, instrument development, analysis, and dissemination format and strategy aims to answer the study objectives and the study questions.

Our substantial data analysis approach, while those will be collected through multiple methods, will be divided into multiple broad stages.

At the first stage: articles/literatures will be read thoroughly and data collection with the help of the data collection instruments (DCI-Quantitative Survey, KII, FGD, IDI & Case Studies) will be conducted.

At the second stage, an initial classification of studies will be organized on the basis of the quantitative analysis of structured data.

At the third stage, we will attempt to address the validity of the data collected in the form of FGD, IDI, Case studies and KII to investigate the study objectives and to develop the business model. The following flowchart depicts the steps of this study:

Reason and benefits for choosing mixed methodology: We select the mixed method research to get the proper and depth insights of the study. Mixed method research enables in-depth exploration of relationships between variables. It helps to clarify and explain relationships found to exist between variables. There are several reasons for using mixed methods research for this study.

Generalizability: Qualitative research usually has a smaller sample size which sometimes could not be generalizable. In mixed methods research, this comparative weakness is mitigated by the comparative strength of valid quantitative research.

Contextualization: Mix method allow us to use qualitative data to illustrate quantitative findings.

Credibility: Using different methods to collect data on same topic can make the result of the study more credible.

Inclusion criteria: We will include people involve with NCD corners of Bangladesh. Service providers and service receiver of the NCD corners

Exclusion criteria: We will exclude peoplewho are not involve with NCD corners of Bangladesh

Analytical Framework:

By this analytical framework we will demonstrate what method of research will be implemented to achieve the objectives

Table 1- Analytical Framework for Choosing Mix Method

Study Population:

• NCD patients who visited the NCD corners of Bangladesh.
• NCD Service providers staff ( Doctor, Nurse, pharmacist, Center head)

Sampling technique:

For the collection of qualitative information, it is planned to conduct Key informant  interviews (KIIs) with the policy makers, planners, managers, and selected service providers (e.g., Doctors, consultants, Nurses, etc.), while FGDs will be conducted to collect information from service providers (such as medical officers, nurses, and support staff) at different tires of NCDC to understand the healthcare delivery problems at primary, secondary, and tertiary levels including their views and expectations. The number of KIIs and FGDs to be conducted and the target groups are provided in previous Table. 

FGD- NCD corners staffs. FGD For the collection of quantitative information, extensive literature review will be done. The objective of literature review is to extract the relevant information for the study and identify the information gap. Based on the gap analysis, decisions will be taken to collect additional information for the study using an appropriate quantitative method. Sampling Distribution:

Qualitative Sample size calculation & distribution:

Data Interpretation and Analysis:

The study consultants will discuss the checklists/guidelines of the KIIS, FGD, IDI & Case studies with the facilitators and note takers elaborately. The study team (2 Facilitators &2 Note Takers) will follow a strict process in processing qualitative data. All qualitative data will be noted on the spot for real-time response. For all qualitative techniques, at the end of each session, the facilitator and note-taker will meet to review the session and ensure that the notes are detailed and accurately reflected the group discussion taken place. If there are any points that will seem to be not well- captured, the notes will be built upon at this stage. Such review will take place immediately following the session so that the discussion will be fresh in the minds of the facilitators’ team. The Qualitative data collection team members will be encouraged to capture detailed notes and, where possible, direct quotes (verbatim) that will be particularly interesting.

Qualitative Data Analysis:

Once the data collection is completed, the study team will prepare and send hard and soft copies like audio recordings of KII, FGD, IDI & Case studies (if the participants allow recording) to the Team Leader for checking the reliability, validity, and internal consistency of the data and other local discourses relating to the study objectives and the core professional team will group the reports as well as analyze then according to the thematic areas by using the pen and paper method.

Quantitative Data Analysis: The analysis of the data obtained from the study of hypertension patients with and without diabetes can be performed using several statistical methods (by using KOBO toolbox). The following methods could be used to analyze the data:

Closing, Reporting Activities

Draft Report Preparation:  On the basis of the collected information and as per TOR the project area draft Report will be prepared and submitted to the Authority for their comments &views.

Final Report Preparation and Submission:  The project will be accomplished through submission of ‘Final Report”.

Selection of Research Assistant

In case of Research Assistant selection process, we will evaluate their educational background and technical knowledge (such as: BSe or Equivalent Pass). We will recruit 4 Research Assistant for this assignment for 30 Days.

Training of the Research Assistant

Three days of training on theoretical and practical sessions will conduct among the research Assistants. Field management, field data collection procedure, role and responsibilities, and ways to collect data from respondents will discuss during the training of Assistant, after successful competition of training, full team will spend one day in practicing data collection from real respondent using final tools.

5A5: Work Schedule

5A5. Work Schedule

SOMZ proposes the following work schedule with time schedule to accomplish the activities during project period February 2024 to  June 2024 ,

Table 5.7