Name of Project: Physical Rehabilitation Project (PRA)

Title of action: Consultancy Service to “develop and test a tool to measure the compliance of prosthetics and orthotics services in Nepal with WHO/ISPO standards and guidelines”

Consultant type: International

1. CONTEXT

This Term of Reference (TOR) sets out the general scope of work, responsibilities and anticipated outputs/ deliverables for the Short Term Consulting Agency (hereinafter referred to as the “Consultant”) to develop and test a tool to measure the compliance of prosthetics and orthotics services in Nepal with WHO/ISPO standards and guidelines. S/he will closely work with Handicap International (HI) Nepal team for PRA program during execution of this assignment.

PRA is a USAID funded program being implemented by HI since June 2019. This program aims to improve the mobility and functional independence of conflict-affected civilians and women, men, girls and boys in need of rehabilitation services in Nepal, through the establishment of a sustainable integrated, public-private rehabilitation system. PRA will support LCDMS in developing and implementing guidelines to accompany service delivery, workforce development and data management at federal, provincial and municipal levels.The project will work in close colloboration with the LCDMS,NHTC, Provincial government (Ministry of Social Development) NFDN[1],PRCs[2], national professional associations, WHO, USAID and other USAID supported programs.

PRA has the following major objectives:

1. The quality of the rehabilitation services is enhanced
2. Access to rehabilitation service is increased
3. The sustainability of PRCs is strengthened.

Prosthetics and Orthotics (P&O) profession is in the course of developing in Nepal, with huge unmet needs in terms of service coverage and workforce^[3]. At present the service is mostly confined to be delivered by private not-for profit organizations (especially non-government organization) and very few semi government entities. P&O service provision in Nepal, in the absence of service provision guidelines, is relying on the capacity of the service providers, availability and skills of P&O professionals. There are more or less 19 service providers including 7 non-government organizations (NGO), 1 government (hospital based), 1 semi-government, 4 hospitals and 6 private centers. There are approximately 40 certified/qualified professionals working in the country, all of them trained abroad, and some others with the long working experience in the field but not academically qualified or trained.

The sustainability of services has been the most challenging factor that all these organizations have to deal with. Humanity & Inclusion Nepal has been supporting the development of Prosthetics and Orthotics profession in Nepal since 2005. In January 2019, The 9 years’ long STRIDE project funded by USAID and implemented by HI through 5 sub-partners (Physical Rehabilitation Centers (PRCs)) came to an end. During STRIDE project period more than 18000 mobility assistive devices were delivered. The project was able to support the establishment of assistive product services including P&O services through development of human resources, quality service delivery and improving access in remote areas through outreach activities. During the project period, government and non-government funds were raised through advocacy at the national level and through the mobilisation of local resources. Among those opportunities, funds were regularly allocated from Ministry of Women, Children and Senior Citizen (MoWCSC) based on Public-Private Partnership model, although no specific Public-Private Partnership (PPP) guidelines to regulate this process were developed and no plan was made by the ministry to further look into needs and availability of services.

Similarly, there are no reference guidelines on P&O service provision defined in Nepal by any authorities. HI and its partners referred to the clinical protocols proposed by International Society of Prosthetics and Orthotics (ISPO) for ensuring the quality service delivery in the country whereas there was no specific assessment carried out on the compliance of the operating procedures from other PRCs^[4].

Rehabilitation services has been recently introduced in Health Policies following continuous lobbying and advocacies from different stakeholders and the needs of long term rehabilitation service for 2015 earthquake survivors. Indeed, “Rehabilitation service” has been mentioned for the first time in the Nepal Health Sector Strategy in 2016 and Physiotherapy (PT) has been included in the list of Essential Health care package that should be available free of cost at all levels in public health facilities. The Ministry of Health and Population (MoHP) of Nepal has not yet integrated the prosthetics and orthotics/assistive products services into the framework of essential public health services whereas have only considered few options of allocating scattered fund. However, MoHP/EDCD through Leprosy Control and Disability Management Section (LCDMS), the disability and rehabilitation focal unit, has published the Nepal Priority Assistive Product List (PAPL) in 2018, in line with WHO’s priority assistive product list, which included the list of 45 essential assistive products (AP) covering the domains of mobility, vision, hearing, communication, cognition and language. This is a significant initiation from MoHP in the field of assistive technology in the country). However, there are no further activities conducted on the development of service provision guidelines, for example calculating the optimal costs and minimum service level standards for assistive products.

PRA project will be highly focused in integrating rehabilitation services in the public health system by collaborating with the MOHP and key institutional stakeholders in developing essential guidelines and implementation of PPP mechanism, standard operating protocols and clinical guidelines, building the capacities of physical rehabilitation centers, building the capacities of rehabilitation professionals. Disable people organizations, local authorities and communities will be involved to increase demand for rehabilitation services and advocate towards the engagement of the government in developing rehabilitation services.

Need of consultancy:

To improve access to prosthetics and orthotics services, WHO, in partnership with the International Society for Prosthetics and Orthotics (ISPO) and the United States Agency for International Development (USAID), has developed and released global standards for prosthetics and orthotics to assist member states in setting up, improving or transforming their systems for delivering these services (2017). A year later, ISPO released new “Education standards for prosthetics and orthotics occupations”. The WHO is also developing a tool to measure compliance with the above mentioned standards. All together, they represent the best international reference for the development of a regulation in system in Nepal.

Assessing the current situation of P&O human resources (need, availability, skills, capacity and work environment), identifying the gaps hindering quality services in compliance with WHO/ISPO standards and guidelines and finally, developing the standard operating procedure, are the current needs to be addressed in the country for ensuring quality P&O services Furthermore, there is an urgent need to help the MOHP defining the minimal quality standard that should be met by private service providers to be accredited and involved in the PPP system. Again, WHO/ISPO standards could help to define those standards. Finally, development of specific mechanisms for financing and providing assistive products (AP) defined in the Priority Assistive Product list is urgent for helping the government to effectively distribute AP to concern population. For that, definition of minimal quality standard for AP is important to estimate the minimal cost of production.

As the global goal of the PRA project is to build the rehabilitation system in the country, keeping MoHP/EDCD/LCDMS on board of the strategical decisions and activities is crucial. So that, tool to be used for carrying out the assessment in compliance with the WHO/ISPO standards is expected to be endorsed by MoHP/ EDCD/LCDMS.

2. DESCRIPTION OF THE REQUIRED SERVICE PROVISION

Ø Beneficiary/Beneficiaries

MoHP/EDCD/LCDMS, POS-Nepal, all the PRCs and service providers (P&O professionals) and relevant stakeholders will directly benefit from the consultancy support. The report obtained from the consultancy will support the MoHP to define the guidelines in assistive technology service provision in Nepal.

Ø Overall and specific goals

Based on the above identified needs, the objectives set for this consultancy are mentioned as under:

1. To test the assessment tool based on WHO and ISPO service standards
2. To help define quality requirements for P&O services and P&O professionals in Nepal, including a set of minimum standards to guide future accreditation process by MOHP in the PPP system (in compliance with WHO/ISPO standard)
3. Adapt the tool to the Nepali context for helping Nepal stakeholders to assess the compliance of minimum standard standards for P&O service provision, including P&O professionals’ capacities in Nepal
4. To recommend a methodology for costing of mobility AP, in line with the national Priority Assistive Product List (for mobility items).

Ø Deliverables:

1. A comprehensive report that outlines strengths and areas of improvement for the system of P&O services in Nepal and includes key recommendations to the government of Nepal to address the gaps based on the assessment tool on WHO/ISPO standard.
2. A guiding document on minimum standards for P&O services in Nepal including a tool to measure compliance for future accreditation of services by the government
3. An assessment tool adapted to Nepali context and minimum standards is developed
4. A costing methodology for prostheses and orthosis
5. The report must be submitted by 30^th February, 2020.

Footnote:

[1] NFDN is a sub-partner of PRA

[2] 5 Physical Rehabilitation Centers (PRCs) are sub-partners of PRA. They are Community Based Rehabilitation Biratnagar (CBRB), Prerana Rehabilitation Center Malangawa, National Disabled Fund (NDF) Bhrikutimandap, Nepalgunj Medical College (NGMC) Kohalpur and Nepal National Social Welfare Association (NNSWA) Mahendranagar. The project will also work with other PRCs through the network of service providers.

[3] A service coverage assessment study conducted in 2016 on 5 physical rehabilitation services supported by STRIDE programme, demonstrated that only 10% of the need of assistive devices had been met

[4] Expect for two PRCs supported by ICRC in Green Pastor Hospital and Army Hospital, which are using ICRC quality operating procedure.