Short Term Consultancy to Revise the Rwanda Dual Clinical Practice Policy and its implementing Ministerial Instruction
Company Information
Palladium is a global leader in the design, development, and delivery of Positive Impact - the intentional creation of enduring social and economic value. We work with foundations, investors, governments, corporations, communities, and civil society to formulate strategies and implement solutions that generate lasting social, environmental, and financial benefits. For the past 50 years, we have been making Positive Impact possible. With a team of more than 2,500 employees operating in 90 plus countries and a global network of more than 35,000 technical experts, Palladium has improved - and is committed to continuing to improve - economies, societies and most importantly, people's lives.

Project Summary
Palladium is implementing the Rwanda Integrated Health Systems Activity (RIHSA), a three-year USAID-funded task order (720-696-20-F-00001) designed to support the Ministry of Health (MoH) in strengthening Rwanda’s health system to provide quality health care for Rwandans while building the capacity of the Government of Rwanda (GOR) to move away from a donor-financed health system towards a self-reliant system. The project is aimed at achieving two major objectives:
1. Reduce financial barriers to health care through a mix of public and private interventions and provide tools for improved domestic resource mobilization and improve health care financing for the GOR.
2. Improve the quality of essential health services at national, facility and community levels utilizing a health systems approach.
Through a focus on financing and quality, USAID-RIHSA provides technical assistance to the GOR on various strategies, tools and approaches that will allow Rwanda to sustainably fund its healthcare system and provide quality care at all levels. The Activity is implemented by a consortium led by Palladium International LLC (Palladium) in partnership with RTI International, the Council for Health Service Accreditation of Southern Africa (COHSASA), Zenysis Technologies, and the Rwanda Agency for Accreditation and Quality of Healthcare (RAAQH).

Context
To ensure equitable distribution of the healthcare workforce, the World Health Organisation (WHO) developed the Global Strategy on Human Resources for Health: Workforce 2030. The strategy aims mainly to streamline the distribution of human resources for health across the private and public sectors to ensure equitable access to healthcare workers and, thus, accelerate progress towards Universal Health Coverage (UHC) and attaining of the UN Sustainable Development Goals (SDGs). This is in response to the difficulties faced by countries to train, deploy, and retain the healthcare workforce to meet the demands of the health system. As part of the efforts towards achieving the above, the Ministry of Health (MoH) in Rwanda developed a Dual Clinical Practice (DCP) policy and Ministerial Instructions (MI) for Health Professionals in 2020. This policy was in response to 1) the growing influence of the private sector in healthcare provision in Rwanda, 2) poor remuneration of healthcare professionals in the public sector, 3) general scarcity and high attrition of human resources for healthcare, and 4) unregulated dual clinical practices in Rwanda. As such, it was recognised that an unregulated dual practice may hamper Rwanda’s efforts in achieving key health outcomes and the attainment of UHC. Therefore, the DCP policy in addition to recognising the challenges faced by the healthcare sector regarding healthcare workforce, sought to put in place a mechanism to compensate health professionals working in public hospitals as well as a governance and accountability mechanisms to ensure proper implementation of DCP in Rwanda. The policy is intended to increase the quality of health services provided in public health facilities and retain highly skilled professionals (medical doctors and dental surgeons) in the public sector.

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The strategic objectives of the policy include:
• To regulate the provision of health care services in public hospitals through a private clinical practice mechanism.
• To improve quality of health care services by retaining health professions in the public service.
• To increase incomes generated by the public hospitals to improve their financial viability.
Excerpts from the DCP policy
To ensure that the quality of care and patient safety is not compromised, the number of patients treated, and procedures performed in DCP must not exceed 50% of those performed in the regular hours of the practitioner. The health professionals allowed under the DCP are General Practitioners, Dental Surgeons and Medical Specialists, and their primary public health facility should be a Medicalized Health Centres, District Hospitals, Provincial Hospitals, Specialised Hospitals, Referrals, or Teaching Hospitals. Under the policy, the primary public facility benefits financially from the DCP services provided by the practitioner by retaining twenty percent (20%) of the revenues generated in outpatient consultations (OPD) and sixty percent (60%) of the revenues generated through medical acts and procedures.

As part of the policy, a monitoring and evaluation framework was created to ensure its proper implementation.
Highlights from the recent assessment of the DCP Implementation
After nearly two years of implementation, in 2022, the MoH with support of partners assessed the implementation and practice of the DCP and Ministerial Instructions (MI). The following were some of the key findings:
• Contrary to the policy, most respondents thought that all clinicians including nurses and midwives were allowed to engage in dual practice.
• All the respondents mentioned that there are no specific committees or official internal mechanisms for the selection and approval of DCP applicants.
• Practitioners (active and prospective) are losing interest in DCP due to various challenges, including delays in payments, and limited number of patients to be seen in the secondary facility, and inadequate infrastructure.
• Practitioners think their share of the DCP revenues is insufficient and unfair.
• A few private practitioners are now seeking public employment, while those still in full-time private practices have requested for increased salaries from their private employers.
• Revenues from DCP account for between 0.1% - 3.6% of total revenues of the public hospitals.
• DCP had increased the retention of specialists in public hospitals; however, there were no figures to corroborate this.
Some of the main recommendations from the assessment include:
• Raise awareness on the DCP policy and Ministerial Instruction among health care providers (hospitals and practitioners) by explaining to them the details of the policy including the benefits and requirements.
• Review the share of revenue between the primary public health facilities and the practitioner by increasing the share and take-home of the DCP practitioner for better motivation and their retention in public hospitals. This includes reviewing the payment of income tax from 30% to 15%. Current withholding tax for consultancy is 15%.
• Provide standardised DCP management tools including a database to ensure that the practice is effectively monitored and managed.
• Advocate for CBHI beneficiaries to also access DCP practitioners in public facilities.
• Ensure hospitals create public awareness on the alternative of accessing DCP services,
• Review the current policies to include other clinical practitioners and allied professionals as well as allow providers to practice in multiple facilities.
The USAID RIHSA in collaboration with the MoH are seeking to recruit a consultant to lead the revision of the current DCP policy and Ministerial Instructions to reflect the some of the recommendations from the recent assessment.

Objectives
The main objectives of the assignment are:
• To review the current DCP policy, Ministerial Instruction, and the Assessment Report of the DCP Implementation in Rwanda Report (July 2022) and incorporate relevant recommendations in the revised DCP policy.
• Interact with stakeholders to obtain further recommendations on the current DCP policy and Ministerial Instruction to enhance the policy
• To assess the influence of the current DCP on retention of healthcare workers in public facilities
• To develop a revised DCP policy and Ministerial Instruction for implementation by the MoH
Expected Deliverables
The expected deliverables include:
• A revised DCP policy and Ministerial Instruction.
• And overview of how the current DCP Policy and Ministerial Instruction has impacted healthcare workers retention in the public sector.
• A summary report of not more than 10-pages explaining the challenges and lessons learned from the DCP policy and Ministerial Instruction revision process.

Timelines
The level of effort for this consultancy is estimated to be not more that 25 working days and to be implemented within three (3) months from the date of signing a contract. The timeline is as follows:
# Activity Timelines
1 Inception Report 1 week from date of signing of contract
2 Document review 2 weeks from date of signing of contract
3 Field work – KIIs and FGDs 4 weeks from date of signing of contract
4 Initial Draft DCP and MI 6 weeks from date of signing of contract
5 Final Draft DCP and MI 8 weeks from date of signing of contract
6 Validation Workshop 9 weeks from date of signing of contract
7 Final Report 10 weeks from date of signing of contract
Proposed Methodology
The proposed methodology may include:
• Key Informant Interviews (KIIs) and Focused Group Discussions (FGDs) with various stakeholders at the National and District levels to identify gaps with the current DCP and MI and give recommendations. These include the MoH, Director Generals of Hospitals, District Heads, Healthcare Workers, Private Hospital Heads among others.
• Review of the current DCP policy, Ministerial Instruction, and the Assessment of DCP Implementation in Rwanda Report (July 2022) to identify gaps and make recommendations.
• Review of the MoH database of healthcare workers to assess recruitment and resignation of healthcare workers from the public sector between 2016 and present, to determine reasons for resignation and destination.
• Review of DCP policies in other countries to identify best practices and incorporate them in the revised DCP policy.
• A stakeholders’ workshop to discuss the recommendations and validate the revised DCP policy and Ministerial Instruction.
Contract Type
This consultancy will be a fixed price deliverable-based contract. Acceptance of the deliverables will be determined by Palladium/RIHSA Health Financing Director. Final approval will be required by the Chief of Party.

Selection Criteria
The applicant must be a consultant with extensive experience in drafting health sector policies.
# Evaluation Criteria Weight (%)
1 Quality of the application and technical proposal 20
2 Applicant’s relevant capacity and demonstrated past performance in developing policies and or conducting similar or related assignment 30
3 Qualifications of the consultant 20
4 Understanding/familiarity with the Rwandan health sector and its policies 10
5 Cost 20
Total Score 100
All proposals received will be reviewed based on the above evaluation criteria. Negotiations will be held with the candidate that scores the highest number of points using the criteria above.
The application proposal should include:
• A description of how the tasks will be successfully accomplished
• A description of the applicant’s relevant capacity and past performance including similar assignments carried out.
• The qualifications of the applicant which should include a current CV
• Understanding/familiarity of the Rwandan banking and health sector
• Cost Proposal detailing the price per deliverable, inclusive of all logistical costs, including transportation, accommodation, data collection and printing costs. The price should also include applicable taxes.

Profile of the Consultant
The consultant must meet the following minimum requirements:
• Extensive experience in reviewing and drafting policies especially for the health sector
• At least Master’s degree in Health Financing, Health Economics, Public Health, Public Health Finance, or similar field.
• Experience in Human Resources for Health programs will be an added advantage.
• Knowledgeable and experience with dual clinical practice policies and regulations, both locally and regionally.
• Sufficient knowledge of the country context and its health system is desirable.
• Demonstrated competence in oral and written English
• Strong organizational skills, attention to detail, and ability to meet deadlines.
• Proven ability to prepare reports in a clear, concise manner.
Interested candidates should apply using the "Apply" button below not later than 28th November 2022.