TORs: National Senior STTA – Health System Expert
Technical Assistance for Third Party Performance Audit of Healthcare Establishments 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
Established through the promulgation of the Punjab Healthcare Commission Act 2010 (PHC Act 2010), the Punjab Healthcare Commission (PHC) is the regulatory body for healthcare facilities in Punjab. PHC’s mandate is to improve the quality of healthcare in the public and private sectors and take measures against all forms of quackery in Punjab. Under Section 13 of the PHC Act 2010, the Commission has the mandate to register all types and categories of Healthcare Establishments (HCEs).
Section 4, sub-section (5), and Sub-section (6) of the Punjab Healthcare Act 2010 provide that the Commission will conduct third-party evaluation through independent performance audits of the HCEs in a phased manner. The Strategic Business Plan (2023-2028) approved by the PHC Board also provides guidance on the Commission conducting third-party performance audits for HCEs to assess the impact of PHC's regulatory framework on the quality of healthcare service delivery across the province.
However, reluctance on the part of stakeholders and capacity constraints on the part of PHC have delayed this process, and this performance audit has not been able to take place so far. To address this issue, PHC, under Section 4(2)(m) of the Act has the provision to engage a team of external experts to conduct these performance evaluations. Punjab Healthcare Commission has requested E4H Punjab to provide technical assistance for undertaking the performance audits of the 250 Category 1 HCEs (50+bedded hospitals), both from public and private hospitals, who have successfully acquired full licenses. This independent audit will not only bring objectivity and impartiality in enforcing quality of care but also help address the capacity constraints within PHC.
Objective
The objectives of a third-party audit of healthcare establishments typically focus on evaluating the performance, quality, compliance, and overall effectiveness of healthcare services in Punjab. Such evaluations are crucial for identifying areas of improvement and ensuring that healthcare providers meet the necessary standards. The main objectives of the third-party audit are as follows.

• To assess whether the fully PHC licensed HCEs across the three tiers of service delivery—in providing services according to MSDS adhere to MSDS
• To verify compliance with local healthcare regulations and standards
• To identify bottlenecks or inefficiencies in operational processes and provide actionable insights to bridge these gaps.
• To ensure accountability by providing an unbiased assessment of the HCE's performance and compliance.

Scope of Work and Methodology
Phase 1: Planning and Preparation
In the first phase, the team is expected to develop an understanding of the scope and breadth of the proposed audit. This will involve, the following activities:

• Conduct meetings with other key stakeholders, including the Delivery Unit team, and other key personnel in the P&SHD and SH&MED, to assess their understanding of and expectations of a third-party audit
• Conduct meetings with PHC Commissioners and Senior Management to define/refine the scope of work
• Conduct a rapid but structured literature review to assist the team in developing a well-thought-out methodology for the audit, identifying key metrics to measure and how best to evaluate weaknesses and challenges within the operating environment of the HCEs under review.
• The team is expected to review key documents, including the Punjab Healthcare Act 2010, relevant regulations, and strategic business plans, MSDS development processes, training methodologies, assessment tools, and inspection results.
• Prepare and present an Inception Report outlining the understanding of the assignment, proposed methodology, implementation arrangements, performance indicators, data collection instruments, key deliverables, and work plan with timelines.
• Following the submission of the inception report, and the finalisation of the methodology, the team is expected to develop assessment/evaluation tools and a performance evaluation plan for field evaluators. The evaluation tool should be informed by the findings of the literature review, and the Key Informant Interviews (KIIs) conducted earlier. It is expected that the tool will cover the standards prescribed in the MSDS and cover the ten functional areas mentioned in the strategic approach section for assuring quality healthcare services delivery.
• Following the development of the tool, the team is expected to conduct trainings for data collectors and evaluators. This should include a structured orientation workshop to establish expectations from and guidelines for the field staff.

Phase 2, 3 & 4: Field Data Collection and Preliminary Analysis

• Conduct on-site audits across the three regions (North, South & Centre) of the province to assess HCEs' compliance with MSDS.
• Collect data digitally on rented tablets for easy analysis, through mutually agreed assessment tool with the PHC and the Department.
• Clean and organise the collected data, performing initial qualitative and quantitative analyses to identify trends, patterns, and anomalies.

Phase 5: Data Analysis, Reporting, and Strategic Recommendations

• Use statistical tools to measure findings and synthesise data into actionable insights, highlighting strengths, weaknesses, and opportunities for improvement.
• Compile a draft report based on the analysis for review and feedback by the PHC.
• Present the analysis and review findings to both the Health Departments and stakeholders.
• Finalise and submit the report in the agreed format, including strategic recommendations for enhancing healthcare quality and compliance across the province.

Team Structure

Expected Deliverables, Outputs and Outcomes
Inception Report: The inception report will define the audit's objectives, scope, and methodology and provide a timeline (Gantt Chart). It will also outline focus areas and limitations and address potential risks with mitigation strategies.
Evaluation Tool: The evaluation tool will include audit questionnaires for all three tiers of HCEs focused on encompassing all ten functional areas of MSDS (as mentioned in the scope of work and methodology section) assuring quality healthcare services delivery.
Data Collection and Preliminary Analysis Report: The preliminary data analysis report provides an overview of HCE performance, key findings on operational effectiveness and quality of care, and potential areas of concern like regulatory non-compliance or inefficiencies. Quantitative data and qualitative insights from patient and staff feedback direct the audit and identify areas for improvement.
Final Audit Report: The final audit report will be a clear, comprehensive, and actionable document that provides recommendations and practical solutions tailored to the challenges and opportunities being faced by the HCEs in Punjab in both the public and private sectors. The final report is expected to effectively use data presentation tools to make complex information understandable and engaging for all stakeholders.
Timeline and LOE
The level of effort for the role is 54 working days, from October 2024 to - December 2024.
Requirements:
Technical Expertise

• Basic Medical Degree (MBBS/BDS); with Post-graduate degree in Public Health, Hospital Administration/health Planning and Management or equivalent
• 18 years of education including basic medical degree (MBBS/BDS) and house job; followed by post-graduate qualification in Public Health, Epidemiology, Health Planning and Management, Health Systems Management, Hospital Administration, or equivalent.
• Minimum of -15 years of experience in leading large-scale health system projects, with a proven track record of successful project leadership.
• Extensive experience in health system strengthening, public health, or hospital management at senior levels.

Competencies

• Expertise in health system analysis, project management, and strategic planning.
• Strong understanding of public health principles, health policy, and healthcare delivery systems.
• Proficiency in using project management tools and software.

Responsibilites

• Serve as the overall leader of the project, overseeing all aspects of project execution, including planning, implementation, monitoring, and reporting.
• Develop and implement the project’s strategic plan, ensuring alignment with project objectives and stakeholder expectations.
• Lead the project team, providing guidance, mentorship, and support to ensure high performance and successful project outcomes.
• Lead the design and execution of high-impact interventions aimed at improving health system efficiency, service delivery, and patient outcomes.
• Act as the primary point of contact for all project stakeholders, including government agencies, health institutions, donors, and other partners.
• Establish and oversee quality assurance processes to ensure that project deliverables meet the highest standards of quality.
• Conduct regular project reviews and audits to identify areas for improvement and implement corrective actions as needed.
• Oversee the project budget, ensuring that financial resources are used efficiently and in accordance with donor requirements.
• Prepare and submit comprehensive project reports, including progress updates, financial statements, and impact assessments.

Deliverables

• Inception Report
• Evaluation Tool

Lead the team in developing the tool and have it approved by the Cabinet before implementing it in the field for all three zones.