TERMS OF REFERENCE
UNICEF KYRGYZSTAN
Programme/Project Title:
Health and Nutrition
Consultancy/Services Title:
Development of training module and organize and facilitate 2
training workshop and 1 ToT aimed at improvement of Child
resuscitation services in Kyrgyzstan
Consultancy Mode:
National
Type of Contract :
Consultant
Mode of Selection :
Competitive
Duration of Contract :
12 working days: 6 days during October 2015 and 6 days during
November 2015 and additional 3 days on–line consultancy during
June 2015 for the Course Director
International
Individual Contractor
Institutional
Single Source
Objective of the consultancy/services
The team of International Experts to develop training module and organize and facilitate 2 training
workshop and 1 Training of Trainers (ToT) aimed at improvement of Child resuscitation services in
Kyrgyzstan
Background
In the frame of National Health Care Reform Programme “Den Sooluk” (2012-2016) and Perinatal Care
Improvement Program in the Kyrgyz Republic for 2008 – 2017 the reduction of maternal and child mortality
rates through increased coverage with evidence-based health care services is highly emphasized. Looking
beyond the Millennium Development goals, in 2012 the Government of the Kyrgyz Republic pledged “A
Promise Renewed initiative” committing to work towards an ambitious target of reduction of under-five
mortality to 20 or fewer deaths per 1,000 by 2035.
A key strategy to reduce maternal and newborn mortality is the expansion of evidence-based effective
perinatal care (EPC) that has been introduced in all provinces of the KR, including 65% of all maternity
hospitals. Sites with EPC implementation are showing promising results in improving maternal and
newborn health and survival. The next step is an implementation of evidence-based neonatal and child
resuscitation care modules (HBB- Help Babies Breath, BLS- Basic Life Support, PALS – Pediatric
Advanced Life skills) so as to strengthen the newborn and child survival. To date, resuscitation capacities
in the country, in terms of skills of medical workers as well as technical equipment, have been left without
adequate attention. In addition, demand for health care and health awareness of vulnerable families is an
important area that needs to be emphasized.
Data from WHO report on assessment of quality services provided to 20 children’s departments at rayon
hospitals demonstrated that following wrong practices were registered:
•
Non necessary hospitalization – in 49% of children
•
Wrong diagnosis – 51%
•
Wrong treatment – 80%
•
Non necessary intravenous injection – 61%
•
Complications caused by medical interventions – 84%
•
Non necessary pain – 99%
The provision of basic life-saving health services is limited as capacity of medical workers is poor and
health facilities lack of human resources, basic medical equipment and infrastructure such as access to
clean water and sanitation. Only one hospital in the south is equipped with special type of ambulance to
provide emergency care services while transporting the child, which can be used to transport children with
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severe cases in life threatening situation. At the same time the system of transportation is not developed
and not funded. It is a barrier to transport children from vulnerable families.
During the last 20 years after the country’s independence, pediatrics emergency and resuscitation care has
been left without adequate attention and large-scale efforts of improvement. This far, the Ministry of Health
has initiated clinical standards of management of children under 5 in hospital care, but still a clear and
comprehensive vision for the strategic directions is lacking. To assess the situation at territorial hospitals, in
2010 the MoH together with partners conducted a survey of the risk factors and the main causes of deaths
of children and found out that:
•
In 37 percent of cases, children were prescribed at once up to 5-6 medicines, and in 20 percent
more than 7-8 medicines, reflecting the absence of standard evidence based approaches for treating
several conditions in children
•
10,6 percent of children who died were examined first time not until more than 6 hours after arrival
in an admissions department by medical personnel, indicating that hospital structures are not rational and
management and referral systems are weak.
•
One third of children patients with diarrhea and 40 percent with acute respiratory infections or
pneumonia were placed in infectious and pediatric departments for more than 6 hours without receiving
any necessary emergency therapy and observation, and thus later were transferred to the intensive care
department in extremely critical condition. This can be considered as a sign of absence of clear referral
criteria and algorithms for provision of timely quality medical services by medical workers on all levels of
medical care system starting from family/community to tertiary level facilities.
The in-depth analysis has brought to surface a number of gaps that need to be addressed in a
comprehensive manner. These gaps and deficiencies are found in infrastructure, life-saving equipment,
supplies and integration of different levels of health system. In addition, since the collapse of the Soviet
system, emergency pediatrics departments have not been provided with any trainings thus clinical skills
and knowledge of health care providers are also a major hindrance for the development. Appropriate
pediatric emergency care is considered highly important and efforts to improve the quality and access to
care will have an impact on reducing morbidity as well as mortality of children under five.
In 2013-2014 several short assessments of situation in emergency care for young children were conducted
by international experts Dr.Arunas Lubshis and Rimantas Kevalas as a part of technical support of UNICEF
to Ministry of Health. Based on their conclusions, main findings of assessments are:
•
Hospital care for young children should be optimized;
•
Primary health care services are not of good quality and because of that sick children are brought to
medical staff at hospital, without referring to primary care level;
•
High level mortality of children at first day of hospitalization demonstrates low quality emergency
care services both at primary and hospital levels;
•
Low quality of emergency care services for sick children rooted in following factors:
i)
Absence of clear criteria for referral and functional responsibilities of health facilities at different
levels of the system;
ii)
Absence of clinical standards, algorithms for emergency care for children; Low level of knowledge
and skills of medical workers, providing services to children in severe health conditions. Non rational usage
of available resources, including of equipment. Units, which provide emergency and intensive care for
children, are compounded by very different modifications of equipment. Medical equipment is insufficient
for intensive care of children in many intensive care units. There is so lack of medical laboratory
equipment. (In many places where children is getting intensive care is no blood gas analyzer).
iii)
Absence of clear medical referral system in terms of system, transport and etc. There is no
transportation system for sick pediatrics’ patients. Critically ill children do not receive adequate treatment in
the territorial hospitals. There they stay unacceptably long, are not transferred to hospital, where can get
the right treatment in the right place (oblast hospital or hospitals where full intensive care and consultations
are available). Transportation system should be based on the principle from the self to a higher level health
facility.
iv)
Absence of training modules, programs on pediatrics advanced care on the level postgraduate
education.
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As a short term strategy it was recommended to start to build team of local experts in the area of
emergency care for young children in a severe health conditions, to bring evidence based knowledge to the
country and initiate the development of clinical standards for main critical health conditions.
Up to now, according to joint plan of the Ministry of Health and UNICEF, signed last year, 8 Basic Life
Support trainings were organized for more than 140 health workers, providing resuscitation services to
children at hospitals (doctors and nurses). According to the agreed plan with the MOH, the 40 health
workers (20 from the north and 20 from the south), who demonstrated best results during the workshop,
will be selected for participation at 2 “Child Resuscitation training”. Out of 40 trained health workers will be
selected 10 best trainees, who will be invited to attend ToT.
Scope of work and key tasks
The purpose of this two 2 days courses is to learn how to work in a team, clearly divide responsibilities
between doctor and nurse, colleagues, how to use standardized methods and skills, use mnemonics that
help to better memorize the sequence of actions in emergency situations. During ToT around 20 selected
medical workers will be trained on providing resuscitation services to children at hospitals from the south
(Osh, Jalal-Abad, Batken) and 20 from the north (Issyk-Kul, Chui, Naryn, Talas, Bishkek) provinces of the
country.
1) Two 2 days workshops in October 2015: International Trainers will be arriving on Saturday and
they will be preparing training rooms on Sunday with support from identified team of the Ministry of
Health. First 2 days training will be organized on Monday-Tuesday. On Wednesday will be day off.
Second 2 days training will be organized on Thursday-Friday. Out of all local participants will be
selected 10 best national trainers for the next second ToT.
2) One 2 days ToT for 10 selected health specialists and 2 days training, which will be
facilitated by newly trained National trainers for local health providers: International Trainers
will be arriving on Saturday and training rooms will be prepared on Sunday. First 2 days training will
be organized on Monday-Tuesday for 10 selected health specialists. On Wednesday will be day off.
Second 2 days training will be organized on Thursday-Friday. This 10 selected newly trained as a
trainers local health specialists will be facilitating training for other 10-15 health workers under the
guidance of International experts.
Participants: 40 selected medical doctors and nurses from pilot hospitals and who successfully passed
BLS training in 2014-2015, will be trained on this advanced 2 child resuscitation trainings (20 participants at
each workshop) in October 2015 by certified and internationally recognized team of trainers. The content of
this workshops should be based on PALS training with adjustment to the local situation in Kyrgyzstan.
Timetable and standard Agenda for 2 days workshop and 2 days ToT
First day
9:00-9:10
9:10-9:20
9:20-9:50
Workshops
9:50-10:50
10:50-11:50
11:50-12:50
12:50-13:10
13:10-13:30
13:30-13:40
Workshops
13:40-14:10
14:10-14:40
14:40-14:55
14:55-15:15
Registration
Lecture: introduction
Lecture: recognision of the seriously ill child
Resuscitation
Breathing
1 group
2 group
3 group
3 group
4 group
1 group
Break
Lecture: fluid and electrolyte management
Lecture: the management of cardiac rythm disturbance
Break
Cardiac disturbance
Infusion
1 group
2 group
3 group
3 group
4 group
1 group
Break
Lecture: respiratory failure and shock
4 group
2 group
4 group
2 group
3
15:15-15:30
15:30-15:40
Workshops
15:40-17:00
9:00-9:10
Workshops
9:20-10:40
10:40-12:00
12:00-13:00
13:00-14:20
14:20-14:30
Evaluation in
groups
14:30-15:30
15:30-16:30
16:30-16:40
16:40-17:00
Lecture: the structured approach to the seriously ill child
Break
Shock
1 group
2 group
3 group
Second day
Lecture: stabilization after resuscitation, transportation
1 group
3 group
Break
Control tests
Break
2 group
4 group
Management of cardiac rythm
disturbance
1 group
2 group
3 group
4 group
Break
Debate, discussion course
3 group
1 group
4 group
4 group
2 group
Respiratory failure and shock
3 group
1 group
4 group
2 group
The group of trainers will be consisted of Director of Course, 3 Doctors Instructors and one Nurse
Instructor.
Assignment and responsibility of the Director of Course ( 3 days on-line, 6 days in country during the
first visit and 6 days during the second visit to the country):
1. To lead the process of preparation of content of children’s resuscitation training module for health
workers of district hospitals (doctors and nurses) based on available global experience, evidence
based interventions and approaches, which can fir content of Kyrgyzstan (within 3 days on-line
work during June);
2. To coordinate the team of consultants, consisted of Director course, 2 doctors and one nurse in
preparation process and actual facilitation of training in Bishkek city;
3. To advise and provide technical support to UNICEF country office and partners from Ministry of
health in preparation of workshop in terms of selection and supply of educational equipment
(manikins, materials, medical equipment and etc.) during 3 days in June;
4. Organize, facilitate, in cooperation with UNICEF and Ministry of Health, 2 national training
workshops to enhance capacity, technical knowledge and skills of health providers, selected for
attendance of this 2 workshops;
5. To be fully responsible for preparation of report with recommendations;
6. To submit training materials, power point presentations.
Assignment and responsibility of pediatric intensive care physician N1, trainer for a period of 6 days
consultancy during first visit and 6 days during the second visit to the country:
-
Prepare 2 standards of critical care on cardiac rhythm disturbances (asystole, pulseless activity,
ventricular tachycardia, ventricular fibrillation)
Training part: skill station (intraosseous infusion and endotracheal route for drug administration)
Training part: teaching station (cardiac rhythm disturbances, 4 scenarios)
Organization of test station (cardiac rhythm disturbances)
Assignment and responsibility of pediatric intensive care physician N2, trainer for a period of 6 days
consultancy during first visit and 6 days during the second visit to the country:
-
Prepare 2 standards (respiratory failure due to obstructive causes and loss of control of
breathing)
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-
Training part: skill station (airway management)
Training part: teaching station (respiratory failure, 4 scenarios)
Organization of test station (respiratory cases)
Assignment and responsibility of pediatric intensive care physician N3, trainer for a period of 6 days
consultancy during first visit and 6 days during the second visit to the country:
-
Prepare 2 standards of critical care (on septic and cardiogenic shock)
Training part: skill station (BLS using automated external defibrillator)
Training part: teaching station (shock case simulations, 4 scenarios)
Organization of test station (shock cases)
Assignment and responsibility of nurse, trainer for a period of 6 days consultancy during first visit and 6
days during the second visit to the country:
-
Prepare 1 standard of critical care (venous access and intraosseous infusion during critical care)
Training part: skill station (airway management, bag-and-mask ventilation)
Training part: teaching station (respiratory case simulations, 2 scenarios)
Organization of test station (shock cases using intraosseous route)
Expected Outputs and Deliverables
Expectations from organization of 2 trainings and ToT on a country level are as following:
Successful implementation of this training is a rare chance to develop new and improve the existing
parameters within the health care system in Kyrgyzstan:
• Integration and standardization of various clinical processes in health care system;
• Optimization of management and administrative processes;
• Establishment of effective communication between various health professionals;
• Assurance of consistent and coordinated assessment and treatment for all patients;
• improving the efficiency of the health system;
These activities (by team of International certified PALS trainers, consisted of Director of the course (3
days on-line, 6 days during the first visit, 6 days during the second visit), 3 trainers physicians, one nurse
(with 6 days consultancy during the first visit, 6 days consultancy during the second visit) will be
implemented in the frame of RWP of UNICEF’s Health and Nutrition Section for 2014-2015.
Details of deliverables:
1) Two 2-days workshops on child resuscitation, based on a global knowledge, experience and adjusted
to local context in Kyrgyzstan are successfully organized in October 2015, 1 ToT and 1 training are
organized in November 2015;
2) Team of qualified local experts is successfully trained;
3) Materials for each training are adapted, prepared and submitted to UNICEF for printing and
distribution in advance, at least 2 weeks before training;
4) Specifications for demonstrational mannequins are shared for further procurement by UNICEF;
5) Final report with recommendations is submitted
Reporting and supervision
The Director of course will represent the team of International trainers and will work closely with Health and
Nutrition Specialist, Health and Nutrition officer and Health and Nutrition Programme Assistant.
At the end of the mission the Director of course to prepare report with recommendations and to have a brief
with Health and Nutrition section.
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Qualification/ level requirements
 University degree, advanced level in Pediatrics, Child Resuscitation; nursing (for nurse)
 broad experience in organization of such type of requested trainings, based on globally recognized
modules and approaches;
 Certification of position of International or Master trainer on this type of trainings;
 practical experience of working in child resuscitation units no less than 5 years;
 experience of organization of this type of trainings or assessments in the area of provision of
resuscitation services to children in Central Asia is a requirement for Director or trainer physician;
 Initiative and ability to organize independently; sense of working thoroughly; good organizational and
communication skills
Languages
 Spoken Russian is requirement, knowledge of written and spoken English an asset
Required expertise and Submission evaluation
years
All submissions will be assessed against the following criteria:
Criteria
Education
University degree, advanced level in
Pediatrics, Child Resuscitation; nursing (for
nurse)
1-5
Professional training
experience
Broad experience in organization of such type
of requested trainings, based on globally
recognized modules and approaches,
preferably based on PALS;
1-5
Certification of position of International or
Master trainer on this type of trainings;
Professional practical
experience
Practical experience of working in child
resuscitation units no less than 5 years;
1-5
Knowledge and
experience of working in
Central Asia period
experience of organization of this type of
trainings or assessments in the area of
provision of resuscitation services to children
in Central Asia is a requirement;
1-5
Russian is requirement, written and spoken
English is asset
1-5
Language
Duty station and official travel involved
Bishkek, Kyrgyzstan.
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If UNICEF determines that the Contractor needs to travel in order to perform his or her assignment, that
travel shall be specified in the contract and the Contractor’s travel costs shall be set out in the contract: In
cases where travel costs have not been set out in the individual contract, the consultant and individual
contractors are expected to submit, within ten days of completion of a specific travel, a voucher for
reimbursement of travel expenses to the appropriate Operations/Human Resources manager.
Reimbursements shall only be processed if travel was duly authorized in the individual contract or by an
authorized manager of the contracting division or office, in writing and prior to the travel. Consultants and
individual contractors are responsible for assuming costs for obtaining visas and travel insurance.
Travel paid for by UNICEF in advance, and travel costs reimbursed after travel, shall be based on economy
class travel, regardless of the length of travel, subject to exceptional approval of business class travel by
the Head of Office/ Division Director, for example for medicals reasons when certified by UN Medical
Services in New York.
Costs for accommodation, meals and incidentals shall not exceed applicable daily subsistence allowance
(DSA) rates, as promulgated by the International Civil Service Commission (ICSC).
Estimated cost and amount budgeted
Estimated cost to be proposed by an applicant. The consultant will be selected based on the “best value for
money” approach. UNICEF will effect lumpsum payment for the services provided by the Consultant upon
satisfactory completion of the services, submission of the outcome report and acceptance of invoice
through the bank.
The duration of work assignment is following:
Director of the course: 3 days on-line work, 6 days in country in October and 6 days in-country in
November
3 International trainers Physicians and trainer nurse – 6 days in country in October and 6 days in country in
November 2015.
The each member of the team will be paid upon satisfactory performance of the service at the daily rate
agreed individually based on qualifications and offered rate.
Note: In all cases, consultants may only be paid their fees upon satisfactory completion of services. In such
cases where payment of fees is to be made in a lump sum, this may only be payable upon completion of
the services to UNICEF’s satisfaction and certification to that effect, and any advance on the lump sum
may not exceed 30% of the fees. In such cases where payment of fees is to be made in installments, the
final installment may not be less than ten per cent (10%) of the total value of the contract, and will only be
payable upon completion of the services to UNICEF’s satisfaction and certification to that effect.
Source of funding/grant reference (date of expiration of the grant):
SC140648 valid until 31.07.2017
SC 140575 valid until 30.06.2017
Drafted:
Cholpon Imanalieva, Health and Nutrition Specialist
Reviewed:
Jamilya Jusaeva, Operation Manager
Approved:
Raoul De Torcy, Deputy Representative
Date:
June 2015
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