Terms of Reference for Baseline Assessment of the Project: “Strengthening Immunization Program”

Terms of Reference for Baseline Assessment of the Project:

“Strengthening Immunization Program”
(Funded by the Centers for Disease Control and Prevention – CDC)

Introduction

The most recent national figure on vaccination coverage in Ethiopia, primarily derived from the 2019 Ethiopian Mini Demographic and Health Survey (EMDHS), indicates that approximately 44% of children aged 12-23 months had received full vaccination. This figure underscores the significant progress made by the Expanded Program on Immunization (EPI) since its inception in 1980, yet also highlights that Ethiopia remains among the countries with a substantial number of unimmunized and under-immunized children. Notably, the 2019 EMDHS data reveals considerable regional variations in vaccination rates, with higher coverage observed in urban areas like Addis Ababa and Harari, and significantly lower rates in regions such as Afar and Somali.

Furthermore, factors such as socioeconomic status, place of delivery, and maternal healthcare access demonstrate a clear correlation with immunization coverage levels. While improvements have been achieved over time, the national full vaccination rate of around 44% in 2019 remains a critical concern, falling short of national targets and global recommendations, thus necessitating continued and intensified efforts to strengthen immunization services across the country.

In response to these challenges, Save the Children, in partnership with the MOH and funded by the Centers for Disease Control and Prevention (CDC), is implementing the “Strengthening Immunization Program” project. This five year initiative (09/24 – 09/29), aims to strengthen immunization services in selected sub-national areas of the Oromia and Amhara regions, which have a high prevalence of unvaccinated (zero-dose) children and are vulnerable to disease outbreaks.

Project Overview

The “Strengthening Immunization Program” is a five year initiative (09/24 – 09/29), implemented by Save the Children in partnership with the MOH and funded by the Centers for Disease Control and Prevention (CDC). This project aims to strengthen immunization services within targeted sub-national areas of the Oromia (specifically Dodola rural, Shashemene zuria, Shala, Ginnir rural, and Raitu woredas) and Amhara (Bati town and Bahirdar town) regions. The overarching goal is to improve immunization services in these areas. The specific objectives, include: implementation of improved tailored delivery strategies to reach un-/under-immunized populations, increasing demand for routine and campaign immunization services, and enhancing collaboration and coordination with government and implementation partners such as the Ministry of Health (MOH), Regional Health Bureaus (RHBs), Zonal Health Departments (ZHDs), The Consortium of Christian Relief and Development Association (CCRDA), and Acasus (a private consulting firm providing digital solution) . Ultimately, the project seeks to achieve strengthened immunization service delivery and improved government and partner coordination and communication in the targeted subnational areas. The primary target beneficiaries include an estimated 189,327 under-five children and 4,376 adults (HW/HEWs, volunteers, and caregivers) directly, with an aim to indirectly reach approximately 659,077 individuals (children and adults) within the project locations.

This TOR for a baseline assessment for the program is essential to establish a clear understanding of the existing situation before project interventions begin, providing critical data for monitoring progress and evaluating the overall impact of the Strengthening Immunization Program. The baseline assessment will include both a household survey to assess coverage levels for immunization in the project communities and understand knowledge, attitudes and practices related to immunization, as well as a health facility assessment to understand planning, processes, as service readiness of both in-facility and outreach immunization services.

The table below presents some of the indicators that need to be measured at baseline to understand the initial state before program implementation and to later evaluate its effectiveness

 

Indicator Type	Indicator name
Process	% of woredas that use digital monitoring systems to track outreach sessions
Output	Proportion of woredas with updated micro-plans
Output	% of health facilities with updated micro-plan
Outcome	% of children vaccinated in project supported areas (population indicator)
Output	% of health care workers scoring 70% or higher on post training knowledge assessment
Output	% of health facilities supported to conduct catchup vaccination campaign sessions
Output	% of health facilities with no reported stockouts of vaccines upon supervision visit

 

Objectives of the Baseline Evaluation

The evaluation aims to:

Baseline Household Survey:

• Estimate immunization coverage, for all antigens in the national routine immunization program, disaggregated by relevant demographics among children age 12 to 35 months in all implementation woredas.
• Assess the level of missed opportunities for immunization.
• Identify key characteristics of fully, partially, zero dose or unimmunized children. Including among special population: IDPs, urban slums, people on the move, returnees and pastoralist communities, that have the least access to and/or utilization of immunization service.
• Assess community knowledge, attitudes, and practices related to immunization with a focus on caregiver’s perception and response to services (service experience). This includes how people are treated and whether the interaction fosters trust, dignity and cultural alignment

 

Woreda and Health Facility Assessment:

• Assess the availability and quality of immunization microplan
• Assess availability and functionality of immunization coordination mechanism at each woreda
• Assess the immunization service delivery and service quality – what is being delivered and how effectively it is delivered including immunization session planning, service delivery strategies, frequency of service delivery, counseling protocols, management of side effects, and overall adherence to care standards
• Evaluate integration of services (immunization with maternal, child health, and nutrition services)
• Assess vaccine logistics, and cold chain management.
• Assess the availability and technical competence of health workers (HWs) and health extension workers (HEWs) to provide immunization services.
• Review the status of vaccine preventable disease (VPD) surveillance in the woredas.
• Examine the immunization information system, monitoring, and supervision systems and data quality.
• Assess/track the annual local government allocation for health and immunization programs.
• Establish a benchmark to monitor performance progress throughout the project life
• To analyze barriers and enablers of immunization uptake, that identify factors that affect provision and uptake of immunization service.
• To analyses the root causes for not utilization of immunization service in the community through an in-depth analysis of individual, community and structural factors
• To map and identify special community: IDPs, urban slums, people on the move, that have the least access to and/or utilization of immunization service. And identify recognizing the unique needs of each group and highlighting major gaps/unmet needs of these special population considering the different immunization program components.
• Identify what strategies should be used for raising the demand for immunization by individuals, households and community members including among special population groups including (IDPs, returnees, urban slums, pastoralist communities)

 

Formative Study (Qualitative Data)

 

Scope of Work

The baseline evaluation will be conducted across seven woredas in the two target regions.

The table below outlines the geographic scope of the Strengthening Immunization project, along with existing health facilities, the estimated total population, and the number of target children within these areas.

Table 1. Estimated Programmatic and Health Facility Population of the CDC-funded Strengthening Immunization Project

 

Regional State	Zone	Woreda	EFY 2023/2016 Population	Under 5 children	Total beneficiary (under five)	# of HPs	# of HC
Amhara	Bahirdar	Bahirdar	412361	55834	47459	11	10
Amhara	Oromia Special	Bati Town	41,964	10,884	9251	8	2
Oromia	East Bale	Ginnir Rural	197441	32440	27574	23	5
Oromia	East Bale	Raitu	54687	8974	7628	10	2
Oromia	West Arsi	Dodola R	270,374	44,425	37761	51	10
Oromia	West Arsi	Shashemene	186,214	30,595	26006	60	12
Oromia	West Arsi	Shalla	240938	39586	33648	46	9
Total			1,403,979	222,738	189,327	209	50

HPs = Health Posts; HC’s = Health Centres

Methodology

The baseline evaluation will employ a mixed-methods approach: a cross-sectional household survey; a health facility readiness survey and a qualitative interviews with woreda health officials and selected community leaders.

Baseline Survey and Health Facility Assessment Design:

The technical proposal for the baseline assessment must utilize comparative methodology to the standards in the technical area of immunization. The WHO guidelines provide a standardized framework for conducting immunization coverage surveys. This framework ensures data quality through robust data collection methods, including well-trained interviewers, rigorous data entry procedures, and robust quality control mechanisms. Furthermore, the guidelines emphasize adherence to ethical principles, including informed consent, confidentiality, and the protection of vulnerable populations. Finally, the guidelines provide valuable guidance on how to effectively use and disseminate survey findings to inform immunization program planning and decision-making.

• For the household survey, which will assess coverage, the 2018 WHO immunization coverage survey guidelines (World Health Organization Vaccination Coverage Cluster Surveys: Reference Manual) must be used. This includes adherence to the recommended minimum sample size and a minimum design effect of 2. Any proposal of a study design or tools utilizing an approach inconsistent with the 2018 WHO guidelines will not be considered. The sampling will consider Amhara and Oromia as two stratas. The other parameters will be calculated based on the guide on the cluster survey reference manual in the above link

 

• For health facility readiness assessment, on Immunization Service Availability and Readiness Assessment WHO Service Availability and Readiness Assessment (SARA) implementation guide must be used. (Service availability and readiness assessment (‎SARA)‎: an annual monitoring system for service delivery : implementation guide, version 2.2)

 

By adhering to these guidelines, the consultant is expected to generate high-quality, comparable data that can effectively inform immunization program improvements as well as contributing to the knowledge base.

 

Sampling:

1. For the health facility assessment, the proposed study design should address the need for assessment of a representative sample of the 259 health facilities in the project implementation woredas (see Table 1 above)..
2. For the household survey, the proposed study design should consider cluster sampling method by clearly following according to WHO 2018 immunization coverage survey assessment guidelines. The sample should be stratified by region. The household survey should include stratification stratified to ensure representation of sub-national areas with minimum stratification by the two regions and with different characteristics, including conflict-affected, drought-prone, and hard-to-reach regions.
3. For the formative study: include KIIs for each woreda health office, representative HCs and HPs from each woreda, and FGDs by including in each woreda for a group of influential leaders, mothers and fathers of children age 12 to 35

Deliverables

The following are the expected outputs for the consultancy:

• Inception report
• Tools finalized with input from Save the Children
• Submission to Ethiopian IRB, follow up to approval
• Study logistics plan
• Cleaned datasets
• Analysis: output files, transcripts
• Custom analyses as needed by request from Save
• Draft study report
• PowerPoint presentation with key findings
• Present the study finding during validation meetings and incorporate input from SC and stakeholders
• Final report

Timeline

The evaluation is expected to be completed within 8 weeks, with the following timeline:

• Week 1-2: Inception phase and finalization of tools.
• Week 3-4: Data collection.
• Week 5-6: Data analysis and draft report submission.
• Week 7: Stakeholder feedback.
• Week 8: Submission of the final report and presentation.

Consultant Qualifications

The selected consultant/team should have:

• Advanced degrees in public health, epidemiology, or related fields.
• Proven experience in conducting household surveys, health facility assessment and qualitative research, for immunization projects.
• The team in the consultancy firm should have sufficient professionals with a mix of qualifications required for this assessment including public health experts and statisticians with proven expertise and experience on Immunization Program
• Expertise in mixed-methods research and experience in implementing studies on multi regional and national levels. proven research experience on the national immunization program preferred.
• Proven experience with electronic data collection, data management and
• Familiarity with Ethiopia’s health system and cultural context.

Application Requirements

Interested applicants should submit:

• A technical proposal detailing the approach, methodology, and timeline.
• A financial proposal outlining fees and expenses.
• CVs of the lead consultant and team members.
• Examples of previous similar work with testimonies.

Administrative Information

Payments:

• 10% upon submission and acceptance of the inception report by Save the Children and CDC that includes the approval of the detailed study protocol. Payment will only be made after CDC provides approval for the full study protocol.
• 50% upon submission of the draft baseline report.
• 40% upon approval of the final report.

Documentation Available:

• Evaluation and Performance Monitoring Plan (EPMP)
• Project proposal and logical framework.
• Project monitoring/MEAL plans.
• Relevant national strategies and sectoral plans.

Required approval of the donor

All bidders shall be aware that CDC funding for the baseline study is contingent upon their review to ensure it does not constitute human subject research. As such, 30% of the baseline study budget will be withheld pending CDC’s determination based on the submitted study protocol. Bidders should factor the time required for this review into their proposed timelines. Detailed information regarding the protocol submission will be provided separately

Selection Criteria

	Evaluation Criteria
	Technical Score (70%)	Points
1	Preliminary Interview	20%
2	Methodology	25%
3	Experience of the consultancy firm for conducting similar works in similar context	10%
4	Capacity	10%
5	Work and Risk Management Plan	5%
	Total	70%

 

Technical proposals scoring 60 out of 70 points or higher will advance to the financial evaluation stage. The technical score, originally out of 70 points, will be scaled down to a maximum of 60 points. The remaining 40 points will be allocated to the financial evaluation. The firm with the highest combined score from both technical and financial evaluations will be awarded the contract.

Terms and Conditions of the Consultancy

• The consultant must adhere to the Save the Children’s Code of Conduct and Child Safeguarding Policy.
• The consultancy firm will cover all field-related costs for its staff.
• All data and products of the baseline evaluation are the property of Save the Children.