E4H Punjab TOR: Development of a Comprehensive Implementation Plan For Community Health Inspectors’ Initiative 

 Programme Overview

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 (2023–2027) provides technical assistance (TA) to Punjab, Federal, and KP governments, implemented by Palladium in partnership with Oxford Policy Management (OPM).

Through its flexible, embedded, and demand-driven model, E4H supports governments to achieve a resilient health system that is prepared for emergencies, responsive to evidence, and delivers equitable, quality, and efficient healthcare services. Specifically, E4H delivers TA across three outputs:

• Output 1: Strengthened integrated health security and preparedness.
• Output 2: Strengthened evidence-based decision-making for accountability and performance.
• Output 3: Improved implementation of Universal Health Coverage (UHC).

Background and Problem Statement

• The Government of Punjab has launched the Maryam Nawaz Community Health Services (MNCHS) under the Punjab Community Health Services Act (July 2025) and formally notified the deployment of Community Health Inspectors (CHIs) through an outsourcing model to expand primary healthcare coverage. To support the implementation and monitoring of the MNCHS, the Maryam Nawaz Programme Implementation Unit (PIU) for outsourcing management and the Maryam Nawaz Monitoring and Evaluation (M&E) directorate have been established within the Health and Population Department (H&PD), Punjab.
• CHIs are licensed mid-level providers (LHVs, nurses) engaged to supplement the shrinking Lady Health Worker (LHW) programme, which has declined from 46,894 in 2013 to less than 39,715 in 2025, with further attrition projected over the next decade. They are mandated to deliver preventive, promotive, and basic curative services, including maternal and child health, family planning, nutrition, screening for communicable and non-communicable diseases, and health education at the community level.
• A provincial CHI strategy has been developed by the H&PD, linked to the Essential Package of Health Services (EPHS) Punjab, NHSP DLI-11, the Punjab Health Sector Strategy (2019–28), Universal Health Coverage (UHC), and health-related Sustainable Development Goals (SDG) commitments, outlining the CHI service package, outsourcing mechanisms, and scale-up plans. In the pilot phase, 500 CHIs have been deployed across four Punjab Human Capital Investment Project (PHCIP) districts (DG Khan, Muzaffargarh, Rahim Yar Khan, and Rajanpur) as the foundation for province-wide expansion.
• The Government plans to further deploy up to 19,500 CHIs across all 36 districts through a third-party outsourcing approach, each covering 4,000 CHIs, with several organisations selected through a tendering process. Clear provincial frameworks, vendor management, and referral and accountability mechanisms are required to operationalise this scale-up and ensure sustainability.

Problem Statement

Despite the Government of Punjab’s notification of the CHI outsourcing model and its pilot in four districts, the initiative still lacks a standardised provincial implementation framework—including district operational plans, vendor management protocols, and supervision mechanisms. The absence of these systems risks fragmented deployment, uneven quality of services, and weak accountability, which could undermine the potential of CHI to address coverage gaps left by the shrinking LHWs cadre. Furthermore, without integration into provincial governance, financing, and accountability structures, and alignment with the National Health Support Programme (NHSP) Disbursement Linked Indicator (DLI) 11, the Punjab Health Sector Strategy 2019–2028, as well as UHC and SDG targets, CHIs risk remaining a parallel, donor-dependent initiative rather than developing into a government-owned, sustainable solution. Therefore, a comprehensive CHI implementation plan is essential to guide scale-up, standardization, and institutionalization, ensuring that insights from the pilots inform province-wide adoption within the Health and Population Department system.

Goal and Objective(s)

To operationalise and institutionalise the CHI initiative as a sustainable, scalable, outsourced cadre that addresses primary healthcare coverage gaps, strengthens community–facility linkages, and contributes to Punjab’s commitments under EPHS, NHSP DLI-11, PHSS 2019–28, and UHC/SDGs.

We will achieve this by pursuing three objectives:

• Objective 1: Develop a provincial CHI framework covering governance, outsourcing, payment, M&E, referral, accountability, and HMIS/EMR integration.
• Objective 2: Design and roll out district operational plans in two priority districts, applying the provincial framework with training, supervision, referral, and QA systems aligned with the government CHI strategy, EPHS, and PHSS.
• Objective 3: Formulate a scale-up and sustainability roadmap for all 36 districts, embedding CHI within H&PD governance, financing, HR, and reporting systems.

Strategic Approach

Contributions to health systems strengthening

This TA strengthens Punjab’s primary healthcare by operationalising the outsourced CHI cadre through a standardised provincial framework, vendor management arrangements, and district rollout plans. It addresses systemic bottlenecks, including the shrinking LHW workforce, fragmented supervision, and weak referral linkages, positioning CHIs as a sustainable supplement/replacement cadre. The TA will embed performance accountability, digital integration with HISDU systems, and supervision mechanisms to ensure service quality, coverage expansion, and institutionalisation within provincial HR and financing systems.

Alignment with other E4H TAs/investments

The TA builds on and complements E4H’s ongoing support for HR planning, PHC quality assurance, and strengthening digital health systems. Specifically, it connects with the planned “Training of Trainers for CHIs” TA by ensuring that training outputs are incorporated into operational frameworks and supervision plans, the “Operational review of Clinic on Wheels” TA, another government initiative to improve PHC under MNCHS, and the “EMR and HMIS Linkage & Interoperability, and Development of HMIS Manual and SOPs for Patient Referral Management,” by ensuring that CHI-generated data and referrals are integrated into provincial digital platforms. The initiative will also align with the Health and Population Strategic Plan, currently being developed by another E4H TA team. 

Alignment with other donors

This TA ensures complementarity with the World Bank’s NHSP (DLI-11) and HCIP investments, UNICEF’s MNCH programming, and WHO’s guidance on community health systems. In addition, it coordinates with the Punjab Family Planning Programme (PFPP) to harmonise CHI deployment with reproductive health and family planning priorities. By situating CHI scale-up within a provincial operational framework and digital systems, the TA reduces duplication, leverages partner investments, and strengthens government ownership and sustainability.

Scope of Work and Methodology

The TA will run from October 2025 to March 2026 and will support the operationalisation and institutionalisation of the CHI initiative through a phased approach in close collaboration with the H&PD, specifically the newly formed MNPH PIU (implementation) the Maryam Nawaz M&E directorate (monitoring, HISDU (digital integration and dashboarding), DHAs (district-level implementation and monitoring), and contracted vendors (service delivery, training and performance management). The Programme Director, MNCHS, will serve as the main focal point for the TA.

Phase 1 – Inception and Diagnostic Assessment

• Conduct inception meetings with H&PD (above-mentioned coordinating sub-units), DGHS, PHDC, DHAs, vendors, and any other identified stakeholders to agree on scope, roles, deliverables, and timelines, including the selection of four districts for initial implementation.
• Establish a CHI implementation coordination forum, chaired by the PIU and M&E directorate as co-leads, to coordinate with all vendors and key stakeholders.
• Undertake a rapid assessment of the CHI pilot and outsourcing model, including service package delivery and community coverage in pilot districts, contracting and vendor management structure, supervision and QA mechanisms, referral protocols and facility linkages, digital reporting mechanisms and integration, financing flows and sustainability risks.
• Prepare an Inception Report and Slide Deck that summarise the preliminary findings, agreed-upon scope, methodology, and stakeholder mapping.

Phase 2 – CHI Operational Framework and M&E Plan

• Co-develop a Provincial CHI Implementation Plan with the MNPH PIU, including SOPs for service delivery, training, supervision, and vendor management, referral and facility linkages, complaint redressal, standardised supervision, digitised data reporting mechanisms and flow, and outsourcing/vendor management tools.  
• Clarify the mandate of the CHI implementation, taking into account the roles of the DC IRMNCH, outsourced vendors, and H&PD units.
• Align framework with ongoing reforms under PFPP, HCIP, NHSP DLI-11, EPHS, and UHC indicators.
• Co-develop a comprehensive M&E plan with Maryam Nawaz M&E directorate and HISDU, including defining KPIs, clear roles and responsibilities for all stakeholders, with defined timelines, means of verification, and periodic reviews (monthly dashboards, quarterly reviews) to track progress, ensure compliance, and enable timely course correction.
• Validate through provincial workshops with the relevant stakeholders.

Phase 3 – District Operational Plan and Piloting

• Prepare costed, district-specific operational plans for prioritised two districts, with a focus on LHW-uncovered areas in close collaboration with relevant DHAs for ownership, HISDU for strengthening digital integration, and PIU/M&E directorate for oversight.
• Include mapping of uncovered areas, services, and workforce availability, district-level referral and supervision mechanisms, digital reporting and dashboard roll-out through HISDU, and financing requirements and resource allocations.
• Conduct district-level consultations with DHAs, vendors, facility managers, and community representatives to ensure a holistic, evidence-based approach and facilitate ownership.
• Facilitate DHAs in finalisation and rolling out of the District Operational plans in two districts (piloting of implementation plan).

Phase 4 – Review and Scale-up

• Conduct a review of the pilot districts to assess the framework/ implementation and refine the tools. Consolidate lessons from district-level operationalisation and adjust the provincial framework and M&E plan accordingly.
• Draft a technical report with a scale-up and sustainability roadmap with a phased expansion plan across 36 districts, prioritising uncovered/hard-to-reach areas integrated with EPHS and PHC reforms.
• Outline governance mechanisms and institutional arrangements, financing requirements and integration into provincial budgets, vendor and performance management mechanisms, digital and HISDU linkages, and HR planning and capacity building strategies.

Sustainability: Capacity Building, Institutionalisation, and/or Transition Planning

Capacity Building:
The focal point of the TA will be the Project Director of the MNCHS Programme, Health H&PD, to ensure long-term sustainability. Provincial and district capacity will be strengthened through the development of standardised tools, SOPs, and handholding support for supervisors managing the CHI initiative, embedded within H&PD structures for continuous professional development. Government-led vendor management mechanisms, including contract-linked performance management, compliance protocols, and regular monitoring of training and service delivery, will be established.

Institutionalisation:
CHI governance will be anchored within existing H&PD structures to avoid the creation of parallel systems. This includes integrating monitoring and reporting indicators that will be embedded into HISDU dashboards, as well as aligning supervision with District Health Authorities.

Transition Planning:
CHI oversight, vendor management, and performance monitoring will be the responsibility of the H&PD, RMNCH directorate, and its PIU and M&E directorate, reducing dependency on donor support while embedding accountability within the provincial system. The transition will include scaling from pilot districts to province-wide implementation, with mechanisms to mobilise domestic and external resources where required.

Deliverables

1. Succinct Inception Report.
2. Provincial CHI Implementation & M&E Plan.
3. District-Level Operational Plans (2 pilot districts).
4. Final Technical Report with scale-up and sustainability roadmap.

Contract Management Specialist (Mid National)

LOE: 30 days

Period: Oct 2025 – Mar 2026

Role Requirements
Develop and operationalise contracting and vendor management systems for CHIs, including SOPs, performance contracts, and compliance mechanisms.

Technical Expertise
Postgraduate degree in management, law, public administration, or equivalent; 10+ years’ overall experience. Experience in health sector contracting and vendor management. Proven ability to develop SOPs, performance-based contracts, compliance systems, and outsourcing models.

Core Competencies
Negotiation; Contract oversight; Performance monitoring; Accountability frameworks.

Deliverables/KPIs
Same as overall TA deliverables.