PN 38 - Ongoing Recruitment: STTA - Junior Level National - Research Associate – Technical Support

Job details

TA Title : Development of Two-way Referral and Continuity of Care between General Practitioner Clinics and Higher Level of Public & Private Healthcare Facilities 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 (2023-2027) provides technical assistance (TA) to Punjab and also to the Federal and Khyber Pakhtunkhwa (KP) governments. The Punjab component is being implemented by Palladium along with Oxford Policy Management (OPM). Through its flexible, embedded, and demand-driven model, E4H Punjab will support 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 will deliver 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. E4H-Punjab works in partnership with the Punjab Department of Health (DOH). Terms of reference Background and Problem Statement Background The Punjab Healthcare Commission (PHCC) regulates and licenses public and private healthcare establishments across Punjab. Approximately 4,000 hospitals and more than 63,000 healthcare facilities are registered with PHCC, including over 8,000 General Practitioner (GP) clinics. This network provides an important opportunity to strengthen the role of primary-level providers in coordinating care across public and private services. The need for stronger coordination is particularly relevant in a health system where approximately 83% of out-of-pocket health expenditure is incurred in the private sector. At the same time, secondary, tertiary and specialised hospitals continue to face high patient volumes and service-delivery pressures. International guidance on integrated, people-centred primary healthcare emphasises structured referral pathways, clear provider roles and continuity of care as essential to improving service utilisation and reducing avoidable pressure on higher-level facilities. Punjab’s public health information system has undergone substantial digitization and expansion, for routine reporting across all districts and in major public hospitals enabling electronic patient records, diagnostics, and pharmacy management. One of the key reform efforts includes the transition toward a more integrated, digitized Hospital Management Information System (HMIS). This transition aims to enable evidence-based decision-making, improve patient tracking, and foster accountability across primary and secondary levels of care. Despite the deployment of Electronic Medical Records (EMRs) and HMIS in Basic Health Units (BHUs), Rural Health Centres (RHCs), Tehsil Headquarter Hospitals (THQs), and District Headquarter Hospitals (DHQs), several operational gaps remain. These include inconsistent data entry practices, a lack of unified standards across different tiers of the health system, and limited capacity among staff to navigate and use the digital tools effectively. In Punjab, patient referral between private general practitioners (GPs) and public or private hospitals is largely informal, fragmented, and weakly regulated: GPs frequently refer patients to higher-level facilities due to limited diagnostic and treatment capacity, yet many patients bypass primary care and directly self-refer to tertiary hospitals, leading to overcrowding and inefficient resource use. Formal referral protocols and integration between private clinics and hospitals are limited, and counter-referral (feedback from hospitals back to GPs) is rarely practiced, resulting in poor continuity of care and weak follow-up. Overall, despite policy efforts to create structured, two-way referral systems and better integrate GPs into the health system, the current situation is characterised by poor coordination, minimal information sharing, and a dominant culture of self-referral, undermining efficiency and quality of care. Against this backdrop, PHCC has identified the need to explore a practical two-way referral model linking GP clinics with higher-level public and private facilities. The TA will support PHCC to assess existing arrangements, determine institutional and operational requirements, and design a model that can be tested in selected settings. Problem Statement There is currently no standardised and accountable two-way referral mechanism linking GP clinics with higher-level public and private facilities in Punjab. This results in inconsistent referral practices, weak counter-referral and follow-up, limited visibility of patient outcomes, and fragmented continuity of care. The TA will address this gap by developing and testing an operationally feasible referral model aligned with PHCC’s mandate and the realities of Punjab’s mixed health system. Goal and Objectives To support PHCC to develop, test and pilot a practical two-way referral (referral and counter-referral) model linking GP clinics with higher-level public and private healthcare facilities to strengthen continuity, coordination and quality of care. Objectives • Assess existing referral practices, provider networks, database and systems, institutional capacity and system readiness in selected settings to define a feasible pilot model. • Co-design and pilot a standardised referral and counter-referral model, including workflows, tools, roles, monitoring arrangements and capacity-building support. • Evaluate and refine the model based on pilot evidence and develop an institutionalisation and scale-up roadmap aligned with PHCC’s licensing, MSDS and quality-assurance mechanisms.Map and define the formal approval, endorsement and notification pathway for adoption of the governance framework, including institutional responsibilities of SHC&MED, PIU, BoG, DG Nursing, affiliated universities and relevant regulatory bodies. Strategic Approach Contribution to Health Systems Strengthening This TA will strengthen coordination across Punjab’s mixed health system by establishing practical referral and counter-referral pathways between licensed GP clinics and higher-level public and private facilities. The approach will support more appropriate service utilisation, continuity of care, provider accountability, and follow-up of patients with chronic and priority conditions, while reducing avoidable pressure on secondary and tertiary hospitals. The model will be designed around PHCC’s regulatory and quality-assurance mandate, with clearly defined provider roles, referral criteria, minimum documentation requirements, feedback mechanisms, and monitoring arrangements. It will prioritise feasibility within existing institutional and digital systems rather than creating parallel structures. Alignment with E4H TAs and Investments The TA will build on and complement relevant E4H investments in Punjab, including: • the Universal Health Coverage and EPHS work, by strengthening referral pathways across levels of care • the HMIS–EMR referral linkages TA, by drawing on lessons from patient referral SOPs, digital workflows, and continuity-of-care arrangements • previous PHCC-focused quality improvement work like the MSDS TA, by linking referral practices with licensing, quality standards, and provider accountability • wider E4H support on service integration, governance, and institutionalisation, by embedding the model within existing government systems and oversight arrangements. This alignment will help avoid duplication, promote consistency across E4H-supported reforms, and ensure that the proposed referral model contributes to broader improvements in access, quality, and continuity of care. Scope of Work and Methodology Phase 1: Inception and Referral-System Assessment • Convene an inception meeting with PHCC and relevant government stakeholders to confirm the TA scope, governance arrangements, workplan, timelines and focal persons. • Review: • any existing PHCC databases, referral guidelines, MSDS provisions, licensing requirements and monitoring mechanisms • current patient pathways and referral and counter-referral practices used by GP clinics and public/private hospitals (if any) • relevant Punjab policies, digital systems and provider directories • lessons from the E4H HMIS–EMR referral linkages TA • Best practice, international literature and guidance (WHO etc.) and LMIC examples (Turkey, Thailand etc.) • Conduct structured consultations with relevant stakeholders including PHCC, H&PD, SHC&ME Department, DGHS, GP/family physician associations, selected public and private hospitals, Punjab Health Initiative Management Company