Doctors without Borders/Médecins Sans Frontières (MSF) is an international medical humanitarian organization determined to bring quality medical care to people in crises around the world, when and where they need regardless of religion, ethnical background, or political view. Our fundamental principles are neutrality, impartiality, independence, medical ethics, bearing witness and accountability.
The Stockholm Evaluation Unit (SEU), based in Sweden, is one of three MSF units tasked to manage and guide evaluations of MSF’s operational projects. For more information see: evaluation.msf.org.
The SEU seeks to contract evaluator/s to conduct an evaluation of the MSF’s intervention for cervical cancer in Gutu, Zimbabwe. This project is implemented by MSF’s Operational Centre Brussels (OCB). Please see the Terms of Reference (ToR) for more information on the background, scope of the evaluation and expected deliverables here:
Deadline to apply: August 9, 2020
Start date: September (date TBD), 2020
End date: Final report no later than mid-December (date TBD), 2020
MEDICAL HUMANITARIAN CONTEXT
Cervical cancer is the fourth most commonly diagnosed cancer among females worldwide. In 2012, the International Agency for Research on Cancer (IARC) recorded 527,624 new cervical cancer cases and 265,672 related deaths. An estimated 90% of the globally recorded cervical cancer-related deaths are in low-and middle-income countries (LMICs), for which 8 in 10 are recorded within the Sub-Saharan African region. Infection with HIV substantially increases the risk of cancers such as cervical cancer.
Morbidity and mortality related to cervical cancer can be considered as a significant public health issue in Zimbabwe. Cervical cancer is the most frequently occurring cancer in women of all races and ages in the country, with a recorded mortality rate of 64% has been recorded. Access to specialized cancer treatment such as Loop Electrosurgical Excision procedure (LEEP) or hysterectomy or radiotherapy for the advanced stage of cervical cancer is extremely limited especially for those living in rural areas. HIV prevalence in Zimbabwe is 12.7% among adults.
Gutu is the third largest district in Masvingo Province in southern Zimbabwe. It has an estimated catchment population of 203 000 people (2012 census). The population is mostly the Karanga, a Shona sub-tribe. Its population density of 22.08 per square kilometer is among the highest in the country. Gutu district is served in total with 29 health facilities including 6 rural hospitals hospital well scattered to cover the district population accessing health care. As everywhere else in the country medical gaps exist and are worsened by the economic situation that Zimbabwe has been going through in this last decade.
In the frame of an existing HIV project in Gutu district of Zimbabwe, MSF decided to expand its activities to include, starting in 2015, interventions focused on cervical cancer for both women living with HIV and the general population. With the general objective to reduce the morbidity and mortality due to cervical cancer in Gutu district, the interventions were aimed at increasing access to both preventive and curative services for cervical cancer.
In collaboration with the Ministry of Health, MSF operated at different levels of care (such as outreach, six rural health centers and Gutu rural hospital), offering capacity building and technical support. The MSF intervention in cervical cancer includes the following medical activities:
Implementation of Human Papillomavirus Virus (HPV) vaccination among HIV-Positive Adolescent Girls and Young Women aged 15 to 26 years old
Visual Inspection with Acetic Acid and Cervicography (VIAC) at health centers and through outreach activities
Pilot of Xpert HPV Testing and Self-Sample Collection for Cervical Cancer Screening
Precancerous lesions (Thermo-coagulation) by outreach activities
Precancerous lesions (Cryotherapy) decentralized in six rural health centers
Advanced lesions with LEEP (Loop Electro Excision Procedure) performed at Gutu Rural Hospital.
Referrals (TAH) and basic psychosocial care for suspected/ confirmed cancer cases.
In addition to the specific objectives stated above, the project defined a clear intention to demonstrate the feasibility of new models of care (cervical cancer) both facility-based and through outreach. These new models of cervical cancer prevention and care can catalyze and enable change to improve outcomes through their adoption at national level and beyond. With this intention advocacy activities were also considered as part of the intervention strategy.
Since 2015, more than 20,000 women have been screened for cervical cancer in Gutu. Amongst those screened, 6% were VIAC positive. 71% of them were managed by Cryotherapy (1,026 out of 1,442) and 642 were referred to tertiary facility for further management. The project plans to handover to the Minister of Health and other partners by the end of 2020.
REASON FOR EVALUATION / RATIONALE
The approaches implemented by MSF in this cervical cancer intervention are relatively innovative in Zimbabwe, especially regarding the “see and treat approach”, aimed at decentralizing screening and treatment services to primary health level. The documentation of such interventions offers then an excellent opportunity to inform policy decision makers in Zimbabwe and other countries in the region.
In addition, MSF operational experience in cervical cancer is also relatively limited with few projects implementing routine CCS. Therefore, the appraisal of this intervention offers a unique opportunity for MSF to document the lessons learned during its implementation and reflect on how it can be adapted and better implemented by MSF in similar contexts.
OVERALL OBJECTIVE AND INTENDED USE
OVERALL OBJECTIVE is to assess the operational strategies and interventions implemented in the cervical cancer project in Gutu, with special attention to their appropriateness and effectiveness (both for women living with HIV and for general population), and to identify the lessons learned that should be considered in similar interventions.
INTENDED USE of this evaluation is aimed at informing MSF-OCB in their conversations with Zimbabwe/Masvingo Ministry of Health or other relevant actors, potentially interested in learning the experiences and/or taking over from MSF, to replicate or scale-up CCS prevention and curative services implemented by MSF. The evaluation findings will also be used by MSF to inform operational decisions on how to address cervical cancer management in similar contexts.
- Do cervical cancer interventions´ objectives correspond to identified needs?
- Is the chosen model/strategy appropriate to achieve the objectives?
Is the intervention appropriate from the beneficiaries´ perspective?
To what extent have the objectives been achieved?
What were the main enabling and challenging factors at community (awareness), facility and hospital level for achievement or under-achievement of objectives?
How did the project respond to the identified challenges?
What can be (or could have been) done to make the intervention more effective?
To which extent do the activities reach the target population? **
Are there any factors that hinder access for the population to screening, prevention and curative services?
How cost-efficient is the program, in terms of the qualitative and quantitative outputs achieved?
EXPECTED DELIVERABLES**Inception Report**
As per SEU standards, after conducting initial document review and preliminary interviews. It will include a detailed evaluation proposal, including methodology. Draft Evaluation Report
As per SEU standards. It will answer to the evaluation questions and will include conclusions, lessons learned and recommendations.**Working Session**
With the attendance of commissioner and consultation group members. As part of the report writing process, the evaluator will present the findings, collect attendances´ feedbacks and will facilitate discussion on lessons learned. Final Evaluation Report
After addressing feedbacks received during the working session and written inputs. ***Other dissemination deliverables to be defined in a separate dissemination plan.
TOOLS AND METHODOLOGY PROPOSED
In addition to the initial evaluation proposal submitted as a part of the application (see requirement chapter), a detailed evaluation protocol should be prepared by the evaluators during the inception phase. It will include a detailed explanation of proposed methods and its justification based on validated theory/ies. It will be reviewed and validated as a part of the inception phase in coordination with the SEU.
· Project documents (project proposals, logistical frameworks, situational reports, annual reports, field visit reports)
· Documentation regarding the ongoing operational research initiatives in the project
· National and regional documentation (Zimbabwe SRH national policies, Zimbabwe reports)
· External literature and documentation of similar experiences
PROFILE/REQUIREMENTS FOR EVALUATOR(S)
- Proven evaluation competencies (minimum 5 years)
- Formal background/studies on public/international health
- Experience in Sexual and Reproductive Health programing (minimum 5 years)
- Experience in Southern Africa region
- Language requirements: English (Fluent)
- Experience in cervical cancer and HIV
- Experience in Zimbabwe
- MSF experience and/or understanding
 International Agency for Research on Cancer (IARC), WHO, 2012.
 Chokunonga E, Borok MZ, Chirenje ZM, Makunike-Mutasa R, Ndlovu N, Nyakabau AM, Vuma S. Zimbabwe National Cancer registry: 2014 Annual Report. Pattern of cancer in Zimbabwe
 Information Centre for Cancer. Human papillomavirus in Zimbabwe report. Accessed on 31 January 2017
 UNAIDS, Data from Zimbabwe, 2018.
 Implemented in the frame of an operational research. It will, therefore, not be included as part of the scope of this evaluation.
 MSF has supported national health ministries to provide screenings and early treatment in some countries like Kenya (VIA and referrals for treatment); Malawi (VIA, thermo-coagulation and referrals for LEEP) and Swaziland (VIA, cryotherapy, referrals for LEEP). MSF has also supported HPV vaccination campaigns for schoolgirls in South Africa (2015) and the Philippines (2017)
The application should consist of a technical proposal, a budget proposal, CV, and a previous work sample.
The proposal should include a reflection on how adherence to ethical standards for evaluations will be considered throughout the evaluation. In addition, the evaluator/s should consider and address the sensitivity of the topic at hand in the methodology as well as be reflected in the team set-up. Offers should include a separate quotation for the complete services, stated in Euros (EUR). The budget should present consultancy fee according to the number of expected working days over the entire period, both in totality and as a daily fee. Travel costs, if any, do not need to be included as the SEU will arrange and cover these. Do note that MSF does not pay any per diem.
Applications will be evaluated on the basis of whether the submitted proposal captures an understanding of the main deliverables as per this ToR, a methodology relevant to achieving the results foreseen, and the overall capacity of the evaluator(s) to carry out the work (i.e. inclusion of proposed evaluators’ CVs, reference to previous work, certification et cetera).
Interested teams or individuals should apply to Evaluations.Sweden@stockholm.msf.org referencing GUCCE no later than August 9th, 2020. We would appreciate the necessary documents being submitted as separate attachments (proposal, budget, CV, work sample and such). Please include your contact details in your CV.
When sending your application, you also agree that we will register your data in our register and manage it in compliance with GDPR. If you are selected for the consultancy, your personal data might be shared with MSF Operational Centres. If you are not selected, we will save your data for up to two years for our statistics unless otherwise requested by applicant.