The Fred Hollows Foundation (The Foundation) is a secular non-profit public health organisation based in Australia, which was founded in 1992 by eminent eye surgeon Professor Fred Hollows. The Foundation focuses on strengthening eye health systems and the treatment and prevention of avoidable blindness caused by Cataract, Trachoma, Diabetic Retinopathy, and Refractive Error. It operates in more than 20 countries across Australia, The Pacific, South and South-East Asia, and Africa. The Foundation was named The Australian Charity of the Year 2013 at the inaugural Australian Charity Awards.
The Kilimanjaro Centre for Community Ophthalmology (KCCO) and The Fred Hollows Foundation (FHF) have been working together for many years implementing different projects. The first contacts were established by the directors of the two organisations and the first project was eye health human resources development in Africa where KCCO, with funding from FHF, organised and conducted a “Management Course for Vision 2020 Programmes in Africa” for 3 different years. The KCCO has also done consultancy work for FHF in Gisenyi (Rwanda) and Western Lake Zone in Kenya, taking a lead in developing Vision 2020 plan for the two regions. In 2017 the KCCO was again involved in consultancy work with the Foundation in evaluating eye care projects in Burundi, and in 2020-2021 in supporting the development of the new national eye health plan for Burundi. KCCO is the main implementing partner in the Australian NGO Cooperation Program (ANCP) project ‘Increasing Access to Equitable Cataract Services In four Regions of Tanzania’ under implementation from October 2021 and is jointly funded by the Australian Government and the Foundation. The project end date was recently revised to June 2025 to take into account COVID and contracting delays in 2021-22.
In Tanzania health care is centralised. The health system structure has seven levels; each with its well-defined level of care and human resources needed. These includes 1. Primary Health Care (PHC) 2. Dispensaries 3. Health centres 4. District hospitals 5. Regional Referral Hospitals (RRH) and 6. National and Specialised hospitals. The National Health Sector Strategic Plan 2021 to 2026 and the pending National Eye Care Strategic Plan guide and inform the implementation of the general and eye health care service delivery respectively.
Cataract is the leading cause of blindness and vision loss in Africa. Despite available solutions to prevent cataract blindness the hospitals in the selected regions in Tanzania are far from reaching recommended cataract surgical rates of 2,000 per million population due to challenges such as lack of equipment, consumables, human resources, and capacity to reach remote communities through outreach activities. On the other hand, access to care by the community is limited due to distance to service providers, fear of surgery, costs and socio-cultural barriers. This project will address these challenges thus contributing to the prevention of avoidable blindness in Tanzania. Apart from cataract, the project will address refractive error by providing eyeglasses to patients and those operated but needing refractive correction to achieve the best post cataract surgical outcome. Other patients needing medical intervention will also be served by the project. In total, more than 9 million people will benefit from the project.
The project outcomes will include integrating eye health care services into the general health system of each hospital, increased public awareness on eye diseases and their management and an increased number of people whose sight is restored through access to good quality care. To achieve above outcomes the project will build the capacity of the regional hospitals by training additional needed staff, purchasing essential equipment/instruments and consumables/medicines, and supporting outreach activities. The project will also create eye health awareness among the people in the regions through local radio, posters, religious institutions, and community meetings. Outreach services will be initiated to reach the people who have limited or no access to eye health care services. Staff in each hospital will be trained on how to ensure good quality surgical outcome is attained and maintained.
As required under ANCP funding the project is required to meet the Development Assessment Committee’s (DAC) ‘Significant’ Gender Equality Policy Marker and ‘Significant’ ANCP Disability Marker. Therefore, the project has a focus on activities that engage marginalised peoples, including women, people living with disability, indigenous peoples and people living in remote and hard-to-reach areas. The project will pay particular attention to reducing access barriers for marginalised peoples.
Expected Outcomes and Outputs
This project intended to achieve the following outcomes and outputs.
Outcome 1: By 2025, eye health care services are integrated into regional and district hospitals in four regions of Manyara, Kagera, Tanga and Mtwara. The output under this outcome includes.
- Detailed implementation plan in place for each region per year
- Data from the project are collected analysed and shared with MoH.
- Health workers trained as Ophthalmic Nursing Assistants.
- Equipment and consumables provided to four regional hospitals.
- Biomedical engineers are trained in each region to maintain and repair eye care equipment.
- 11,400 cataract surgeries performed across four regions.
- 400 children referred for cataract operation from across the four regions.
- 10,000 people corrected for Refractive Error
Outcome 2: By 2025, at least 80% of cataract surgeries achieve the WHO recommended visual acuity of >6/12. The output under this outcome includes.
- Eye care teams trained in quality management.
- CSOM established in each region.
- 24 mentoring visits and 9 supportive supervision conducted.
- Day one, 4 weeks and 6-10 weeks post-surgery follow up done in each region for each outreach.
Outcome 3: By 2025, eye health services will be more equitably accessible for women and people with a disability. The output under this outcome includes.
- Eye units have an Action Plan to implement equity-sensitive interventions.
- Women in microfinance groups trained in basic eye health awareness to increase eye health referral.
- Partnerships developed with disabled people’s organisations to better engage people with a disability in eye health services.
Outcome 4. By 2025, eye health is integrated into community and primary health care and communities in the four target regions have increased awareness of eye health services. The output under this outcome includes.
- Community sensitization/awareness integrated into community and primary health care in each region.
- The Kilimanjaro Centre for Community Ophthalmology (KCCO)
- Ministry of Health
- Kagera regional referral hospital
- Tanga Regional referral Hospital
- Mtwara Regional Referral Hospital
- Manyara Regional Referral Hospital
Purpose of the evaluation
The purpose of this mid-term evaluation is to assess the mid-way progress of the project towards achieving the intended objectives and to identify any changes needed to ensure that they are and to inform further program planning. The consultant is expected to review the evaluation questions and develop the necessary tools to collect data.
The primary intended users of the mid-term evaluation will be The Foundation’s:
- Programs Division (including Program Development Team and country program teams)
- Tanzania program Team
- Country Support Network and other country teams
- Development Effectiveness Team
These teams provide advice and/or make decisions about the choice and design of programs across The Foundation.
The evaluation is also likely to be of interest to a range of secondary users, including:
- International eye health sector NGOs, the Australian Department of Foreign Affairs and Trade.
- Ministry of Health in Tanzania.
- Project Implementing partners (KCCO and other eye health organizations in the country).
Evaluation scope and key questions
This is a mid-term evaluation of the ‘Increasing Access to Equitable Cataract Services In four Regions of Tanzania under implementation between October 2021 to June 2025. The following indicative evaluation questions will be used to assess the status of the project. However, the consultant will have latitude to expand the set of questions to suit the evaluation.
- To what extent has the project design/ model been aligned to the country eye health strategic plans and initiatives?
- To what extent is the theory of change and assumptions underlying this project continuing to hold?
- To what extent are risks identified at the commencement of the project being effectively mitigated? Are there any new risks that have emerged? How might these be managed going forward?
- Is the project having any negative unintended consequences? If so, what are these, and how might these be managed going forward?
- To what extent are eye health data collected, analysed, and used for decision making?
- To what extent has the project facilitated training of health workers as Ophthalmic assistants? What are the existing gaps? What % of those trained were male/female? If there is a gap, what were the reasons for this and what more could be done to address this?
- How has the project supported access to equipment and consumables? How did this support increase eye service delivery?
- To what extent has the project met the training targets for biomedical engineers? What more could be done to enhance capacity of engineers to maintain equipment?
- To what extent have the targets for cataract surgeries been met (Total/Male/Female) How do these results compare to prevalence rates for males and females? What are the existing gaps? What are the reasons for these gaps? What more would need to be done to close these gaps?
- To what extent have children referral systems been established? What has been the impact of this? What are the remaining gaps? What more could be done to address these?
- How has the project supported refractive error services? What improvements are needed?
- What % of people screened for RE were male/female? What % of people requiring correction were male/female? What % of people corrected for RE were male/female? Was there a variance between need and access by sex? If so, what were the reasons for this, and what more could be done to narrow this gap?
- To what extent have eye care teams been trained on quality management? What capacity gaps are still existing, and what more is needed to address these?
- To what extent has CSOM been entrenched in service delivery across the regions? What are the existing gaps, and what more could be done to address these?
- To what extent are post operative follow up conducted? Of those who received post-operative follow up, what percentage were male/female? How does this compare with the ratios for those receiving cataract surgery? What improvements are needed?
- To what extent is eye care service delivery strengthened through mentorship and supportive supervision? What improvements are needed?
- To what extent has the project achieved 80% good cataract surgery outcomes? What is required to achieve the target by 2025?
- To what extent is eye health integrated into community and primary health care? To what extent have community awareness raising activities (and materials) been accessible to different groups including women, persons with disabilities, indigenous peoples, and ethnic minorities and those living in remote areas with limited access to primary healthcare? How could these be improved going forward?
- To what extent have the FHF, implementing partner and other partners worked together to ensure the project objectives are realized? What value has FHF brought to the project beyond funding? How could this be strengthened with the existing implementing partners?
- What are the key challenges if any that have affected the implementation of the project? What more could be done to address any of these outstanding challenges?
- To what extent are the project results in eye health service delivery going to be sustained at the four regional hospitals beyond the project period? What interventions are required to increase the sustainability of the project results?
- To what extent has the project contributed to more equitable access for women and persons with disability? If so, in what ways and what evidence is there of this?
- Have any issues been identified that will prevent some social groups from participating in and benefitting equally from the program? If yes, how can the program be further amended to ensure that these groups benefit equally?
- How much progress have eye units made on developing and implementing actions plans to implement equity sensitive interventions? What interventions have they undertaken and with what effect?
- To what extent has the basic eye health awareness training of women in micro-finance groups led to increases in referrals to eye health services?
- What partnerships have been developed with Disabled Persons Organisations and to what extent and in what ways has this resulted in improved access of persons with disability to eye health services?
- What other points of entry and opportunities exist for engaging marginalised groups of women, girls, gender diverse peoples, or people with disabilities through this project?
- In what ways has the project taken steps to address barriers faced by women and persons with disability in accessing eye care? What difference have these changes made?
- What are the main barriers that women and persons with disability still face in accessing eye care? What more could be done to address these gaps?
- Are the needs of any groups of people in relation to this program different enough that a separate program component focusing on that sub-group needs to be created?
- What types of data must be collected to track the impacts of the program on women, girls, gender diverse people, people with disabilities and any other social group?
- Have any potential unintended negative consequences of the investment on different social groups been identified? If yes, following the ‘do no harm’ principle, how can these risks be mitigated against and monitored?
- Has partner capacity been assessed, and what gaps and needs have been identified by partner agencies themselves to implement the actions needed to achieve GEDSI outcomes?
- To what extent have the project achieved the DAC Gender Markers as per ANCP requirements (Refer ANCP guidelines on DAC gender Marker)
- To what extent has the project met the DFAT ANCP disability marker for level one on disability mainstreaming and how can the project improve to Twin Track marker (Refer to DFAT ANCP disability inclusion guideline?
FHF’s Country Program Manager for Tanzania will recruit a research consultant/institution to conduct the mid-term evaluation. The selected evaluation consultant will be required to prepare detailed research methodology in collaboration with FHF regional and head office team. The consultant will be required to propose the right methodology for the evaluation but at the minimum the chosen methodology should be broad enough to accommodate both quantitative and qualitative methods.
Specifically, Information to answer the evaluation questions will be gathered through a two-stage process; Stage 1: Desk Review
- Review of background information including relevant policies, frameworks and guidance (to be provided by The Foundation to the consultant)
- Review of project documents and existing related project reports and monitoring data
- Review of eye health prevalence and service delivery data
- Fine tune key evaluation questions based on findings of desk review.
- Prepare tools, consent procedures, forms etc. to guide data collection in Stage 2.
- Prepare and submit application for ethics approval.
- Obtain Ethics approval to undertake Stage 2.
Stage 2: Key Informant Interviews and Focus Group Discussions
- Undertake key Informant interviews with relevant stakeholders.
- Undertake focus group discussions with relevant stakeholders.
- Prepare and share draft report detailing findings and recommendations.
- Based on feedback, prepare final report.
The following deliverables are expected from the consultant in completing the assignment:
- Evaluation/Inception Plan and methodology, including timelines.
- Completed data collection tools in line with evaluation questions.
- Prepare and obtain ethics review to conduct the evaluation.
- Presentation and validation of preliminary findings
- Draft and final evaluation reports including summary report, summarized slide decks for dissemination of findings.
- Presentation of evaluation summary (methodology, findings, recommendations, and learning) to broader Foundation staff. The content and timing of the presentation will be negotiated with the consultant.
The Foundation shall require all raw data collected/generated during the evaluation provided in an agreed format. A backup of raw data shall be provided in a form accessible to the Foundation. The Foundation will provide the following:
- Focal person to support in undertaking the assignment.
- Provide documents required for desk review.
- Give feedback on the evaluation plan and methodology.
- Provide feedback on draft data collection tools, reports, and other deliverables.
- Support coordination between the consultant and partners during the entire evaluation activities.
- ANCP Evaluation template which the required DFAT funding acknowledgement
The Mid Term evaluation is expected to start in October 2023 for an estimated duration of 30 working days. This will include desk reviews, fieldwork, interviews, and report writing and final presentation to FHF. The evaluation is scheduled to take place starting October 2023 as per the indicative schedule.
Activity Person Responsible Completion date
Finalisation of Mid Term Evaluation TOR MERL Team 20th September 2023
Contracting Contracts Team 20th October 2023
Evaluation Plan, Methodology and Ethics Protocol Consultant 10th November 2023
Document review 20th November 2023
Ethics review and approval Consultant TBD
Focus Group Interviews Consultant TBD
Key informant interviews Consultant TBD
Data analysis and synthesis Consultant TBD
Draft Mid Term report Consultant TBD
Final Mid Term report Consultant TBD
Internal dissemination of Mid-term Evaluation Consultant TBD
Evaluation team & qualifications
This evaluation will be contracted to an independent evaluator or team who will work closely with The Foundation staff in the design and implementation of the evaluation. The Foundation seeks to engage the services of an independent individual or registered organization, that have the following experiences and expertise in project/program evaluation.
At least a master’s degree in medicine, Public Health, Ophthalmology, or related health sciences.
- Demonstrable experience in evaluation of public health programs including health systems assessments.
- Experience in development and use of quantitative and qualitative data collection tools and evaluation methods
- Experience in preparing ethics application and obtaining ethics approval from a research institute for qualitative and/or mixed-method research.
- Strong knowledge and experience working with the health care systems in Tanzanian and overall understanding of local health sector policies.
- Strong experience in using GEDSI or other equity framework(s) to evaluate progress against equity objectives.
- Strong analytical skills
- Excellent spoken and written communication skills in English.
The consultant (s) agree to not divulge confidential information to any person for any reason during or after completion of this contract with The Foundation. Upon completion or termination of this contract, the consultant (s) undertake to return to The Foundation any materials, files or property in their possession that relate to the work of The Foundation. The consultant will be responsible for safety, security and administration of primary and secondary data collected from FHF or otherwise.
All intellectual property and/or copyright material produced by the evaluator/s whilst under contract to The Foundation remain the property of The Foundation and will not be shared with third parties without the express permission of The Foundation. The evaluator/s are required to surrender any copyright material created during the term of the contract to The Foundation upon completion or termination of the contract.
The Fred Hollows Foundation is committed to ensuring that its activities are implemented in a safe and productive environment which prevents harm and avoids negative impacts on the health and safety of all people, particularly children, vulnerable people, and disadvantaged groups. The Foundation has a zero-tolerance approach to sexual exploitation, abuse, and harassment of any kind. All personnel including contractors/consultants are expected to uphold and promote high standards of professional conduct in line with The Foundation’s Safeguarding People Policy including Code of Conduct. Contractors/consultants will be expected to sign and adhere to The Foundation’s Safeguarding Code of Conduct and provide any background checks as required.
Any consultants involved in this evaluation will be required to have in place insurance arrangements appropriate to provision of the requirements in this Terms of Reference including travel insurance.
Ethical and other Considerations
The evaluator and evaluation team are expected to maintain high professional and ethical standards and comply with The Foundation’s Research and Evaluation Policy. The Foundation is committed to ensuring a safe environment and culture for all people, including children, with whom we come in contact during our work. All members of the evaluation team will be required to comply with The Foundation’s Safeguarding People Policy and sign the Safeguarding Code of Conduct. Additionally, the consultant will ensure that the following ethical considerations are observed: Informed Consent; Confidentiality and Privacy; Disclosure of Potential Risks and Benefits to participants; Equity and Fairness; Balance Power Dynamics between participants and researchers; Respect for Cultural Norms; Provide Feedback Mechanisms; Avoid Reporting Bias; and Compliance with available Legal and Regulatory Requirements.
This evaluation is being commissioned by The Fred Hollows Foundation in Tanzania. Individual or institutions interested should submit a cover letter, resume, technical and financial proposals to The Foundation office in the Kenya regional office by 16th October 2023. Please reference “Consultancy to Conduct Mid-term Evaluation for the project **‘**Increasing Access to Equitable Cataract Services In four Regions of Tanzania’ and send to the following address: [email protected] Only submissions with complete documents as stated in the TOR and those meeting minimum requirements will be considered. Qualified consultants may be subjected to a background check on child protection as a condition for engagement.