1. Introduction/Background

The East African Community (EAC) is a regional inter-governmental organization comprised of the Republics of Burundi, Kenya, Rwanda, Uganda, South Sudan and the United Republic of Tanzania. It has an average population of 177 million people, land area of 2.5 million km square and combined GDP of $193 billion.

The EAC was established under article 2 of the Treaty for the Establishment of the East African Com- munity (“the Treaty”) that entered into force in July 2000. The objectives of the EAC are to develop policies and programmes for widening and deepening co-operation among the Partner States in political, economic, social and cultural fields, research and technology, security, legal and judicial affairs for their mutual benefit. The EAC envisages accelerated, harmonious and balanced development and sustained expansion of economic activities. The treaty further provides for regional cooperation on health, cooperation for international partners and non-state actors, management of refugees and internally displaced populations, and gender empowerment and rights of the child among others.

1.2 The EAC Health Sector Investment Priority Framework (2018 – 2028) 

The East African Community (EAC) through its Vision 2050 seeks to be “An upper-middle income region within a secure and politically united East Africa based on principles of inclusiveness and

accountability”. Investing in human capital development and thus a healthy and well-educated population has been identified as one of the most critical enablers for the attainment of the region’s vision. Other pillars that are expected to also contribute to favorable changes in the demographic, social, economic and environmental profile include infrastructure development; agriculture, food security, and rural development; industrialization; natural resource and environment management; and tourism, trade and services.

The region witnessed a dramatic increase in life-span from 51 years in 2005 to 61 years in 2016, a progress that comes with new challenges of growing burden of non-communicable diseases such as high blood pressure, diabetes and cancers yet the burden of communicable diseases such as HIV/AIDS, Malaria and Tuberculosis; maternal, neonatal and nutritional diseases and injuries have remained stubbornly high.

Further, the increasing global health security threats of epidemics, pandemics and antimicrobial resistance threaten the integrity of the region’s health systems, travel, trade and overall wellbeing. The World Bank and United Nations Economic Commission for Africa (UNECA) reports that in addition to causing over 11,000 deaths, the 2014/15 West African Ebola Virus Disease caused severe shocks to investment, production, travel, consumption and revenue generation – overall fiscal impact of the pandemic in 2015 stood at 8.5% of GDP in Liberia, 9.4 % in Guinea, and 4.8% in Sierra Leone1.

Currently, EAC Partner States pursue a mixed health system in which the public and private sector service providers account for close to 50% of health outputs; 36%, 36% and 28% of Total Health Expenditure (THE) is financed by public (government), donor and out-of-pocket sources respectively. Health insurance coverage ranges from less than 2% in Uganda and South Sudan; 25% in The United Republic of Tanzania; 28% in Kenya; 50% in Burundi and 92% in Rwanda.

About 70% of the EAC’s medicines, vaccines, and other health technologies are sourced from outside the region. Achieving Universal Health Coverage (UHC) is an ambitious sustainable development tar- get whose attainment is heavily dependent on the symbiotic relationship between health and eco- nomic development.

The EAC Summit of the Heads of State seeks to position the region as a health sector investment destination of choice and harness the sector’s huge potential contribution towards the region’s socio- economic transformation agenda in terms of promoting healthier lives, generating employment, fostering social and political stability, driving technological innovation and contributing to higher productivity and economic output2 . It’s important that the EAC systematically prepares for and taps into the huge global health market which in 2015 stood at about USD 7.3 trillion (10% of global GDP),

1 World Bank. 2016. 2014-2015 West Africa Ebola Crisis: Impact Update

² High-Level Commission on Health Employment and Economic Growth (2016). Final Report of the Expert Group. Geneva: World Health Organization – http://apps.who.int/iris/bitstre am/10665/250040/1/9789241511285-eng.pdf).

ranking only 3rd to value of the GDP of USA and China3. The Business and Sustainable Development Commission in 2017 identified 60 of the fastest growing market opportunities associated with the achievement of SDGs in four key economic systems – food and agriculture, cities, energy and mate- rials, and health and wellbeing4.

Together, they can potentially unlock US$12 trillion a year in terms of revenue and savings by 2030 and generate 380 million new jobs – 50% and 90% of the revenue and new job respectively are located in low and middle-income countries. Twelve (12) of the 60 fastest growing opportunities are in the health and well-being domain: Risk pooling, remote patient monitoring, tele-health/, advanced genomics, activity services, detection of counterfeit drugs, tobacco control, weight management pro- grams, better disease management, electronic medical records, better maternal and child health, Healthcare training and Low-cost surgery.

The ten-year EAC health sector investment priorities agenda was severally considered by the EAC Sectoral Council of Ministers of Health through its 13th, 14th and 15th Ordinary Meetings as well as the 2nd and 3rd Extra-Ordinary Meetings and the EAC Council of Ministers through its 35th and 36th Ordinary Meetings.

The regional health sector investment priorities were arrived at through a process of prioritizing regionally agreed upon priorities as documented in Article 118 of the Treaty for the Establishment of the EAC; the EAC Health Policy, EAC Health Sector Strategic Plan and EAC Vision 2050. National health policy priorities as well as Africa regional and global frameworks such as Agenda 2063 and the SDGs also informed the process.

A team of health financing, economics and planning experts drawn from all the Partner States was established to draft the framework for subsequent consideration by the policy organs.

The EAC Policy Organs primarily focused on the promotion of investment priorities that have high impact on the attainment of EAC’s regional integration and social – economic development aspirations.

The regional investment priorities, which are nine, were set to focus on addressing, but not limited to, the following key public health challenges that are prioritized in national and regional health sec- tor policies and plans:

1. 1. Malaria control and elimination;
   2. Elimination of HIV and AIDS;

³ New Perspectives on Global Health Spending for Universal Health Coverage. Geneva: World Health Organization; 2017. Licence: CC BY-NC-SA 3.0 IGO

⁴ Business and Sustainable Development Commission. 2017. Better Business Better World – The Report Of The Business & Sustaina- ble Development Commission, 2017

1. 3. Tuberculosis prevention and control;
   4. Elimination of preventable maternal new born and child deaths;
   5. Prevention and control of NCDs (common cancers, renal complications, cardio-vascular com- plications among others);
   6. Emerging and re-emerging diseases (including epidemics and pandemics)

The nine priorities were classified under two groups namely A) Health infrastructure, systems and services development and B) Health research and development. The total cost for the two groups of interventions is estimated at USD 3,175,699,500.

1. Health infrastructure, systems and services development

• • Priority 1: Expansion of access to specialized health care and cross border health services
  • Priority 2: Strengthen the network of medical reference laboratories and the regional rapid response mechanism to protect the region from health security threats including pandemics, bio-terrorism and common agents
  • Priority 3: Expansion of capacity to produce skilled and professional work force for health in the region based on harmonized regional training and practice standards and guidelines
  • Priority 4: Increase access to safe, efficacious and affordable medicines, vaccines, and other health technologies focusing on prevalent diseases such as malaria, TB, HIV/AIDS, non-communicable diseases (NCDs) and other high burden conditions
  • Priority 5: Upgrading of health infrastructure and equipment in priority national and sub national health facilities/hospitals
  • Priority 6: Establishment of strong primary and community health services as a basis for health promotion and diseases prevention and control
  • Priority 7: Expansion of health insurance coverage and social health protection
  • Priority 8: Improvement of quality of healthcare, health sector efficiency and health statistics

2. Health research and development
   • Priority 9: Strengthening of Health Research and development

2. Purpose

The Mid-Term Review (MTR) will assess the progress of implementing the agreed investment priorities and sub-priorities and framework, as well as identify program and operational issues and recommend course of actions.

The review is being undertaken at the midpoint of the framework implementation and will pave the way for improved delivery for the remaining implementation period and propose amendments (if any) required.

3. Objective

The main objective of the evaluation is to review the status of EAC Health Sector investment priorities at the mid-point and propose recommendations.

4. Scope of work

The evaluation will cover the implementation of the agreed Health sector investment priorities during the period 22^nd May to July 31^st 2022 . The evaluation will be conducted at the regional and national levels, covering the 6 Partner States forming the EAC.

The evaluation will assess the following investment priorities and sub-priorities:

1. Health infrastructure, systems and services development

1. 1. Priority I: Expansion of access to specialized health care and cross border health services
      1. Sub priority 1.1: Expand the capacity of the East African Centers of Excellence for Higher Medical Education, Health Services and Research (Cost Estimate: USD 319,800,000)
   2. Priority 2: Strengthen the network of medical reference laboratories and the regional rapid response mechanism to protect the region from health security threats including pandemics, bio-terrorism and common agents
      1. Sub priority 2.1: Establish seven (7) EAC Regional Medical Diagnostic Centers of Excellence (Cost Estimate: USD 160,700,000)
      2. Sub priority 2.2: Establish an EAC Regional One Health Rapid Response Mechanism to enhance the region’s capacity to rapidly mobilize experts and provide necessary supplies such as Personal Protective equipment to combat major epidemics and pandemics such as Ebola and Marburg (Cost Estimate: USD 12,100,000)
      3. Sub priority 2.3: Establish regional sentinel disease surveillance sites in epidemic prone areas and provide appropriate facilities (Cost Estimate: USD 25,150,000)
      4. Sub priority 2.4: Support Partner States to upgrade port, cross border and One Stop Border Post (OSBP) health facilities to increase capacity of detecting and managing cross border health threats (Cost Estimate: USD 3,225,000)
   3. Priority 3: Expansion of capacity to produce skilled and professional work force for health in the region based on harmonized regional training and practice standards and guidelines
      1. Sub priority 3.1: Modernize University Teaching Hospitals and National Referral Hospitals in the region in terms of infrastructure, technology (including ICT for learning) and personnel in the region (Cost Estimate: USD 175,400,000)
      2. Sub priority 3.2: Expand the capacity of five (5) mid-level health workforce training institutions in terms of infrastructure, technology and personnel support in each Partner State (Cost Estimate: USD 195,800,000)

1. 3. 3. Sub priority 3.3: Strengthen regulation of health professionals by strengthening the Partner States’ National Health Professionals Regulatory Authorities. (Cost Estimate: USD 8,750,000)
   4. Priority 4: Increase access to safe, efficacious and affordable medicines, vaccines, and other health technologies focusing on prevalent diseases such as malaria, TB, HIV/AIDS, non-communicable diseases (NCDs) and other high burden conditions
      1. Sub priority 4.1: Partner States to provide incentives for local manufacturing of medicines, vaccines, and other health technologies that meet international standards of quality, safety and efficacy. (Cost Estimate: USD 335,000,000)
      2. Sub priority 4.2: Assure quality of medicines, vaccines, and other health technologies through strengthening the EAC Partner States’ National Medicines Regulatory Authorities (NMRAs) (Cost Estimate: USD 30,000,000)
      3. Sub priority 4.3: Establish an EAC Regional Pooled Bulk Procurement mechanism to facilitate pooled bulk procurement of medicines, vaccines, and other health technologies 11 EAC Health Sector Investment Priorities Framework (2018 – 2028) (Cost Esti- mate: USD 50,000,000)
      4. Sub priority 4.4: Strengthen the network of national quality control laboratories and the EAC Regional Chemical Reference and medicines and health technologies Quality Assurance laboratory to assure quality of medical products and devices including at cross border points as part of the OSBP Infrastructure. (Cost Estimate: USD 90,000,000)

1. 5. Priority 5: Upgrading of health infrastructure and equipment in priority national and sub national health facilities/hospitals
      1. Sub priority 5.1: Rehabilitate/build five (5) priority secondary or tertiary hospitals per Partner State and equip them with modern and sustainably maintained equipment (including at cross-border posts to facilitate joint actions in addressing cross border health threats (Cost Estimate: USD 391,500,000)
      2. Sub priority 5.2: Establish an EAC Regional e-Health Infrastructure to facilitate service delivery through Telemedicine, capacity building and knowledge management among national and sub national referral hospitals five (5) regional priority secondary and or tertiary hospitals from each Partner State (Cost Estimate: USD 30,000,000)
      3. Sub priority 5.3: Implement an EAC regional institutional healthcare green power/energy, sanitation and water supply project in five (5) regional priority secondary and or tertiary hospitals per Partner State (Cost Estimate: USD 90,000,000)

1. 6. Priority 6: Establishment of strong primary and community health services as a basis for health promotion and diseases prevention and control
      1. Sub priority 6.1: Establishment of a mixed community health worker and skilled health workforce-based community health system in priority settings (e.g. highlight populated yet with intractable high levels of healthcare challenges in terms of

mortality, morbidity and health systems weaknesses) supported by robust community health information systems that are linked to the formal health facility-based health information systems by all Partner States (Cost Estimate: USD 300,200,000)

1. 1. 2. Sub priority 6.2: Promote regional integrated high impact interventions for the prevention, control and elimination of malaria, TB and HIV/AIDS, non-communicable dis- eases (NCDs) and other high burden conditions. (Cost Estimate: USD 624,200,000)

1. 7. Priority 7: Expansion of health insurance coverage and social health protection
      1. Sub priority 7.1: Each Partner State to establish and or expand their National Health Insurance and social protection schemes to support the Universal Health Coverage, including financial risk protection, as outlined in the Sustainable Development Goals (Cost Estimate: USD 46,200,000)
      2. Sub priority 7.2: Implement and expand portability of benefits of social health protection as part of the overall social protection agenda in support implementation of the EAC common market ideals (Cost Estimate: USD 2,720,000)

1. 8. Priority 8: Improvement of quality of healthcare, health sector efficiency and health statistics
      1. Sub priority 8.1: Conduct one national health sector efficiency study every three years. (Cost Estimate: USD 5,400,000)
      2. Sub priority 8.2: Scale up accountability of results and resources through innovative approaches such as Maternal and perinatal death surveillance and response (MPDSR), surveillance for other common causes of mortality among the population and com- munity level Civil Registration and Vital Statistics (CRVS). (Cost Estimate: USD 32,000,000)
      3. Sub priority 8.3: Strengthen health information, statistics and measurement in the EAC through upgrading of ICT infrastructure and technical human resource capacity in data collection, analysis and knowledge management (Cost Estimate: USD 37,500,000)
      4. Sub priority 8.4: Develop a regional patient centered healthcare quality improvement model (Cost Estimate: USD 9,740,000)

2. Health research and development

9. Priority 9: Strengthening of Health Research and development
   1. Sub priority 9.1: Establish an EAC Regional Health Research and Development Facilitation Mechanism (Cost Estimate: USD 132,815,626)
   2. Sub priority 9.2: Establish an EAC Regional Observatory on Health Research and Development (Cost Estimate: USD 3,223,874)
   3. Sub priority 9.3: Investment in Digital Health Technology for better research for health, health services delivery and health outcomes (Cost Estimate: USD 21,175,000)

5. Evaluation methodology and approach

This evaluation will involve both quantitative and qualitative methods. Data will be gathered through desk review of work plans, resource tracking tools available, reports and related documents and interviews with key informants. Evidence gathered through interviews will be triangulated with data from desk review. Measures will be taken to ascertain data quality, validity and credibility. The findings will be substantiated by valid evidence on record.

1. 1. Desk Review

A list of documents to be reviewed will be prepared by EAC secretariat Health Department in coordination with the partner states and the Consultants. The documents will be shared electronically with the evaluator. The documents to be reviewed include, but not limited to, the detailed EAC Health Sector Investment priorities framework including the cost estimate, Partner States Health Strategic Plan/Policies and Health Annual budget and Annual Reports (including annual health expenditure on health), Global Health Reports. Desk review will be conducted prior to interviews with key inform- ants.

1. 2. Key Informant Interviews

Key informant interviews will be conducted by the evaluator / consultant supported by EAC Health Staffs. Interviews will be conducted with different stakeholder in relevance to each of the Health Priorities/Sub-Priorities.

• • • EAC Secretariat, Health Department, representatives of partner states,
    • EALA
    • Health focal points representing the areas of the health priorities framework in partner states
    • Civil society organizations (regional and country level)
    • Donors and development partners including covering the area of the Health Priority Frame- work,
    • Other Regional Economic Communities (SADC Secretariat) and the African Union (AU)
    • African Union including Africa CDC
    • WHO Regional Office and Country offices
    • UNFPA, UNICEF, UNAIDS Country Office
    • Other Multilateral Organizations: Global Fund, GAVI
    • Bilateral Organizations: USAID, CDC, CTB and other Bilateral working at PS level and contributing in the Health Sector

6. Dissemination phase

In preparation of the Midterm Evaluation report, the consultant will present the findings to the Joint technical working group on Systems and policy and RMNCAH & HIV and AIDS, Sida, and other stakeholders in a one-day workshop. The workshop will be aimed at further synthesizing and contextualizing the findings through inputs from diverse group. The final report will be shared with the EAC secretariat for final adoption.