Terms of Reference (ToR)
Development of Health Insurance Model for the Emptiers

1.0 Introduction
SNV Netherlands Development Organisation is a not-for-profit development organisation working in the sectors of WASH, Agriculture and Energy through providing advisory services, facilitating knowledge development, networking, strengthening local capacity builders, and carrying out advocacy at national and international levels. Founded in 1965, SNV has built a long term local presence in countries of Africa, Asia, and Latin America. For more information, please refer to our website: www.snv.org

SNV is implementing a program City Wide Inclusive Sanitation Engagement (CWISE) in Southern Bangladesh under the leadership of Local Government Authorities (City Corporations and Municipalities). Over the past 5 years, the program has successfully developed a multi stakeholder coordination mechanism at the local level under the leadership of Local Government Institutions, bringing together local authorities, utility, national agencies, universities, private sector and civil society around urban sanitation. The main objective of the project is to demonstrate a city-wide, pro-poor, accountable, safe and sustainable faecal sludge management services for the urban context in Bangladesh, showing improvement in the living environment and contributing to the health and well-being of the urban population.

The CWISE program is being implemented in 5 Southern cities (Khulna, Jhenaidah, Kushtia, Jashore and Benapole) and Gazipur in Bangladesh. SNV aims to support Local Authorities in Khulna (Khulna City Corporation and Khulna Water Supply and Sewerage Authority) along with Gazipur City Corporation, Jhenaidah, Kushtia, Jashore and Benapole Paurashavas to address service delivery challenges in Faecal Sludge Management (FSM) and advance the development of the sector as a whole, through strategic engagement with Government Agencies (sector Ministry, relevant Departments and their service delivery channels at sub-national level) and partnering with other experienced civil society and private sector organisations working in the sector. The project partners aim to facilitate a decisive shift in sector thinking, culture and practice through close alignment with respected sector agencies and working collectively with government and local partners to address underlying systemic sector issues that limit sector development. The project consists of 6 major components: 1) Sanitation demand creation and behavioural change communication; 2) Strengthening sanitation supply chain development; 3) Improving WASH Governance and multi-stakeholder sector development; 4) Sustainable Finance and Investment; 5) Introducing environmentally safe treatment and re-use technologies; and 6)  Processing documentation for future learning and replication of the interventions in other areas in need.

2.0 Background and Rationale
Bangladesh is a striking example of the rapid progress in access to sanitation where open defecation has been reduced from 19% in 2000 to 1% in 2015 (estimated by UNICEF). However the inability to sustain use of existing toilets and unsafe disposal of faecal sludge pose the next challenges in improving health and economic situation of urban populations. Widely unregulated FSM services, overwhelmingly shouldered by the traditional independent emptiers, is not supportive to gradual scaling-up to cater to the needs of the city-wide population. While the transition from manual to mechanised FSM services takes place, standards setting and professionalization of sludge emptying and transportation is of utmost importance to restore community health and environmental safety and to ensure continued capacity of service providers.

Mainstreaming Occupational Health and Safety (OHS) measures in faecal sludge (FS) collection, transportation, disposal, processing and re-use is the key to minimizing accidents while carrying out FSM activities and to control health and environment related hazards and eventually ensuring good health of the emptiers and the community as a whole. The FSM services in Bangladesh are overwhelmingly dependent on independent / manual emptiers who have both little awareness (due to lack of training) and motivation (due to poor pay) to observe OHS measures including personal protective equipment (PPE). Since there is an ongoing transition taking place from manual emptying to mechanised emptying, OHS will become even more of a dominant factor when the present FSM services will be multiplied at scale throughout the cities.

Apart from the social stigma that these emptiers face, they are also exposed to certain health problems by virtue of their occupation. These health hazards include exposure to harmful gases, cardiovascular degeneration, musculoskeletal disorders, infections, skin problems, back pain, neck pain and asthma, spillage and contamination, and respiratory system problems etc. Moreover, these health risks directly effect on the productivity the emptiers and causes financial losses which they are unable to afford, resulting long term health hazards including their family. The health hazards can be minimized by providing an effective OHS training and also, regular awareness programs can be conducted to impart training regarding safer work procedures and use of personal protective devices. But only awareness programme and providing training cannot minimize/reduce the health hazards of the emptiers. Therefore, Health insurance, as a risk pooling and risk minimizing mechanism, is indeed important to protect the emptiers from devastating financial losses due to health hazards.

In Bangladesh, faecal sludge emptying is overwhelmingly done by the manual emptiers though in some cities vacutug service is also available. However, their service is constrained by a number of factors. The manual emptying is most hazardous as the emptiers usually do not use anything other than some buckets and a plastic drum for transport. These manual emptiers do not even use hand gloves to avoid contact with sludge. In few instances, they use pump machines to pump out liquids from the septic tank or pit and then manually empty the remaining solid sludge. The method is extremely harmful for both the emptier and the environment. According to Bangladesh Institute of Labour Studies (BILS), from 2013 to 2016, about 51 emptiers died during emptying septic tank whereas in last 10 month it was 35 which is almost doubled from previous year record. Therefore, it is utmost important to ensure health and safety of emptiers in their work place. Health insurance is one of the most fundamental types of insurance after life cover in terms of being an absolute necessity for day labour like emptiers who are vulnerable to health hazards in their workplace. It also is important as it provides financial security to meet health related contingencies.

The Government of Bangladesh (GOB) is constitutionally obligated to provide the basic necessities of life, including food, clothing, shelter, education and medical care to its citizens. However, poverty, lack of knowledge, and other barriers keep many people (especially socially excluded/ vulnerable group like emptiers/sweepers) from accessing services essential to maintain health and making healthy choices. One major barrier is financial; a large number of health services in Bangladesh are obtained through out-of-pocket expenditures made at the point where health services are received or medicines are purchased. Such high out of pocket expenditures on health can lead to loss of productive assets (selling items to pay for medicines) and threaten economic survival, especially in countries with high rates of catastrophic illnesses, such as Bangladesh. Heath spending is different from other spending and is characterized by different parameters however healthcare expenses are often unpredictable. It is difficult for most part to predict when one would need emergency (such as accident at work place) or curative care which, in the absence of pre-payment and risk sharing mechanisms (like health insurance), makes it very difficult to meet the sudden demand for health expenditures at time of illness. Moreover, social and economic disadvantages may result in lower access than is desirable and also illness may adversely affect an individual’s economic pursuits and income, which often have a hugely negative impact on a household’s ability to manage its daily demand for the most essential goods. To be effective in these conditions, a health care financing mechanism must offer financial protection against ill health and from financial consequences associated with obtaining medical care.

3.0 Objectives
The key objective of providing health insurance is to improve access to health care and provide financial protection to health shocks and illness for emptiers and their family members. This involves mechanisms that help emptiers to overcome social and psychological barriers in accessing health care, reducing out-of-pocket cost of treatment and preventing further impoverishment due to catastrophic health expenditure. 

The initiative will contribute to support LGIs (City corporations/ Paurashavas) for developing and implementing health insurance scheme for the emptiers.

The specific objectives of this assignment are:

  • to review and assess existing different health insurance model for LICs in urban context of Bangladesh;
  • to review existing challenges,  gaps/ barriers for providing health insurance to the emptiers;
  • to recommend potential interventions to minimise/eliminate the identified challenges gaps/ barriers;
  • to develop different models for providing health insurance scheme for the emptiers;
  • to recommend innovative financing solutions/mechanism for implementing health insurance scheme/model.

4.0 Scope of work

  • Discussion with SNV Urban Sanitation Team to understand the assignment, the background and expectations from the study.
  • Interviews / e-discussion/workshop with relevant personnel from different government departments, LGIs (city corporations/ paurashavas), insurance companies, different NGOs/ development organisations/ private sector stakeholders working on health insurance to LICs at the national and local level.
  • Review and determine existing challenges/ gaps/ barriers for ensuring health insurance to emptiers;
  • Develop a compilation report on in-depth assessment/ analysis of existing challenges, barriers and provide recommendations to overcome the barriers;
  • Develop innovative schemes for providing health insurance to the emptiers including financial models and provide recommendation for implementation of the models
  • Develop innovative financing solutions/ mechanism as well as the viability of providing health insurance scheme to the emptiers;

5.0 Deliverables
The Consultant is expected to deliver a comprehensive and high quality analytical report to above mentioned scope of work:

  • Inception report along with detailed work plan of the assignment
  • The scope of the review and process followed (methodology, information and data sources; supporting and reference documentation, etc.);
  • An evidence based assessment and compilation report of existing and potential health insurance models for LICs and the obstacles/barriers to accessing health insurance and provide recommendation to overcome the barriers;
  • A comprehensive and viable health insurance scheme including financial model for accessing health insurance coverage for the emptiers;
  • Proceeding of national level Consultation workshop to validate the findings; The workshop will be held in Dhaka and the consultant must ensure participation of key relevant stakeholders to validate the findings. The Consultant should keep separate budget for organising the validation workshop.
  • The final report incorporating different schemes for health insurance including financial model and recommendation for innovative financing solutions/ mechanism along with the other supporting information in the annexes.

6.0 Human resource requirement
The Consulting Firm/ Consultants must have experience working for development organisations in the past and already have expertise and experience in the field of health insurance for LICs, and preferably also the WASH sector. The Consultant must attach the CVs of the key personnel to the proposal.

7.0 Timeframe
The total duration of the assignment will be for 12 weeks after signing of the contract. Commencement of the services is expected to be started by First week of April 2019.

8.0 Implementation arrangements
The Consultant will report to the Team Leader (SNV Urban Sanitation Programme) for each of the deliverables, and will work closely with the Sanitation Business Advisor for day to day reporting and also with the Urban Sanitation Team.

SNV will make payments to the agency after deducting applicable TAX and VAT in compliance with the rules of Bangladesh. Payment will be made to the agreed account based on the receipt of invoice after the successful completion of each of the following phases of the assignment:

Milestone Payment schedule Estimated date
Upon Signing of the Contract
30% of the total budget
First week of the signing the contract
Upon submission of the assessment and compilation report on existing health insurance model for LICs in Bangladesh,  and obstacles/barriers to accessing health insurance for the emptiers and provide recommendations to overcome the barriers and approved by SNV
40% of the total budget
Within eight weeks of the signing of the contract
Upon submission of the final report including all documents developed within the assignment period and approved by SNV
30 % of the total budget
Within twelve weeks of the signing of the contract

9. Application
Interested organisations or consulting firms are requested to submit their technical and financial proposals with the details on organisational overall and similar experience, methodology including activities and milestones, budget details, time frame and CVs of experts. Electronic copy of the proposal duly signed should be submitted to bangladesh@snv.org  with the subject line: Development of Health Insurance Model for the Emptiers latest by 27 March 2019.

Or Hard copy can be submitted to:
SNV Netherlands Development Organisation
House 345, Road 2, Sonadanga R/A 2nd phase, Khulna

For any query related to the ToR, please contact Tanvir Chowdhury, Sanitation Business Advisor, SNV. Email: tchowdhury@snv.org