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.

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

1. Assess existing referral practices, provider networks, database and systems, institutional capacity and system readiness in selected settings to define a feasible pilot model.
2. Co-design and pilot a standardised referral and counter-referral model, including workflows, tools, roles, monitoring arrangements and capacity-building support.
3. 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, Punjab Health Foundation and other relevant actors.
• Assess:
  • how referrals are currently initiated, received, documented and followed up
  • whether receiving facilities provide feedback to referring GPs
  • existing digital and paper-based tools
  • provider incentives, constraints and willingness to participate
  • PHCC’s operational capacity and regulatory levers to oversee the model.
• Select the pilot geography and facility network using agreed criteria, including concentration of licensed GP clinics, availability and willingness of receiving public/private facilities, manageable referral distances, service capacity and specialist availability, and feasibility of data collection and PHCC oversight, and agree on mechanisms to follow through.
• Agree a limited set of referral pathways and mechanisms on how they will be executed for the pilot, prioritising routine, elective and chronic-care referrals.
• Engage all the GPs and family physicians in disease reporting, which may include notifiable diseases, like dengue, covid, etc., initially; and ultimately the introduction of a uniform comprehensive reporting system in the scope of work for all GPs that goes beyond disease-based recording and reporting.
• Engage GPs in immunisation and family planning services
• Submit a concise inception and referral-system assessment report, including confirmed pilot scope, baseline findings, stakeholder roles and implementation plan.

Phase 2: Co-design of the Referral Model and Pilot Package

• Co-design and fine tune a practical two-way referral and counter-referral model with PHCC.
• Define referral pathways that are implementable within Punjab’s context keeping in consideration ethical and confidentiality principles.
• Develop and validate referral and counter-referral SOPs and reporting mechanisms.
• Assess existing PHCC/H&PD digital platforms and determine the minimum viable digital solution. Existing systems will be adapted or used where feasible; development of a new application will only be considered if jointly agreed, technically feasible and adequately resourced.
• Agree baseline and pilot indicators.
• Submit the referral model and pilot implementation package to PHCC for validation.

Phase 3: Provider Training and Pilot Implementation

• Confirm participation and nominate focal persons in each referring and receiving facility.
• Orient participating providers on referral criteria and pathways, use of agreed tools or digital platform, documentation and information-sharing requirements, counter-referral and follow-up responsibilities, and patient consent and confidentiality.
• Use a practical blended training approach combining short orientation sessions, demonstrations, job aids and on-the-job support.
• Conduct a time-bound pilot in the selected facility networks, with the final number of districts, facilities and pilot duration confirmed during inception.
• Provide regular technical backstopping and convene periodic implementation reviews with PHCC and participating facilities.
• Use routine pilot data and targeted provider/patient feedback to identify operational bottlenecks and test corrective actions.

Phase 4: Evaluation, Refinement and Institutionalisation

• Analyse pilot performance against the agreed baseline, indicators and feasibility criteria.
• Assess provider participation and compliance, referral completion and counter-referral rates, continuity-of-care outcomes, operational burden and costs, digital and data-management feasibility, PHCC’s capacity to monitor and sustain the model, and implications for licensing, MSDS and quality-assurance processes.
• Refine the referral model, SOPs, tools and monitoring arrangements based on pilot findings.
• Validate findings and recommendations with PHCC and relevant government and provider stakeholders.
• Submit a concise pilot implementation and evaluation report; and a final institutionalisation and scale-up roadmap.

Capacity Transfer, Sustainability and Institutionalisation

• PHCC will co-design, validate and conduct oversight of the referral model, with designated focal persons responsible for coordination, monitoring and follow-up during the pilot.

• Capacity building will be embedded in implementation rather than limited to one-off training. PHCC staff and facility focal persons will receive practical orientation, coaching and on-the-job support on referral workflows, data review, troubleshooting and performance monitoring.

• The model will define responsibilities for referring GP clinics, receiving public and private facilities, PHCC oversight teams and relevant H&PD and SHC&ME Department counterparts.

• Where feasible, referral requirements will be linked to PHCC’s existing licensing, MSDS, inspection and quality-assurance processes, rather than maintained as a stand-alone project mechanism.

• Existing government digital and reporting systems will be used or adapted wherever possible. Any new functionality will be limited to what PHCC can realistically administer, finance and maintain after TA completion.

• During the pilot, the TA team will progressively shift from direct implementation to mentoring and oversight, with PHCC and facility focal persons taking responsibility for routine monitoring and corrective action.

Deliverables

1. Inception Report: Approved workplan, governance arrangements, stakeholder engagement plan, and evidence of inception consultations.
2. Referral Model and Pilot Implementation Package: PHCC-validated referral model, including SOPs, workflows, tools, monitoring framework, implementation guidance, training/job aids, and agreed digital approach.
3. Final Report with Pilot Findings and Recommendations: Refined referral model and implementation package based on pilot findings validated by relevant stakeholders.

Position Title:

Research Associate – Coordination Support (Junior National)

Duty Station: Lahore (with travel as required)

Duration / LOE: Mid-August 2026 – March 2027 (LOE 120 days – subject to change until the start of the TA)

Reporting To: Senior Health Systems Expert / E4H Punjab Programme Team 

Role Purpose

Provide operational, coordination, logistics, and stakeholder engagement support to facilitate implementation of the referral systems technical assistance.

Key Roles & Responsibilities

• Coordinate stakeholder consultations, meetings, workshops, and field activities.

• Support logistics, scheduling, and communication with participating facilities.

• Maintain project trackers, meeting records, and follow-up actions.

• Assist with workshop organisation, reporting, and documentation.

• Provide administrative and coordination support across all TA deliverables.

Requirements

Technical Expertise

• Bachelor's degree in Public Health, Social Sciences, Management, Development Studies, or related discipline.

• Minimum 5 years of overall professional experience.

• Experience in programme coordination, stakeholder engagement, workshop management, or project administration preferred.

• Experience supporting government or donor-funded health programmes is an advantage.

Core Competencies

• Stakeholder coordination

• Workshop and event management