E4H Punjab TOR - Targeted Technical Assistance for PHC-Facing AMR Learning and Rational Antibiotic Use among Allied Health Professionals in Punjab

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

Pakistan and Punjab continue to face a significant antimicrobial resistance burden, driven by complex human health, animal health, pharmaceutical, infection prevention, regulatory and behavioural factors. In Punjab, multiple actors influence antimicrobial use, including both health departments, the Punjab Healthcare Commission (PHCC), Institute of Public Health (IPH) Lahore, provincial Drug Control structures, , professional bodies, pharmacies, PHC providers and community-facing health cadres.

E4H current AMR mandate is situated in the transition following closure of the Fleming Fund Country Grant. The TA will recognise and build on Fleming Fund-supported human-health platforms and achievements, including AMR surveillance and reporting, laboratory and microbiology capacity, stewardship and IPC linkages, data-use practices, and coordination mechanisms, while avoiding duplication and confirming the precise assets during inception.

The National Action Plan on AMR 2.0 (2025-2029), including Punjab participation in the national process and provincial priorities, will serve as the principal strategic reference for this TA. The assignment will translate relevant national priorities into an implementable provincial package and roadmap for the public and private health sectors

The support envisioned in Punjab focuses on practical learning, targeted advocacy and facility-level action. It does not attempt broad provincial AMR planning, major laboratory expansion or full-scale implementation. If UKHSA or other partners support provincial AMR planning, E4H will align with that work and avoid duplication.

The TORs frame the proposed technical assistance (TA) around a rational, value-for-money package that uses existing institutions, existing training platforms and selected technical anchors rather than creating new systems or attempting province-wide rollout. 

E4H support will be practical and selective. It will map AMR assets and partner support, refine a limited PHC-facing learning package, support orientation and applied learning for Allied Health Professionals through selected institutional partners, and use one or two higher-level learning or technical sites only where needed for content validation, case material, antibiogram interpretation or stewardship examples.

Problem Statement

Punjab has several AMR-relevant initiatives and institutional actors, but practical linkage remains limited between AMR evidence, stewardship, IPC, prescribing behaviour, regulatory levers and the knowledge base of PHC-facing cadres. Current initiatives are not yet consistently connected across physician-led stewardship, prescribing accountability, AMC/AMU, microbiology and AST practices, periodic antibiograms, AWaRe-informed decisions, IPC, quality standards, MSDS oversight, dispensing, referral and patient counselling.

In addition to prescriber Physicians, who have a key role in AMR control, Allied Health Professionals (Pharmacists, Laboratory Technicians, Nurses) can support more consistent messages on rational antibiotic use, IPC, referral, counselling and basic stewardship practices, but they require a concise, context-appropriate learning module and facilitation approach linked to existing quality-of-care and regulatory systems. .

A targeted TA is needed to strengthen these connections, support selected institutions and facilities, develop provincial guidance, and establish a sustainable scale-up pathway.

Goal and Objective(s)

Goal

To strengthen provincial and facility-level AMR containment and antimicrobial stewardship in Punjab through an integrated package of learning, institutional support, technical guidance, MSDS recommendations and a sustainable roadmap aligned with NAP-AMR 2.0

Objectives

• Develop and institutionalise an AMR/AMS learning package and CPD short course through IPH, with differentiated materials for priority cadres.
• Integrate and disseminate WHO AWaRe classification, antibiogram use, AMC/AMU and other relevant AMR information within learning, clinical governance and quality platforms.
• Strengthen physician-owned antimicrobial stewardship systems in selected teaching hospitals through baseline review, multidisciplinary teams, action plans, mentoring and progress tracking.
• Develop draft provincial antimicrobial stewardship guidance for consultation, validation and formal government consideration.
• Prepare recommendations for incorporating proportionate AMS oversight and verification requirements into PHCC MSDS and related quality-assurance processes.
• Map partner support and institutional assets and develop a sustainable Punjab roadmap for AMR containment across public and private health sectors.

Target Groups and Technical Focus

Physicians and institutional leadership will be positioned as the principal owners of stewardship. Priority supporting cadres will be selected according to direct AMR relevance and may include pharmacists, microbiologists, culture-laboratory technologists, nurses, IPC personnel, public-health professionals, quality managers, facility supervisors and relevant trainers.

Differentiated content will include: prescriber stewardship and accountability for physicians; AMC/AMU, dispensing and AST-based stewardship advocacy for pharmacists; good microbiology practices, culture and susceptibility testing quality, facility AMR reporting and periodic antibiograms for microbiologists and culture-laboratory technologists; and focused stewardship, specimen, referral, counselling and IPC responsibilities for nurses, IPC and PHC-facing personnel.

IPC content will remain focused and proportionate because IPC is already embedded in MSDS and has received substantial post-COVID attention. The package will place greater emphasis on stewardship, prescribing behaviour, microbiology, antibiogram use, AMC/AMU, AWaRe and institutional accountability.

Strategic Approach

Contributions to health systems strengthening

The TA will strengthen PHC-facing AMR learning by refining and applying a concise module for Allied Health Professionals on rational antibiotic use, AMS, IPC, red flags and referral, patient counselling, AWaRe awareness, and safe practice within existing mandates.

One or two teaching hospitals or academic institutions may be engaged only as technical anchors for validation, case examples, antibiogram interpretation and practical learning inputs.

Alignment with other E4H TAs/investments

The TA aligns with E4H Output 1 by supporting integrated health security, IHR capacity, rational antimicrobial use, IPC and data-informed action. It complements E4H work on health security governance, quality of care, patient safety and regulatory strengthening by translating AMR priorities into practical learning for PHC-facing cadres.

The TA will build on E4H entry points with the Punjab Healthcare Commission and IPH, including possible linkages with MSDS orientation, quality standards, inspection learning tools, facility support, licensing dialogue, training and professional engagement. This TA is also aligned with the following TAs already completed during 2025-26 workplan:

• Revision of Public Health Act
• Health Manager’s Capacity Building on IHR
• IHR Task Force Convening
• Simulation exercises

Alignment with other donors

The TA will map ongoing AMR-related support in Punjab before confirming activities to avoid duplication with other partners like  UKHSA, WHO, and others.. E4H support will only complement existing AMR surveillance, laboratory, IPC, quality, regulatory and stewardship investments.

Engagement with Drug Control, pharmacy actors, professional bodies and clinician or allied health forums will focus on feasible actions related to antibiotic sale, dispensing, prescribing behaviour, patient counselling and stewardship messaging, while recognising provincial responsibilities and relevant DRAP linkages.

Scope of Work and Delivery Methodology

The TA will be delivered from September 2026 to March 2027 through four linked workstreams. Delivery will combine provincial technical work, institutional co-development, facility-level support and dissemination through existing systems.

Phase 1 - Inception, mapping and baseline

• Conduct institutional, partner and asset mapping and document relevant Fleming Fund-supported platforms and current partner investments.
• Complete a focused baseline assessment of selected teaching hospitals and institutional systems covering AMS governance, prescribing, pharmacy, AMC/AMU, microbiology, AST, antibiogram production, IPC linkages and reporting.
• Apply transparent selection criteria for priority cadres and learning sites, including AMR relevance, leadership commitment, service volume, laboratory/pharmacy functionality, data availability, public/private representation and feasibility.
• Confirm the results framework, stakeholder-engagement and endorsement pathway, final workplan, scope boundaries, risks and coordination arrangements.

Phase 2 - Package, guidance and system design

• Co-develop with IPH a modular CPD short course and differentiated materials for physicians and priority AMR-relevant cadres, using existing national and partner materials where suitable.
• Prepare practical AWaRe, antibiogram, AMC/AMU, AST and stewardship resources, job aids, facilitator guidance, case scenarios and competency-based pre/post assessments.
• Draft provincial AMS guidance defining governance, multidisciplinary team functions, prescribing review, pharmacy and laboratory roles, data review, reporting, escalation and accountability.
• Review relevant PHCC MSDS provisions and develop proposed AMS additions or revisions with feasible indicators, evidence requirements and oversight options.
• Agree dissemination arrangements, including trainer orientation, CPD channels and, subject to approval, publication on IPH, PHCC and relevant health-department websites. 

Phase 3 - Institutional and facility implementation

• Orient nominated trainers and deliver targeted learning sessions through IPH and participating institutions, with materials differentiated by cadre.
• Support selected teaching hospitals to establish or strengthen physician-led multidisciplinary AMS arrangements and prepare time-bound facility action plans.
• Provide technical mentoring on AWaRe-informed prescribing, pharmacy-led AMC/AMU review, AST-based decisions, good microbiology practices, periodic antibiograms and submission of reports to hospital management and laboratory leadership.
• Facilitate structured review meetings to monitor action plans, barriers, enablers and early implementation evidence.
• Consult public and private sector stakeholders on provincial guidance and MSDS recommendations.

Phase 4 - Validation, endorsement, dissemination and roadmap

• Validate the CPD course, provincial AMS guidance, teaching-hospital action plans and PHCC MSDS recommendations through designated technical and government forums.
• Submit final products through agreed institutional channels for written endorsement or approval by the competent authorities.
• Prepare a costed and prioritised Punjab roadmap for AMR containment, aligned with NAP-AMR 2.0 and building on Fleming Fund-supported platforms, with actions, lead institutions, sequencing, resource implications, indicators, risks and public/private scale-up pathways.
• Hand over editable products and a dissemination package to nominated government and institutional counterparts.

Sustainability: Capacity Building, Institutionalisation, and/or Transition Planning

Embedded learning and capacity support

Capacity support will focus on practical understanding of AMR, rational antibiotic use, AMS concepts relevant to PHC, IPC basics, patient counselling, referral, escalation and feedback. The package will be suitable for Allied Health Professionals, supervisors, trainers or institutional focal persons.

Institutionalisation through existing systems

The TA will explore how module materials and learning can be linked with PHCC quality standards, MSDS-related orientation, IPH training channels, Drug Control dialogue, CPD platforms, supervisory routines, facility support tools and patient safety or quality improvement mechanisms.

Transition and handover

The final phase will consolidate editable module materials, job aids, facilitation notes, action-tracking templates, stakeholder reflections and scale-up options. These will be handed over to participating government or institutional counterparts for future use and adaptation.

Deliverables

1. Inception Report and Slide Deck: Institutional and partner map; documented assets; hospital/system baseline; cadre and site-selection criteria; final workplan; engagement and endorsement plan; scope boundaries; risk register; results framework.
2. Refined AMR Learning Module and Practical Learning Package: IPH CPD short course; differentiated materials; job aids; AWaRe, antibiogram, AMC/AMU and AST resources; trainer package and assessments; draft provincial AMS guidance; teaching-hospital action plans; proposed PHCC MSDS revisions; dissemination package.
3. Sustainable Punjab roadmap for AMR containment: Implementable, prioritised and costed roadmap for public and private sectors aligned with NAP-AMR 2.0 and Fleming Fund-supported platforms; governance, sequencing, financing options, indicators, risks, accountability and scale-up plan.

Position Title:

Clinical AMR/AMS and Microbiology Specialist (Mid National)

Duty Station: Lahore, with travel to selected teaching hospitals and technical institutions as required

Duration / LOE: September 2026 – March 2027 (LOE 75 days – subject to change until the start of the TA)

Reporting To: Public Health Expert / E4H Punjab Programme Team

Role Purpose

Provide focused clinical and laboratory leadership for antimicrobial stewardship (AMS) in selected teaching hospitals, strengthening prescribing review, microbiology and AST practices, antibiogram use, multidisciplinary coordination, and facility-level action planning. The role will ensure that hospital-facing AMR/AMS products are practical, evidence-informed, and aligned with SHC&ME Department systems.

Key Roles & Responsibilities

- Lead assessment and review of antimicrobial stewardship governance and practices in selected teaching hospitals.
- Review prescribing practices, culture and antimicrobial susceptibility testing (AST) systems, and use of microbiology data for clinical decision-making.
- Support development, interpretation, and practical application of facility antibiograms.
- Strengthen linkages between clinicians, microbiology laboratories, pharmacy teams, and AMS committees.
- Provide technical inputs on AWaRe-informed prescribing, antimicrobial use review, and stewardship decision-support tools.
- Support establishment or strengthening of physician-led multidisciplinary AMS committees and facility action plans.
- Mentor hospital teams on practical stewardship approaches, prescribing review, AST-based decisions, and microbiology-informed care.
- Contribute technical content to the AMR learning package, provincial AMS guidance, teaching-hospital action plans, and the Punjab roadmap for AMR containment.
- Ensure hospital-facing outputs are aligned with SHC&ME Department systems, clinical governance arrangements, and institutional realities.
- Undertake other TA-related tasks assigned by the Public Health Expert or E4H Punjab Programme Team.

Requirements

Technical Expertise

Advanced degree in Medicine, Clinical Microbiology, Pathology, Infectious Diseases, Pharmacy, Public Health, or a related field.
Minimum 10 years of overall professional experience.
Demonstrated experience in hospital antimicrobial stewardship, prescribing review, culture and AST systems, and antibiogram development or interpretation.
Experience in strengthening coordination between clinicians, microbiology laboratories, pharmacy teams, and multidisciplinary hospital committees.
Experience in mentoring hospital teams and translating AMR/AMS evidence into practical facility-level action.
Familiarity with Punjab teaching-hospital systems and SHC&ME Department structures is desirable.

Core Competencies

- Clinical and laboratory technical leadership
- Antimicrobial stewardship mentoring
- Microbiology and AST interpretation
- Multidisciplinary team facilitation
- Evidence-based clinical decision support
- Ability to translate technical findings into feasible facility action plans and learning materials