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					                                                       Case study on
        Factors influencing the increasing uptake of MCH services in ethnic minority areas
                                         Terms of Reference – 3 June 2011


1.       Background
Under the auspices of the 2009-2011 Joint Program China Culture and Development Partnership Framework
(CDPF), the Ministry of Health (MOH), the National Population and Family Planning Commission (NPFPC),
UNICEF, WHO and UNFPA are collaborating to develop and test an innovative approach to health care and
service provision in ethnic minority areas. The objective is to gain a better understanding of, and to address,
cultural factors influencing maternal and child health (MCH) seeking behavior and uptake of MCH
programs/services. Ongoing interventions include: (i) capacity building of local health providers on emergency
obstetric care, MCH counseling, communication for behavioral impact, and culturally sensitive service
provision; (ii) design of local information, education, communication (IEC)/behavior change communication
(BCC) materials, and client education and health promotion interventions; (iii) advocacy on culturally sensitive
programming in ethnic minority areas.
Despite remaining disparities between the health status of ethnic minorities and the majority Han population,
and the limited availability of reliable data from the local MCH information systems, the improvement of MCH
in remote areas of China has been outstanding over the past 10 years as indicated in the table below.
                              Infant, under 5 and maternal mortality1 in Western Provinces of China2:
                                                                                     2000          2004          2008

      Infant Mortality Rate in Western Provinces (‰)                                  49.2          43.2          22.4

      Under-five Mortality Rate in Western Provinces (‰)                              60.8          51.2          28.5

      Maternal Mortality Ratio in Western Provinces (per 100,000 live births)        114.9          93.7          51.1


These results have been accompanied by a steady increase in MCH care coverage, which is reflected in the
MCH care indicators in Western Provinces (increased ANC, HD and PNC coverage rates). During the CDPF
activities, various local MCH workers and village doctors have indicated that home deliveries - which were the
norm 10 years ago - are the exception today.
MCH national policy and programs have improved the availability, accessibility and quality of MCH services,
and the IEC/BCC campaigns conducted by health authorities are probably also contributing to improved
health seeking behavior of local populations. However, other factors may also be contributing increased
health awareness and improved local practices related to MCH.
In 2009 a socio-cultural study was undertaken under the same program, to explore traditional beliefs and
practices regarding MCH among ethnic minorities in 6 pilot counties3. Findings suggest that socio-cultural

1
  Data source: statistics from MOH in Social Progress in China: statistics related to MDGs (2009; National Bureau of Statistics)
2
  The Western Region includes 12 Provinces: Inner Mongolia, Guangxi, Chongqing, Sichuan, Guizhou, Yunnan, Tibet, Shaanxi,
Gansu, Qinghai, Ningxia and Xinjiang
3
  Longchuan and Mang/Luxi in Yunnan, Leishan and Congjiang in Guizhou, Hualong in Qinghai, Gyamda in Tibet

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factors play a significant role in health related behaviors. Enabling and challenging factors were identified and,
on the enabling side, evidence of changing attitudes towards the uptake of facility-based health services was
reported. A growing acceptance of modern ideas regarding MCH care was in particular evidenced among
those who had worked away from home. Associated with this, many respondents indicated however that
parental influence continues to be strong and sometimes takes precedence over individual preferences -
meaning that changes in thinking were not necessarily yet reflected in behavior change. These factors were
mentioned but not probed in-depth in the 2009 study.
The influence of internal migration, which is causing major social, economic and cultural changes in China,
appears to be another likely factor influencing changing practice. Approximately 200 million domestic
migrants periodically return to their hometown. Due to the restrictions generated by the current household
registration system (‘hukou’), as well as limited social insurance coverage, and barriers to accessing essential
public services in destination locations, a large proportion of migrant women return to their hometowns to
give birth, where delivery is free or subsidized. The influence of these population movements on local
cultures, particularly on maternal and child health seeking behavior, has not been studied.



2.       Overall objective:
The overall objective of this study is to explore in greater depth various factors that appear to be influencing
the uptake of maternal and child health services in selected counties that have significant ethnic minority
populations in south west China. Findings of the study will complement those of the 2009 Study on traditional
beliefs and practices regarding MCH in Yunnan, Guizhou, Qinghai and Tibet. The study will be conducted in
the two CDPF counties in which migration is a significant phenomenon:
      In Hualong: targeting Hui and Tibetan people
      In Leishan: targeting Miao, Shui and/or Dong people


Specific objectives are to:
1. Explore the extent to which the following variables are impacting on the uptake of MCH services:
      government policy promoting free maternal deliveries
      upgrading of health service facilities
      MOH and NPFPC-promoted BCC strategies and IEC materials
      returning migrants with ‘new’ or ‘modern’ ideas
      role/influence of parents/in-laws in terms of health seeking behavior and whether this is changing
      role/influence of religious/spiritual leaders in relation to health behavior and whether this is
       changing
      influence of popular media
2. Recommend ways in which existing positive influences can be strengthened by MOH to improve MCH
   programs in remote ethnic minority areas, and to promote informed decision-making on MCH issues.




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3.       Research methodology
A combination of research methods will be used. In the first instance, a quick review will be conducted to
obtain background information about Hualong and Leishan on i) migration dynamics, ii) relevant health and
MCH policies, iii) information, education and communication tools used by the health services, plus an
overview of popular media that may relate to maternal child health (if this exists) and iv) the general MCH
situation among the targeted communities living in Hualong and Leishan.
The primary means of data collection will be focus group discussions (FGD) and in-depth key informant
interviews (KII) amongst selected stakeholder groups. These tools will need to be designed to suit the specific
stakeholder groups.
With a special focus on individuals and families affected by migration, stakeholders will include:
      Pregnant women and their husbands
      Recently delivered women and their husbands
      Parents of the above, including mother-in-laws
      Older people caring for grandchildren
      Religious/spiritual/traditional leaders
      Health service providers (MCH managers, MCH workers and village doctors)
      Traditional health providers
      Young women and young men not yet married
Data should be analyzed by sex, age and ethnicity, as well as migration status/experience of pregnant and
recently delivered women, and with respect to adult children of older people caring for grandchildren.
It is suggested that the study interviews a minimum of 50 pregnant women and mothers (of children under 5)
and 20 fathers from each ethnic group. At least half of the respondents should have migration experience.
The exact sampling size will be determined and agreed during the design of the study instruments.
The research team will be responsible to ensure that high ethical standards are respected during the data
collection phase: anonymity of respondents, privacy and confidentiality, and voluntary participation.



4.       Study setting
The case study will be undertaken in the 2 MDG counties where the proportion of emigrants is the most
important: 1) Hualong County, Qinghai province and 2) Leishan County, Guizhou Province
The demographic data of these 2 counties is as follows, according to latest local statistics:
                        Total         Percentage of rural       Percentage of minority population    Number of out-going
                      population          population                                                 migrants (% of pop.)
Hualong (QINGHAI)      252,000               92%                               79%                         56,000
                                                                       (Hui, Tibetan, Salar)               (22%)
Leishan (GUIZHOU)      161,000               90%                               98%                         30,000
                                                                 (Miao, Shui, Dong, Yao, Yi, Buyi)         (19%)




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5.          Tentative time frame
The study including the field data collection is expected to be completed over a period of 5 months, starting
July 2011, with the draft report submitted by November 2011.
The tentative schedule is as follows:
July                  Review of local statistics concerning migration dynamics, MCH programs and status; study
                      instruments’ design and piloting, interviewer trainings, discussion and application of
                      research permits from national and local authorities.
August/September Field study, qualitative data collection
October/November Report writing and finalization.



6. Background documentation

UNFPA will provide copies of related CDPF project documents including the report of the 2009 Study on
traditional beliefs and practices regarding MCH in Yunnan, Guizhou, Qinghai and Tibet
Background information of project sites including population and migration demographics, health, religion,
MCH services provision etc. will be collected by the study institution. Some of this information will be
provided by the local Health and FP Bureaus.



7.          Consultancy
7.1         Assignment, deliverables
Following a competitive selection process, the identified national research institution will be responsible for
the development of study design (which will require approval by UNFPA), organization and conducting of field
work, and authoring of a research report based on sound analysis of research data.
Specifically, the selected national research institution will be required to:
       a. Obtain the necessary research permission from relevant national and local authorities, in particular
          MOH.
       b. Collect data regarding i) migration dynamics, ii) relevant migration, health and MCH policies, iii)
          information, education and communication tools, as well as an overview of broader public media
          that may relate to maternal health and iv) the general MCH situation among the targeted
          communities living in Hualong and Leishan.
       c.   Develop data collection tools, including FGD and KII guides; pre-test these.
       d. Organize a training for interviewers.
       e. Conduct the surveys in the selected ethnic communities.




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7.2 Expected outputs

          A clear study design and detailed study instruments (in English and Chinese).

          A comprehensive research report including research findings, analysis of data and recommendations
           for future interventions. Report will be prepared in English and Chinese.

          The research institution will be expected to present the research findings to UNFPA, key national
           partners and other stakeholders within the framework of the final activities of the CDPF.


7.3        Profile of research institution
In line with the expected deliverables, the institution must possess the following credentials in order to be
considered for this consultancy:
      a. experience in conducting research on culture, health and broad population and social science issues
      b. sound expertise in qualitative research
      c.   as part of its research team, staff who can demonstrate that they have in-depth understanding and
           knowledge of health and socio-cultural-related situations of the targeted ethnic minority groups
      d. a proven record of coordinating work with local authorities and delivery of quality work under time-
         pressure
      e. ability to correspond and provide analytical reports in English and Chinese


7.4        Estimated budget
The total budget for the research should be no more than USD 20,000, involving the following items:
a. Consultancy fee to the national research institution for study instruments development, field interview,
   data entry and analysis, and writing of report.
b. Travel and accommodation costs of the research team from the national research institution to and from
   survey sites.
c.    Training workshop for interviewers and remuneration to interviewers.
d. Other relevant costs incurred by the national research institution.


7.5        Selection process
Interested institutions/research teams should submit a technical and financial proposal to UNFPA China Office
before 17 June 2011, to the following email: couffignal@unfpa.org.
The application should include the following:
a. Technical proposal commenting on the TOR and its criteria; a research design that demonstrates a clear
   understanding of the overall and specific objectives; a detailed and a description of the research
   methodology. This narrative note should also present a tentative work plan timeframe and budget for the
   study.

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b. CVs of the research team.
c.    Financial proposal detailing the budget and timeframe.
Applications will be reviewed by UNFPA China Office. The MOH and UNFPA-Asia Pacific Regional Office (based
in Bangkok, Thailand) will be consulted. The pre-selected institutes may be invited to discuss their proposals
before final selection.
A service contract will be signed between the selected institution/research team and UNFPA. The contracted
institution/team will be supervised by UNFPA. The assignment will start at the beginning of July.


7.6       Terms of contract
The Research Team will be responsible for meeting the objectives of the study and providing the above
deliverables. More specific roles and responsibilities will be outlined in the contract with UNFPA. A team
leader will be appointed to be responsible and accountable for the implementation of the study.
One-half of the consultancy will be paid upon submission and approval of study instruments, and the
remaining half will be paid upon submission and approval of the final report.




For further information about this consultancy, please contact Ms Xiao Liangliang (Liangliang@unfpa.org ; tel
139 11 81 05 31) or Mr. Manuel Couffignal (Couffignal@unfpa.org ; tel 139 11 03 69 57)




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