Evaluation of new partnerships in the programme “Close the Gap: Sufficient, Competent and Motivated Nurses and Midwives” in Tanzania and Zimbabwe

I. IntroductionThis is the Terms of Reference (ToR) for the Evaluation of the programme CLOSE THE GAP: SUFFICIENT, COMPETENT AND MOTIVATED NURSES AND MIDWIVES (GLO-0759 RAF-23/0074) and its local partners Tanzania National Nurses Association (TANNA) in Tanzania and Zimbabwe Nurses Association (ZINA) in Zimbabwe.The current programme agreement and plan started on 31.3.2024. The current programme period ends on 31.12.2028.This ToR sets out the expectations for this Evaluation process and deliverables.II. Backgrounda) About NNOThe Norwegian Nurses Organisation (NNO) (Norsk Sykepleierforbund, NSF) is a national professional nurses organisation and labour union representing about 130,000 registered nurses, midwives and nursing students in Norway.NNO was founded in 1912 and focuses on professional, social, and representational policies, concerning areas such as public health, ethical nursing standards, as well as collective bargaining aimed at improving, e.g., working hours, working conditions and pay. NNO is politically neutral and has some 3000 elected union representatives.NNO has been involved in international development work since the 1980s, with programmes/projects supporting the development of strong nurses’ organisations in Africa. This work has been, and currently is, supported and partly financed by the Norwegian Agency for Development Cooperation (Norad1).b) About TANNAThe Tanzania National Nurses Association (TANNA) has approximately 10 000 members, with 57 regional branches across Tanzania.The Nurses’ Association was founded in 1971. In 2005 the constitution was reviewed and the association changed to its current name to Tanzania National Nurses Association (TANNA), including both registered and enrolled nurses to join the organisation.TANNA is a professional organisation and was established to unite and empower nurses and midwives, promote professional development, uphold ethical standards, advocate for members’ rights and welfare, and contribute to the delivery of high-quality healthcare services. TANNA is currently in process of transferring status from association to union, a change that will enable TANNA to negotiate and undertake collective bargaining for the nurses/midwives it represents.The TANNA leadership is elected during the Annual General Meeting. Elections are conducted every three years. The association also has a board of trustees appointed for a tenure of three years. Moreover, the association is governed by a Nurses National Council of leaders from the 57 branches, and the day-to-day affairs are overseen by an elected National Executive Committee of 10 individuals.c) About ZINAFounded in 1980, Zimbabwe Nurses Association (ZINA) is both a nurses’ union and a nurses’ organisation. ZINA currently has a membership of around 9,400 nurses. ZINA draws its membership from public and private health facilities in the country. It is a supportive body for all nursing matters related to education, service, leadership development, standards, and quality care. The organization is managed by a standing committee of six members plus ten provincial chairmen. It operates in compliance with Zimbabwe’s National Nurses Act and Nursing Council Code of Ethics.ZINA is the only voice of nurses in Zimbabwe covering the public sector, private sectors and mission institutions. Moreover, ZINA is registered as a trade union, with the legal mandate to negotiate with government on working conditions. As a mother body, ZINA has subgroups under its umbrella. These include the Association of Midwives, Anaesthetists, Occupational Health Nurses, and Mental Health Nurses. ZINA is also affiliated with regional, international, and local associations. These include the Southern African Network for Nurses and Midwives (SANNAM) and the Eastern, Central and Southern African College of Nursing (ESACON), and the International Council of Nurses (ICN).ZINA’s vision is to “advocate for empowered nursing, evolving nursing profession and accessible healthcare in Zimbabwe”.c) NNO's partnership modelAs described in NNO's Strategy for International Development Cooperation (2023-2029), civil society is an important driving force in societal development in all countries. Strong and independent organisations can help promote democratisation, realise human rights, and reduce poverty. NNO believes that strong nurses and midwives' organisations are important contributors in holding governments accountable for having sufficient, competent, and motivated health personnel in a country. This is at the core of NNO's partnership model.NNO's partnership model puts increasing emphasis on technical and professional cooperation with decreasing financial support to administration. This is reflected in collaborative project activities like joint seminars and knowledge exchange in areas like advocacy/lobbying; membership recruitment/administration; strategic communication; and organisational development of democratic member-based organisations.The division of labour, roles, and responsibilities between NNO and its partners differs slightly depending on the activity. In most cases, the partner is the implementer while NNO has a supporting and/or advisory function. For example, in terms of organisational development, the local partner is responsible for planning, executing, and evaluating local trainings. NNO may be a discussion partner in terms of e.g., the content of the training, and may also contribute with an expert.In other areas, NNO might have more responsibility for organising and delivering capacity building activities, especially when there are specific expertise or experiences within the NNO structure that is to be shared with the partner. When NNO has a more active role in the activity, emphasis is on making sure that the capacity of the partner is strengthened during the process.In terms of other technical support, NNO often challenges the partner when it comes to – for example – setting realistic targets, how to assess learning outcomes, how to ensure learning is applied, the documentation of results, etc. This is followed by support, e.g., on how to develop and use simple monitoring and evaluation tools, and how to analyse and apply findings.d) Brief programme backgroundThe 5-year programme, “Closing the Gap: Sufficient, Competent and Motivated Nurses and Midwives (GLO-0759 RAF-23/0074)” is co-funded by the Norwegian Agency for Development cooperation (Norad) and NNO and has four local partners: National Organisation of Nurses and Midwives of Malawi (NONM), Rwanda Nurses and Midwives Union (RNMU), Tanzania National Nurses Association (TANNA), and Zimbabwe Nurses Association (ZINA). The two latter are subject to this Evaluation.In brief, the core of the programme is summarized as follows:Nurses and midwives are the backbone of the health system. Yet they are overworked, undervalued, and underpaid. Many also lack the skills, equipment, and support to do their job effectively, and safely. These are contributors to the fact that Africa is lacking millions of health personnel.The planned effect on society of this programme is that universally accessible, equitable, and affordable quality health services are ensured in Malawi, Rwanda, Tanzania and Zimbabwe. The goal of the programme is to contribute to having sufficient, competent, and motivated nurses and midwives capable of addressing the population's current and emerging health needs.Civil society, represented by strong and independent organisations, is an important driving force in development. Hence NNO provides professional, technical, and financial support to TANNA and ZINA for them to be: 1) a democratic, accountable, inclusive and sustainable organisations for nurses and midwives in Tanzania and Zimbabwe respectively; and 2) effective watchdogs and advocates.By realising these outcomes, TANNA and ZINA will contribute to better status, pay and working conditions for nurses and midwives; a more competent, qualified, and capable healthcare workforce; greater leadership opportunities for women; and better healthcare and public-sector policy, legislation, and reforms, amongst others. This will again contribute towards the realization of countries’ current and emerging health needs.III. Objective and purpose of the EvaluationThe evaluation is set out as a requirement in GLO-0759 RAF-23/0074, Specific Conditions §9.1: “Reviews focusing on progress to date shall be carried out for each of the country projects: TANNA and ZINA by end of 2026; [...].”The Evaluation aims to:a) assess and describe the level of progress in TANNA and ZINA, and the partnership achieving its planned outputs, outcomes and overall objective in the programme period 2024-2026, including cross-cutting issues as gender, inclusion, and equality, as set out in the results framework.b) assess and describe, if relevant, if there are any other achievements/results/impacts that are not covered by the project’s result framework, but that the project has contributed directly to, especially since 2024 and to date.c) assess TANNA and ZINA and the partnership’s alignment with and potential contribution to national plans and targets/goals, and map potential opportunities at the national level.d) reflect on potential wider societal impact that the development of TANNA and ZINA may have in the two countries, and how the organisations could position themselves to maximize potential impact.e) give examples of positive change that TANNA and ZINA have contributed to, for 1) nurses and midwives, 2) the nursing- and the midwifery professions, 3) patients, and 4) society at largef) assess how the programme has been managed by TANNA and ZINA, including financial management (/ anti-corruption), the efficiency and effectiveness of TANNA and ZINA’s work processes, monitoring and evaluation. Internal and external factors affecting this shall be described and explained.g) assess and reflect on the various aspects of the partnership with NNO, and NNO technical (non-financial) support.h) assess and describe internal and external risk factors that (may) have had an impact on activities, outcomes, ability to achieve results and the organisation’s development. As part of this analysis review the organisations’ risk matrix and assess if any adjustments are needed to better reflect the contextual risk landscape as of 2026.i) identify prioritized areas and recommendations for the continued work of TANNA and ZINA.j) identify key areas and indicators, internal and external, that affect TANNA and ZINA’s financial sustainability and future ability to operate without the financial support of NNOk) reflect on the operational context in Tanzania and Zimbabwe, i.e., the space and environment for professional organisations and (labour) unions, the culture for getting organised in member-based organisations, culture of voluntarism, level of trust in the government and level of trust in the society at large.The Evaluation may also assess and reflect on other areas that come up during the review process, that are relevant to the objective and purpose of the Evaluation.IV. MethodologyBackground: NNO's system for result managementNNO's system for result management is based on Results Based Management (RBM) principles and a human rights-based approach. In practice this means that NNO uses various feedback loops to assess and map progress towards set targets.The feedback loops are, among others: quarterly activity-, output- and outcome monitoring tools (partner to NNO); data collection and monitoring tools used by the local partners; partnership meetings between NNO and the local partners; local stakeholder meetings; quarterly NNO steering committee meetings; and regular partner-NNO online meetings.NNO uses external evaluators to perform mid- and end-term reviews and evaluations. In addition, NNO facilitates south-south and partner-to-partner exchanges (e.g., seminars) for additional learning and sharing of experiences and good practices.For the programme under review, there is a joint logical results framework (consolidating two partners) that uses several defined concepts such as overall objective, outcomes, outcome indicators, outputs and output indicators. The framework was developed in close collaboration with TANNA and ZINA, and the other partners. It is expected that all activities supported by NNO/Norad, as defined in detailed annual plans developed by TANNA and ZINA, contributes towards achievement of the outcomes and objective in the results framework.NNO's system for results management also includes planning and results-based budgeting that involves calculating and proposing resource requirements based on pre-determined results, rather than merely based on scheduled outputs or activities. A central tool is the overall programme budget, which provides a direct link between expected results and resource requirements.The framework is dependent on critical assumptions about the environment and context, taking into consideration major external and internal factors and conditions as well as clearly defined accountabilities and indicators for results. The budget is reported against in every quarter. When conditions and requirements change, the budget is revised accordingly. This is a partner-NNO process that is usually done once or twice a year.The human rights-based approach specifies the subjects of the project results, i.e., the rights-holders and the duty-bearers. Typically, the rights-holders are the nurses or their patients, while the duty bearers are different levels of government, or employers. The outputs aim to close capacity gaps while outcomes reflect improvement in the performance of, or the strengthened responsibility of, the rights-holders and duty-bearers. Furthermore, the results specify the realisation of human rights as laid down in the SDGs (and other international instruments).NNO and local partners have mutual accountability, which applies to both the use of resources as well as the achievement of results. This is done through a shared agenda, ensuring space for dialogue and negotiation, reciprocal trust, transparency, and evidence that is collected and shared amongst all partners.Methodology for the evaluationThe consultant(s) should describe how they will proceed to conduct the evaluation.The proposed methods must sufficiently address the issues and questions outlined within the ToR, specifying the specific review issues, questions, methods of data collection, and analysis that will be undertaken. Preferably, it should encompass a mixed method approach. It should also allow for wide consultation with all interested partners and stakeholders. Assumptions and limitations must be stated clearly.Approaches that allow for review over a longer period are of particular interest.It is suggested that the methods should include, but not be limited to the following,a) Document review.Should include, but not be limited to, the following documents:- Programme applic…