Call for Expressions of Interest – Healthcare financial diaries study: research technical support

1. BACKGROUND

Kenya has made important strides in improving some health outcomes and lowering user fees for many services. However, those changes have raised new questions about the functionality of health finance mechanisms and incentives for supporting greater access to public health. For example, the removal of user fees at primary care facilities resulted in stock outages and long wait times. As a result, out of pocket expenses for Kenyans increased by 90% between 2013 and 2018, and foregone care rose from 13% to 28% (KHHEUS) – FinAccess 2021 reported an even higher rate of 54% of those going without medicine.

Kenya’s programme to eliminate out of pocket expenses for maternity care in public facilities, Linda Mama, corresponded with an increase in live births attended by a skilled provider from 66% in 2014 to 89% in 2022. However, only 69% of the lowest wealth quintile of mothers are receiving this care (KDHS 2022). Due to poor reimbursement processes, facilities providing this care are often starved of funds, force patients to pay for covered services, or turn away patients attempting to use it (Orangi et al 2021, Muinde 2020).

Such evidence around disconnects between policy aims and patient experiences has not yet been collected systematically. Studies are often focused on one issue e.g. maternity care (Orangi 2021), confined to limited geographies (Muinde 2020), or focused on understanding the role of a specific financial tool like insurance (Janssens et al 2022). There is lack of a comprehensive understanding of the drivers of health seeking behaviour in ways that are contemporary to the current policy context and that disentangle when various drivers (including knowledge, affordability, distance, wait times, perceptions of quality) take precedence in a household’s decision-making process.

A lot of effort is being employed on strengthening the supply side of healthcare in Kenya. For instance, the Bill & Melinda Gates Foundation and other partners are supporting the Kenyan government in strengthening its health system building blocks and capacities. There is also a good understanding of the healthcare supply-side, bolstered by periodic surveys on access to healthcare and health finance such as DHS, KHHEUS, KHIBS, and FinAccess. But knowledge and capacity gaps exist in addressing demand-side drivers and dynamics, which is essential for designing policies and approaches to address these gaps, and positioning healthcare as an integral part of household resilience.

There is need therefore, for detailed demand-side qualitative and quantitative data to deepen our understanding of: health seeking behaviours; healthcare financing and its implications for household budgets; impacts on household vulnerability, inequalities and prospects for growth; and understanding of decision making. For instance, the original Kenya Financial Diaries (2012-2013) demonstrated that household decision makers weighed financial trade-offs when deciding whether to pay for insurance, seek care for a household member, or attempt to grow their already low incomes. Poor quality and incomplete care was effectively a tax on the poor. Individuals often sought care three or four times before receiving a correct diagnosis and treatment. Although these key insights were produced and shared, the data on health seeking incidents and drivers was not collected systematically enough to create a fuller picture of the health experiences of Kenyan households over a wide range of health issues, including basic primary care, maternity, chronic conditions, emergencies, and inpatient care.

In order to understand Kenyan households’ health needs, their healthcare seeking and financing behaviour, FSD Kenya intends to undertake a health financial diaries study. The study will provide a grounded, human view of health demand and access, filling an important gap in policymakers’ understanding of the ways people seek care and the linkages between policy and implementation choices and the care seeking outcomes of patients. It will also deepen understanding on how households finance healthcare and thus enable important policy discussions and inspire new health financial innovations to address the challenges observed, ultimately improving access to healthcare and strengthening households’ and women’s resilience. Although the focus of this research is health finance, other components such as gender may be identified and embedded in the investigation depending on key stakeholders’ interests.

In addition to providing new depth of insight around healthcare demand and access, this study will update and broaden understanding of the financial lives of Kenyans ten years after the Kenya Household Financial Diaries study was conducted, and in the context of significant changes in the health and finance landscape. Since the initial study, for example, healthcare delivery has been devolved to the county governments (was previously a function of the national government).

More recently, a new social health insurance policy has been introduced, mandating all Kenyan adults and residents to contribute 2.75% of their gross incomes to a Social Health Insurance Fund (SHIF). The policy has also gotten rid of programmes like Linda Mama, which had made a significant contribution to access to maternal and neonatal health, among others. The Diaries will therefore take place concomitantly with a major policy shift in healthcare financing. To this end, the study will provide a valuable source of data and evidence on key aspects such as affordability of healthcare financing and impacts of healthcare finance on household resilience, gender empowerment and inclusive growth. This will usefully inform policy implementation and refinement, capturing the realities on the ground.

FSD Kenya is seeking technical support in undertaking this Healthcare financial diaries research which is expected to run for duration of about 2.5 years.

2. OBJECTIVES

The objective of this consultancy is to undertake a comprehensive healthcare financial diaries study in Kenya to generate deep insights on health needs, health seeking and financing behaviour in the context of Kenyans’ current financial lives and economic realities, as a bedrock for the development of appropriate health policies and creative financial solutions for women and households.

3. SCOPE OF WORK

The consultancy firm will undertake a comprehensive financial diaries study across a nationally stratified sample, over a period of one year, in close collaboration and with guidance from FSD Kenya and an advisory group representing key stakeholders in the health and health finance sector. All aspects of the study will be covered including design and development, fieldwork implementation management, data coding and analysis, and preparation of the related communications outputs for dissemination. The research (from planning to dissemination) is anticipated to span about 2.5 years. The specific components of the scope are outlined below:

i) Research design – sample design & research instruments

ii) Diaries implementation

iii) Analysis and communications

4. REQUIREMENTS FOR EOI SUBMISSION AND SHORTLISTING

Interested consultancy firms should provide evidence that they meet the following mandatory requirements:

• A track record in successful implementation diaries research/similar research exercises in a developing economy context;
• Demonstrable ability by proposed core researchers in conducting comparable field research
• Analytical capability to process a huge volume of data into a form which is usable by industry and policy makers
• Excellent communication and interpersonal skills: Ability to work well with a wide cross-section of stakeholders
• Ability to plan, work and deliver within strict timelines

Expressions of interest must include a capability statement, of no more than three (3) A4 pages, which shows evidence of relevant skills and experience in providing the services required for this assignment. Abridged CVs of key personnel only, of not more than two (2) pages in total, should also be included in addition to the three-page capability statement