Background and Introduction

The Government of Kenya has committed to reach universal health coverage by 2022. In light of this commitment, ILO aims to support the National Health Insurance Fund (NHIF) to extend its coverage to uncovered population groups. UHC is a central objective of social protection systems and the cornerstone of the effective realization of the human rights to health and social security (in line with SDG 3.8.). In this perspective, a number of countries have taken steps to unify their social health insurance system and cover their population through a single risk pool, which has shown positive results in terms of equity.

The National Health Insurance Fund (NHIF) was created as a facility for ‘formal sector’ (contractually employed) individuals to participate in a risk-pooling (social) insurance system, to meet the cost of inpatient treatment for its contributing members and their immediate family members. In 2020, according to NHIF, the Fund had 9.1 million principal members covering 25 per cent of the population, but only 44.4 per cent of members were active contributors. NHIF membership is mandatory for all Kenyans who have attained the age of 18 years and are working in the formal sector. In recent years, NHIF has reviewed its portfolio of activities in the light of expanding its services and coverage to workers in the informal economy (with their families) and vulnerable groups. Voluntary members are required to make a contribution at a monthly rate of KES 500 while those in formal employment contribute based on a graduated scale as per their income with the least being KES150 and a maximum of KES1700. In 2020, 3.6 million members from the informal sector were voluntarily insured. However, out of the 3.6 million, only 1.5 were active members, meaning that they have paid their contributions in the last 12 months. NHIF is facing the challenge of voluntary members joining the Fund when knowing that they are in need of a medical procedure (e.g. surgery) and then dropping out again (adverse selection). NHIF further extended the waiting period for a procedure to 90 days from 60 days after making the first payment as a stop gap measure to this address adverse selection There has been ongoing discussions on establishing different social economic categories for different levels of contributions particularly in the informal economy. However, in order to introduce such a system, a complex socio-economic assessment mechanism would have to be set-up to assess means of contributing and capacity to pay among the informal economy and rural workers; further measures have also been introduced to enhance sustainability of NHIF for instance paying premiums one year upfront before voluntary contributors can access services, which has further exacerbated the inadequate coverage of the informal and rural economy workers.

NHIF has four further categories of members: (a) those elderly individuals over 70 years who receive benefits from the Inua Jamii 70+ cash transfer programme: (b) the Health Insurance Subsidy Programme (HISP), which targets children classified as Orphans and Vulnerable Children (OVCs) linked with care-givers and listed as beneficiaries of the OVC-CT programme;(c) Secondary students in public schools and (d) Civil Servants. Data on the vulnerable populations is provided by the Directorate of Social Assistance/Social Protection Secretariat. The government envisages the automatic enrolment of all recipients of the Inua Jamii Senior Citizens’ Programme and persons with disabilities in the NHIF. In some cases, counties or third parties such as UNHCR pay the contributions for specific groups, such as vulnerable refugees.

NHIF has 150 service points with 70 fully autonomous branches across the country. Each of these branches offers all NHIF services including payment of benefits to hospitals or members or employers. Smaller satellite offices and service points in county and referral hospitals also serve these branches. The benefit package has been enhanced to cover outpatient and in-patient services, major and minor surgeries, renal dialysis, cancer treatment and radiotherapy which can be accessed in all NHIF contracted government, private and faith-based healthcare providers. The NHIF uses capitation to pay for outpatient services and fee-for-service (FFS) for both outpatient and inpatient services for enhanced schemes such as the Civil Servants Scheme. Furthermore, NHIF uses daily rebate to pay for inpatient services and case‐based payments for benefits that are packaged and pre-authorized. All members of the scheme select an outpatient facility where they can access health services. Emergency services can also be provided in other facilities.

Despite having developed a strategic plan for NHIF expansion for 2018-2022, NHIF continues to encounter challenges regarding coverage of the population. Only part of the informal economy are members of NHIF and considerably less are covered in case of ill health due to the delay in paying premiums. NHIF needs to prioritise strategies that sustain active contributions towards the Fund from informal economy workers. Contributions are fixed at an amount that is not affordable for many households, considering that the informal economy is not homogeneous and has strong fluctuations in income. It needs to be considered that households rapidly move between income quintiles depending on seasonal income, transitory poverty, and catastrophic health expenditures. The rules that have been implemented to improve the sustainability of the Fund targeting voluntary members, such as paying the whole year to access services and late payment penalties, are seen as punitive and leave little flexibility for members further disadvantaging the uncovered groups. Flexible, income-tiered and innovative payment models have proven to be successful to get informal economy workers to contribute regularly in countries such as Indonesia and the Philippines. Other models that have effectively worked are based on greater population segments being subsidizes by government revenue such as in Thailand and Mexico. At the same time, there are supply-side challenges such as quality and service delivery issues, such as quality assurance, stock-outs and service perception by the population, that need to be addressed. It is noteworthy that NHIF has leveraged on technology to improve efficiency including biometric system, E-claims processing, digital and online registration and payment platforms, and an MIS system that is networked with all NHIF service points and healthcare providers and provides real-time information on access to health services. However, administrative procedures including claim management and prevention of fraud can be improved.

Scope of Work

The government has committed to reaching universal health coverage by 2022, a basic human right that is also enshrined in the Constitution of Kenya of 2010. COVID-19 has further highlighted the importance of social health protection for all. The consultancy will support NHIF to develop a strategy for extending coverage towards higher population coverage (population’s current financial status and the feasibility of an extension relating to technical, administrative, financial and the availability of services). This will include horizontal expansion of health coverage towards uncovered groups focusing mainly on workers in the informal economy and their families, refugee and migrant populations, vulnerable groups such as persons with disabilities and people living with HIV. Vertical expansion of coverage towards a higher level of coverage (benefit package and financial protection) will be taken into account considering supply-side limitations.

Project objectives:

Demand side assessment to inform the strategy for extending social health protection.
1. Conduct a literature review including existing national frameworks and studies as well as review best practices identifying pathways for extension.
2. Undertake a deeper qualitative assessment of the nature of informal economic units and informal non-poor workers, their health insurance needs, their contributory capacity and constraints to access potential health coverage through NHIF as well as the attractiveness of the scheme by assessing current beneficiaries experience with NHIF and their satisfaction with NHIF’s services and benefit package.
3. Support lead consultant in the development of strategic options to extend NHIF to currently uncovered groups/workers in the informal economy and their families including costing of these options.

Development of a strategy for extending social health protection

The consultant will conduct qualitative research to develop a deeper understanding of the informal economy workers’ and economic units’ behaviour regarding health insurance. The assessment will cover workers in the informal economy ability to pay, motivations and obstacles to join, with the view to design the right set of incentives, within and beyond the health insurance system, to expand their affiliation. It will also cover attractiveness of the scheme by assessing current beneficiaries experience with NHIF and their understanding and satisfaction with NHIF’s services and benefit package. This assessment will provide strategic directions (e.g. set of incentives, enrolment mechanisms, benefit packages, premium and institutional setting) with an aim of setting up a pilot to experiment and learn about inclusion of these populations in health insurance coverage. The assessment will build on a literature review and the analysis of existing national surveys and administrative sources and mainly conduct primary data through and complement the envisage Focus Group Discussions (FGDs).

The consultant will further support the lead in the formulation of scenarios for the NHIF strategy. Key stakeholders will have to be consulted to validate the design of the strategic options. The extension options should consider workers in the informal and rural economy as well as other vulnerable groups such as refugees, migrant workers PWDs, PLHIV. The final strategy should include a costed action plan and monitoring framework ready for piloting at county level.

Project Management

The consultant will work under the supervision of the ILO under the leadership of the National Social Protection Secretariat and the Ministry of Labour. Oversight and guidance will be provided by the Technical Committee which will endorse outputs and deliverables.

Timeline

Q4 2022 and Q1 2023.

Expected Deliverables

The consultancy will be expected to deliver the following:

Inception Report: Outlining the understanding of ToRs, FGD and KII guides, assessment framework for NHIF, stakeholder mapping, annotated outline of the Strategy and results of literature review.
Qualitative research: Detailed beneficiary assessment covering uncovered workers in the informal economy and current beneficiaries.
Final strategy: Support the final strategy document with the costed action plan and monitoring framework as final product.

Required qualifications, desired competencies, technical background and experience

The consultant will require the following experience and skills:

Relevant advanced academic degree (public health, development studies, economics or related fields); solid knowledge of social health protection programs and health insurance;
Experience with health financing and health insurance institutions.
Demonstrated experience working on social health protection policies, assessments and studies;
Specific experience in undertaking complex social, economic and health research.
Experience working with governments, international donors and others.
Excellent writing and communication skills in English.

Logistics

The consultant will plan and organize its own logistics including travel, accommodation and meetings. However, ILO officers based in Kenya will provide support. The consultancy will entail 2 missions to Kenya to conduct FGDs and support the development of recommendations on the extension of coverage. The consultations and meetings/forums may also be held virtually. Adherence to COVID-19 protocols as per the national authorities/UN/ILO guidance will be expected.

Expected Duration

All assignment’s deliverables are expected to be delivered to the satisfaction of the ILO by 31-04-2023.

Payment Arrangements

The number of working days for the assignment is XX working days; the daily rate is 450 USD (Total amount of USD). The amount of the contract including travel is as follows:

Total Daily rate | Unit Cost (USD) | Frequency | Total (USD)

Travel

Accommodation

Consultancy days

Total

The ILO will disburse the contract total amount in several instalments based on the below table, and upon the satisfaction of the ILO, as follows:

Key Deliverables | Instalments | Amounts

Upon the delivery of deliverable number 1 | 20 per cent of the total fees | XXX USD

Upon the delivery of deliverable number 2 and 3 | 60 per cent of the total fees | XXX USD

Upon the delivery of deliverable number 3 | 20 per cent of the total fees | XXX USD

Total |100 % | XXX USD

How to apply

Interested applicants should submit their technical and financial proposal and capability statement/detailed Curriculum Vitae to [email protected]

The financial proposal should be all-inclusive and include a breakdown (professional fees, travel related expenses, communications, utilities, consumables, insurance, etc.)

Deadline for application is 14th October