Individual consultant to assess the feasibility of implementing a community-based health insurance (CBHI) in Garissa County, UNICEF Kenya Country Office at UNICEF

Job no: 533200

Categories: Social and Economic Policy, Consultancy

Community-based health insurance (CBHI) is considered as an effective means to provide financial protection against the cost of illness and improving access to quality health services for those excluded from formal health insurance schemes. International evidence generally shows that CBHI has a positive impact on utilisation rates of health services and moderate positive effects on improving financial protection, with Rwanda and Ghana being the two countries in Sub-Saharan Africa that explored CBHI to the greater extent .
It has also been observed that the poorest households risk to remain excluded as they cannot afford to pay premiums and, when looking at CBHIs in relation to the realization of the UHC, that they tend to stay small in size and to be quite fragmented. However, an appropriate design of CBHIs and additional government measures to cater for the most vulnerable – such as social protection interventions – and to integrate CBHIs into national systems greatly mitigate these risks.
Importantly, CBHIs tend to enhance community empowerment, can help build trust and familiarize people with the concept of insurance . This also highlights that CBHIs rely on existing social capital within communities, and particularly on the solidarity and trust that let community members put together their resources for common use .
UNICEF Kenya’s current country program (starting July 2018 up to June 2023) is aligned with Vision 2030 and supports the transition towards a UHC in multiple ways. In the framework of the Gates foundation-sponsored “UNICEF Country and Regional Levers to Scale and Replicate a basic package of RMNCH, social protection and Nutrition via Primary Health Systems in Eastern and Southern Africa and in West Central Africa”, UNICEF Kenya is exploring the implementation of a CBHI in Garissa county, targeting pregnant and lactating women and focusing on Maternal, Newborn and Child Health (MNCH), as well as consider mainstreaming of NHIF membership in the NSNP.
Garissa County: Snapshot of health and poverty situation
Garissa County is located in North Eastern Kenya and has a population estimate of 868,256 in 2017 . Garissa is among the poorest counties in Kenya, with a 65% poverty rate, vis à vis a national average of 36%. Looking at child poverty, 129,435 children, or 66%, are multidimensionally poor, compared to an average 45% in Kenya  (Figure 1). This also means that a relatively high share of the Garissa population benefits from the cash transfer programmes comprised in the NSPS (Figure 2), and overall 11,609 households are registered as beneficiaries of the NSNP . Programmes currently implemented in Garissa include the Cash Transfer for Orphans and Vulnerable Children (CT-OVC), the Older Persons Cash Transfer (OPCT), the Cash Transfer for People with Severe Disabilities (PwSD-CT), the presidential bursary for orphans, the Hunger Safety Net Programme (HSNP), Food for

Assets and Cash for Work.

Community-based organizations and community structures play a vital role in multiple aspects of life in Garissa. For instance, land is often community-owned, there are various cooperative societies, including SACCOs, as well as women groups and youth groups, and several local NGOs working at community level are active in the county . Community structures are involved in the health sector through the Community Units, but also play an important role in other fields, ranging from security to management of natural resources.

Goal and Objectives

The goal of this consultancy is to assess the feasibility of the CBHI pilot in Garissa county, and to explore the mainstreaming of NHIF membership among beneficiaries of the NSNP. The assessment will take into account multiple aspects, notably the overall willingness and ability of community members to contribute to the CBHI and the specific health needs of pregnant and lactating women enrolled in the NSNP, in a view to ensure the CBHI enjoys broad community support and involvement, as well as to  inform the benefit packages to be devised. The scope of the assignment also includes the design of a proposed CBHI and the formulation  of a feasible implementation, both to be developed in close collaboration with the Garissa County Government and the community representatives and to be validated with relevant stakeholders.

RWP areas and UNDAF outputs covered

This assignment contributes to UNDAF Strategic Result Area (SRA) 1 Human Capital Development and SRA 2 Transformative Governance, and particularly to Outcome 1.2: By 2022 people in Kenya access high quality services at devolved level that are well coordinated, integrated, transparent, equitably resourced and accountable and Outcome 2.6: By 2022, marginalized and vulnerable people have increased access to and utilize social protection, and services for prevention and response to gender based violence and violence against children.
The consultancy also contributes to UNICEF Country Programme Document Outcome 4 (Social inclusion): An increased number of children from the poorest & most vulnerable households benefit from shock-responsive & integrated social protection interventions, as well as from child-specific policies, and more specifically Output 4.1: Social service demand is strengthened through modelling of evidence-based linkages between social protection and social/economic sectors (including health, nutrition, protection, energy, and HIV) in select counties, as well as to Outcome 1 (Reduced Mortality & Stunting): Increased proportions of vulnerable children, pregnant and lactating women, including adolescent girls, have equitable access to and use quality WASH, Nutrition, Health, and HIV/AIDS services to reduce their risk of mortality, preventable diseases, stunting and other forms of malnutrition, and improve their birth outcomes.

Activities and Tasks

Specifically, the key task for the consultant will be:

Conduct feasibility assessment of the CBHI

The assessment will look at the feasibility of introducing a CBHI in Garissa. The analysis will take into account community-specific dynamics and will entail broad and in-depth consultations and interviews with stakeholders. These will encompass community members and community structures and organizations – notably other possible solidarity-based ones – as well as health providers, relevant institutions and stakeholders. The analysis will look at the willingness and commitment the community has towards establishing a CBHI, at the existing social capital and at the level of risk aversion of potential members, to provide suggestions on the key features that could make a CBHI likely to succeed. Moreover, the assessment will determine the main health needs of the pilot target group (i.e. pregnant and lactating women that benefit from the  NSNP), in order to identify actual demand-side and non-medical barriers (e.g. transport costs) that constraint access to essential health services. The identified constraints will help inform the future benefit package the CBHI could offer to its members and that would need to include non-medical costs.
The analysis will also include a desk review of national and international relevant practices. It will keep into account that in the long-term the CBHI should be absorbed – or at least closely linked – to the NHIF.

Draft the design of the CBHI and map the relevant stakeholders

Based on the feasibility assessment and on the inputs gathered from stakeholders, the consultant will draft the design features of the CBHI, possibly providing few options and highlighting their risks and advantages. The consultant will also undertake a mapping of relevant stakeholders, whose contributions will help inform the design.    
The feasibility study and the design will need to be validated by the community and the Garissa county government in a dedicated workshop.

Devise a plan of action for the implementation of the CBHI

The consultant will prepare a plan of action for the implementation of the CBHI, that specifies milestones, timelines, actors involved and key actions, highlighting risks and mitigation measures as well. The plan should also foresee dissemination activities and ensure the introduction of the CBHI maintains a community-based and participatory approach throughout its phases.

Work relationships

The consultant will be responsible for the production and finalization of the deliverables and will work under UNICEF administrative and technical supervision, in close collaboration with the Garissa county government. The consultant will engage with the main health and social protection stakeholders in Garissa, and particularly with local players and relevant community structures and organizations.
The consultant will report to the Social Policy (Social Protection) Specialist in UNICEF KCO and will work in close collaboration with the Social Protection and Health teams in both UNICEF KCO and Garissa Zonal Office (ZO).
It should be also noted that:

• Payment is on satisfactory completion of deliverables duly authorized by the Supervisor of contract.
• Specific deliverables of acceptable quality must be submitted at the planned times.  
• Performance will be evaluated considering quality of deliverables, consultation with stakeholders, timeliness of deliverables of and comprehensiveness of work as defined in the terms of reference.
• The consultant is expected to carry out the design process in accordance with professional communication development standards