Enhancing Adherence to Diabetic Retinopathy (DR) Care Study in Kenya - Fred Hollows Foundation

Enhancing Adherence to Diabetic Retinopathy (DR) Care Study


The Fred Hollows Foundation (The Foundation) is a secular, non-profit public health organisation based in Australia, which was founded in 1992 by eminent eye surgeon Professor Fred Hollows. The Foundation focuses on strengthening eye health systems and the treatment and prevention of avoidable blindness caused by cataract, refractive error, diabetic retinopathy, and trachoma. The Foundation operates in more than 20 countries across Australia, The Pacific, South and South-East Asia, the Middle East, and Africa. The Foundation was named The Australian Charity of the Year 2013 in the inaugural Australian Charity Awards.

Project background

The Foundation’s 2019-2023 Strategy identifies DR as a priority eye health condition. In 2019/20, modelling was performed to explore the impact of our DR programs. In 2018, The Foundation screened approximately 85,000 people for DR and supported 17,600 treatment sessions in several countries. FHF does not currently routinely collect data on treatment completion. However, data from some countries where we support DR activities suggests that 10% or less of people who commence treatment complete it. We found that The Foundation’s DR work in 2018 resulted in 172 years of sight saved, compared to 2 million years of sight saved through its cataract work.

Vision loss due to DR can be prevented or delayed through treatment. However, the effectiveness of treatment is dependent on early initiation and completion of the treatment course. FHF’s modelling found that the most effective way to improve efficiency is to increase treatment commencement and completion rates among those with sight-threatening DR. To explore how programs can be improved, The Foundation collaborated with the ICEH to complete a literature review. Studies have shown that capacity building, task shifting, and equipping hospitals with fundus cameras can improve DR referral and treatment follow-up in various LMICs. But the review found no relevant interventions to improve adherence to DR treatment in low- and middle-income countries (LMICs). This is an important knowledge gap that The Foundation can address.

The current study involves the conduct of a formative phase of work that is intended to lead to establishment of a large-scale trial to test the efficacy of strategies for enhancing adherence to DR care. The formative phase of work involves a rigorous situational analysis and co-design process with key stakeholders in Kenya. The study will elaborate on this preliminary information.

Aims and Research Questions

The current study seeks to:

  1. To understand the context, health system, existing patient DR care pathways, and barriers and enablers of DR treatment engagement, and
  2. To identify a set of intervention strategies to increase the proportion of people with referrable (sight-threatening) DR who commence and complete treatment, and partners for their testing across the target countries strategies. The intention is that these strategies will be tested in a future phase of this project.

The following research questions guide study activities:

Research questions

Data sources

  1. What is the estimated burden of diabetes and DR in Kenya?

Published reports and papers

  1. What patient-to-service interactions and service-to-service links constitute the DR patient pathway – framed around the following elements of a patient care pathway: ‘screening/monitoring’, ‘diagnosis’, ‘treatment planning’, ‘treatment’, ‘follow-up’, ‘exit’.

Stakeholders, local documents and published literature

  1. What is the level of patient ‘drop-out’ at each patient-to-service interaction point along the DR patient pathway?

Service use data

  1. What are the most significant health system, diabetes and eye care service, care provider and patient related factors supporting and limiting patient engagement with each of the patient-to-service interactions along the care pathway?

Stakeholders, patients, published reports and papers

  1. What interventions do key local stakeholder propose will be effective in improving treatment completion rates?


The Consultancy

The aim of this consultancy is to support the conduct of this study. The consultant will be expected to:

  • Conduct reviews of peer reviewed publications to respond to research questions 1 and 4. A systematic approach to these reviews is anticipated, and a protocol will be developed and approved prior to execution. A template for this protocol will be made available.
  • Conduct reviews of grey literature to respond to research questions 2, 3 and 4. It is anticipated that publications will be sourced from websites and via local stakeholders, and a protocol will be developed and approved prior to execution to guide the review.
  • Conduct a series of key stakeholder surveys/interviews to respond to research questions 2, 3, 4 and 5. Stakeholders will include a) Hospital/facility administrators or managers responsible for oversight of diabetes and DR care; b) Health care providers involved in the provision of diabetes and DR care, including primary care, specialist care, and allied health staff; c) Policy makers responsible for government diabetes or DR policy and plans; and d) Diabetes and DR patients, ranging in age, location, gender and disease severity, and including those who have been referred but not treated and those who have received DR treatment in part and in full.
  • Facilitate extraction of hospital/healthcare facility data to respond to research question 3
  • Work alongside the global study team to develop a detailed ‘patient journey map’ that details the touch points between patients and providers from the point of diabetes diagnosis to ongoing follow-up after the completion of DR treatment.

This study is to be undertaken across a number of countries and the protocols and data collection tools will be developed centrally in the first instance to ensure consistencies across study sites to the extent feasible and appropriate. It is expected that the consultant in Kenya will provide input into the protocol and data collection tools, working with the study team to adapt to the Kenyan context and add missing detail. The consultant will work with the study team to identify stakeholders and the source of documents, determine appropriate sample sizes, and identify appropriate recruitment approaches. The consultant will also support the study team to secure local (Kenya) ethical approval for the study.

Deliverables and Milestones

Deliverable / Milestone


  1. Finalized protocol/s and data collection tools for all activities - 2 weeks from the commencement date
  2. Ethical approval - Submitted 3 weeks from commencement
  3. Literature reviews completed - 4 weeks from commencement
  4. Data collection activities completed - 8 weeks following ethical approval
  5. Patient DR care journey map. (note: a template will be provided) - 2 weeks following completion of data collection activities
  6. A comprehensive report, using the 1:3:25 format. (note: a template will be provided) - 4 weeks following completion of data collection activities
  7. Up to three presentations of the findings - 8 weeks following completion of data collection activities

The consultancy will take place for a period of 5 months, from July 2023 to December 2023 (inclusive). A detailed plan of key consultancy activities will be discussed and agreed upon by the Project Team and the Consultant.

Essential skills and experience

The successful applicant/team for this consultancy will have:

  • At least a master’s degree in Medicine or Public Health, Ophthalmology, Public Policy or Development related fields
  • Strong knowledge and experience working with the local health care systems and overall understanding of National health sector policies and statistical sources
  • Experience conducting situational analyses and providing advice on strategies to influence government policy and practices.
  • Experience interacting with with health teams, health facility staff, and communities.
  • Strong quantitative and qualitative analytical skills and familiarity with development and use of data collection tools and evaluation methods
  • Excellent spoken and written communication skills in local language and English
  • Demonstrable experience in monitoring and evaluating programs that use advocacy for policy influencing

The following additional skills and experience are highly desirable:

  • Knowledge and experience in eye health and a sound understanding of programs and strategies relating to eye health in respective country.
  • Experience in carrying out field observations and developing service blueprints
  • Experience delivering findings to a variety of audiences

Management and logistics

This consultancy is being commissioned by The Fred Hollows Foundation (FHF). This study is to be undertaken across a number of countries and the protocols and data collection tools will be developed centrally in the first instance to ensure consistencies across study sites to the extent feasible and appropriate. The FHF global study team, alongside FHF staff working in-country will support this project and work closely with the consultant to deliver the project outcomes. Roles and responsibilities and modes of communication across the study team will be negotiated and agreed at a project initiation meeting.


The consultant agrees to not divulge confidential information about project design, findings, participants, or staff members to any person for any reason during or after completion of this contract with The Foundation. Upon completion or termination of this contract, the consultant undertakes to return to The Foundation any materials, files or property in their possession that relate to the business affairs of The Foundation.

Ethical Considerations

The study activities will be carried out in line with The Foundation’s Research and Evaluation Policy (attached). The consultant/s will work closely with the FHF team to obtain approval to carry out this work by the relevant Human Research Ethics Committees. The consultant is expected to adhere to and uphold the principles of ethical research conduct at all stages of this assignment.

Intellectual Property

All intellectual property and/or copyright material produced by the consultant whilst under contract to The Foundation remain the property of The Foundation and will not be shared with third parties without the express permission of The Foundation. The consultant is required to surrender any copyright material created during the term of the contract to The Foundation upon completion or termination of the contract.


Any consultants contracted for the work outlined in this ToR will be required to have in place insurance arrangements appropriate to provision of the requirements in this ToR including travel insurance.


The Foundation is committed to ensuring a safe environment and culture for all children with whom we come in contact during the course of our work. The consultant/team members will be required to comply with The Foundation’s Child Protection Policy and sign the Child Protection Code of Conduct (to be provided during contracting).

How to apply

Should you wish to submit an expression of interest to undertake the work described, please submit the following documents by email to procurementkenya@hollows.org by June 20, 2023. Only submissions with complete documents as stated in the TOR and those meeting minimum requirements will be considered. Qualified consultants will be subject to a background check and child protection as a condition for engagement.

  • A cover letter briefly addressing the key selection criteria and including names and contact details of two referees.
  • A curriculum vitae of the project lead and proposed team members, with brief description of the project team roles and responsibilities (if relevant).
  • One to two examples of previous written work; and
  • Schedule of fees.