Maternal Mortality Data Leads to Free Maternity Services Nationwide in Kenya

In 2013, Kenya’s Ministry of Health turned to its health information system to investigate the cause of alarmingly high rates of women dying in childbirth, at the time 488 per 100,000 live births each year. What they found was a problem with access: more than a third of women were giving birth at home without a skilled health provider due to financial and geographic barriers to accessing health facilities. In June 2013, President Uhuru Kenyatta declared maternity services free in all Kenyan public health facilities. Just a year after this declaration, there was a reported 26.8% increase in the number of deliveries in hospitals and maternal mortality had dropped significantly from 488 to 362 deaths per 100,000. In addition, antenatal care attendance increased 16.2% in 2014 among the county referral hospitals. As a result of this exemplar use of data to inform policy and positively impact maternal health, Kenya has made larger investments into strengthening its health data collection systems. In particular, the government partnered with the World Health Organization to form the Kenya Health Data Collaborative to further harmonize their data collection efforts and provide clear data for policy makers.

Main Components

The initial investigation into the high maternal mortality rates mined data from the Health and Demographic Surveillance System of Kenya. This national system registers and geo-spatially defines the entire Kenyan population. A household census is conducted three times per year to capture basic demographics, including births and deaths in the past four months. To ensure validity, field staff visit the GPS-located households at least one month after the reported death to validate the death and record the cause of death. Analysis of this data led to the conclusion that the high maternal mortality rates were a result of having home births. Studies analyzed from other low and middle-income countries, as well as in-country interviews with women, pointed to financial and geographic barriers that influenced women to choose having their birth at home.

Following this report, President Kenyatta’s declaration aimed to decrease the financial barrier to accessing maternal health services. It included the following:

• Pregnant women may access free maternity services in all public health facilities. This includes antenatal and post-natal care up to six weeks after delivery or for referrals made due to pregnancy related complications.
• The user fees normally charged in dispensaries and health centers were abolished.

Both of these were stipulated with the mandate that health facilities that provide these free services are later reimbursed by the Ministry of Health headquarters as per the number of deliveries conducted. The rates are 2500 shillings (USD 28.7) per birth at level 2 and 3 health care facilities and 5000 shillings (USD 57.5) at level 4, 5 and 6 health care facilities. These rates cover all types of deliveries and are paid directly to the facilities.

Evidence of Implementation Strategy

Just one year after President Kenyatta’s declaration, the Kenya Health Information System reported a 26.8% increase in the number of deliveries in hospitals and maternal mortality had dropped significantly from 488 to 362 deaths per 100,000. In addition, antenatal care attendance increased 16.2% in 2014 among the county referral hospitals.

Cost and Cost-Effectiveness

The government allocated 4 billion Kenya shillings (USD 44.4 million) in the 2013/2014 budget for implementation of the free maternity services program. Under this program, the health centers and dispensaries were reimbursed and the government set aside 3.6 billion Kenya shillings (USD 40 million) to hire 7,500 additional health workers to cope with the expected increase in workload.

In the 2013/2014 fiscal year, Kenya reported spending approximately 2.4 billion Kenya shillings (USD 23 million) on its health information system. However, this only represents 5% of total government and donor public health expenditures.

The African Population and Health Research Center is currently analyzing findings from a two year study on the cost-effectiveness of the free maternal care policy in Kenya. However, interim reports point to the fact that this national program had duplication and overlap with other healthcare programs, such as Tanykina Community Healthcare Plan, leading to a decrease in cost-effectiveness. Overlap with existing programs should be investigated and considered before introducing a new, national program.

Perceptions and Experiences of Interested People

The health ministry’s principle secretary, Dr. Nicholas Muraguri looks positively on this approach; he cites this example to demonstrate the power of good data to inform policy decisions.

The Kenyan government, specifically the Ministry of Health also views this program favorably. Since 2013, Kenya has made significant investments in strengthening data collection tools such as household surveys, health management information systems and civil registration.

Benefits and Potential Damages and Risks

A cross-sectional study conducted at Kenyan hospitals reported that major implementation challenges included “inadequate supplies (86%), inadequate funding (38%), staff shortage (92%), lack of motivation among health workers (62%), overwhelming workload (89%) and abuse of services by clients (32%).” The study reports thus that strategies for better implementation include employment of more staff, motivation of health workers, improvement in policy financing, training of health workers and provision of adequate supplies.

While there may be challenges to implementation, the benefits are clear: just one year after President Kenyatta’s declaration, in 2014 the Kenya Health Information System reported a 26.8% increase in the number of deliveries in hospitals and maternal mortality had dropped significantly from 488 to 362 deaths per 100,000. In addition, antenatal care attendance increased 16.2% in 2014 among the county referral hospitals.

Furthermore, from this experience, Kenya has made larger investments into strengthening its health data collection systems. In particular, Kenya partnered with the World Health Organization to form the Kenya Health Data Collaborative to further harmonize their data collection efforts and provide clear measurables for policy makers. This is a significant step on the road to overall improved health outcomes in Kenya.

Scaling Up Considerations

• Consider existing health programs that may overlap with the new program. Ensure programs work efficiently and in harmony.
• Investigate the financial state of the nation for long-term sustainability of the program and health data information system.
• Ensure an updated and accurate health data information system that provides correct data to inform policy decisions. This includes quality technical and professional components, as well as nation-wide (or local if applicable) reach.

Barriers to Implement

As mentioned in potential damages and risks, barriers to implementation include:

• Inadequate funding
• Inadequate supplies
• Staff shortage
• Lack of motivation among health workers
• Overwhelming workload with an increase in hospital deliveries and requests for antenatal care
• Abuse of services by clients

Equity Considerations

While President Kenyatta’s declaration decreases the financial burden on pregnant women in having hospital births, it does not address the geographical barrier highlighted as another clear cause of high rates of home births. Rural women thus may not benefit as much as urban women.

References:

1. Njuguna, J. et al. BMC Health Services Research. (2017). Impact of Free Delivery Policy on Utilization of Maternal Health Services in Country Referral Hospitals in Kenya.
2. Wamala, E. Pan African Medical Journal. (2015). Implementation Challenges of Free Maternity Services Policy in Kenya: the Health Workers’ Perspective.
3. UNICEF. (2015). Annual Report 2015: Kenya.
4. Health Policy Project. Maternal and Newborn Health Care in Kenya. Policy Changes to Benefit Women: Ministry of Health Implements Free Maternity Services Nationwide. (2015).
5. WHO. Kenya Takes Steps to Save Mothers’ Lives, Showing Why Better Data Matters. (2016).
6. Health Data Collaborative. Kenya. (2017).
7. Desai, M. et al. PLOS. An Analysis of Pregnancy-Related Mortality in the KEMRI/CDC Health and Demographic Surveillance System in Western Kenya. (2013).
8. Ministry of Health, Kenya. Kenya Health Sector Strategic and Investment Plan (KHSSPI) July 2013-June 2017. (2013).
9. African Population and Health Research Center. Maternity Fee Waiver in Kenya: Interim Findings. (2016).

Could it work?

As a result of this exemplar use of data to inform policy and positively impact maternal health, Kenya made larger investments in strengthening its health data collection systems. The country then went on to partner with the World Health Organization (WHO) to form the Kenya Health Data Collaborative to further harmonize their data collection efforts and provide clear measurables for policy makers. The use of evidence to drive decision can be replicable in different contexts and health system.

Will it work?

In Kenya, the national system registers and geo-spatially defines the entire Kenyan population. A household census is conducted three times per year to capture basic demographics, including births and deaths in the past four months. To ensure validity, field staff visit the GPS-located households at least one month after the reported death to validate the death and record the cause of death. The data is published and upon analysis of this data, they were able to conclude the high maternal mortality rates were a result of having births at home and were able to take action. This is specific to the Kenyan data collection system and there are cost implications for any country wishing to implement a similar system. However, partnering with the WHO further improved the efficiency and effectiveness of their systems and the Health Data Collaborative is open to all countries, from any income level, to join the collaborative to share and learn.

Is it worth it?

Overall, the targeted intervention based on valid data improved the health outcomes of mothers. The intervention
implemented in Kenya was specific to the country’s needs and would not necessarily be the same intervention implemented in another country. There are financial costs and challenges associated with a nation-wide program implementation of free maternity services.