Kenya has some of the highest maternal and newborn mortality rates in the world. In 2014, more than half of women were giving birth at home without skilled care and just a third of health facilities provided maternity services. In Bungoma County, these figures were even lower. To change this, the MANI project identified barriers preventing women from accessing quality care. We supported the county government to address these issues, leading to the percentage of women delivering with skilled attendants doubling, from 41% to 84%, by the end of the four-year programme.
MANI identified three key obstacles for women trying to access professional maternal healthcare:
Retraining traditional birth attendants
The first of these barriers, was that women themselves were often reluctant to seek hospital-based care, with many preferring to place their trust in traditional birth attendants. MANI harnessed the trusted position of traditional birth attendants, retraining over 400 of them to become birth companions. The retrained companions then encouraged women to deliver in health facilities, successfully bringing more than 14,900 women to the centres.
Birth companions played an important role alongside facility staff. “[They] really know how to encourage these mothers and they have time, unlike us - I am attending to her and [I have] another patient” One front line health worker commented. The birth companions are also able to provide longer-term support for new mothers. “In the past, when a baby was born, we would just leave it that way,” a birth companion explained. “Now we follow up until the baby reaches six months. We follow up that he has got immunizations.”
Providing vouchers for transport to the hospital
Women opting to deliver in a facility then faced a second obstacle, as many struggled to reach the facility. MANI provided transport vouchers for poor women, working with boda-boda motorbike drivers to operate this service to more than 90 health facilities. “The transport subsidy gave me and my baby an opportunity to receive care despite the heavy rains and the dark night,” said Christine, who received one of the vouchers. “Today when I look back I may not have gone to the health facility [without the vouchers], especially at night”.
More than 43,000 vouchers were distributed, with subsidised boda-boda riders transporting a third of all women delivering in the centres. The innovative scheme has proved successful, increasing access to local medical centres and ensuring fewer women give birth without skilled assistance at home.
Incentivising health workers to provide quality care
The third barrier to care, was weaknesses within the health service itself. MANI sought to increase the number and the quality of maternal and newborn health services, implementing performance based financing to incentivise improvements through cash rewards. As a result, capacity for emergency obstetric and newborn care has grown. Out of the facilities which introduced performance based financing, only one met the standards for Emergency Obstetric and Neonatal Care (EmONC) prior to the scheme. However, by the end of the programme, 27 health facilities were able to consistently provide this level of care. These facilities were also reported to be more resilient, with performance-based payments limiting the impact of strike disruptions in 2016 and 2017, creating a stronger and more reliable service.
Providing round-the-clock service using green energy
MANI further improved the resilience of health centres by addressing intermittent power supplies. Less than two-thirds of rural health facilities in Bungoma County are connected to the national grid, and even the on-grid clinics faced frequent power outages, sometimes lasting up to ten hours.
“Every time we get black outs, we use kerosene lamps to perform deliveries and we have to refer the infants with complications to Bungoma County Referral Hospital,” a senior hospital nursing officer in Sirisa explains. “In 2016, we lost more than ten babies with complications, who we could not resuscitate as a result of power outages.”
The MANI programme installed solar powered energy in 33 health facilities that was customized to the power needs of each health facility, facilitating a continuous electricity supply for the first time.
“I used to pay for a motorbike to ride to Mechimeru Health Centre to pick up vaccines, and at 3pm we had to return them before they lost potency – the cost for all this came out of my own pocket,” Moses, a nurse from the Mumbule Dispensary describes. “MANI installed the solar panels for lighting and to power a vaccine fridge. The neighbourhood knows that we now provide a 24-hour service and we have increased our deliveries.”
By minimising the obstacles preventing women from accessing maternal healthcare, MANI has successfully increased access to medical care. At the start of the programme in 2014, a third of women delivered in lower level health facilities and two-thirds delivered in referral level facilities. Thanks to MANI’s innovations, by 2018 these figures had reversed: the majority of women now deliver in lower level facilities, with the minority accessing referral level care. MANI has helped Bungoma county bring quality care closer to home.