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HEALTH-KENYA: Two Dollars And Change: Enough To Save a Mother’s Life

Joyce Mulama

KISUMU, Jun 12 2009 (IPS) - At the age of 14, Zulekha Mumma delivered her first child. At 21, the birth of her seventh child killed her. She died from excessive bleeding in her home in Nyalenda, a slum on the outskirts of Kisumu city in western Kenya, some 400 kilometres from Nairobi.

“It was too late for me to get her to hospital. By the time I realised her condition was serious, blood was flowing from her body like a tap and she took in her last breath,” Mama Apondi, a traditional birth attendant who was helping Mumma to deliver, told IPS, still distraught at the memory of Mumma’s death two years ago.

Not one of Mumma’s children was delivered in hospital where there is skilled health care, a familiar situation in Kenya where only 40 percent of deliveries take place in hospitals.

The rest give birth at home with the help of birth attendants who are not equipped to deal with complications from pregnancies, contributing to high maternal mortality rates. Official figures indicate that maternal mortality stands at 414 deaths per 100,000 live births.

Two thirds of these deaths are due to postpartum haemorrhage (severe loss of blood during pregnancy or labour), sepsis (bacterial infection), eclampsia (severe hypertension in pregnancy) or a ruptured uterus, which birth attendants like Apondi can neither predict nor deal with.

Voucher programme in detail

The voucher programme commenced in June 2008, costing 6.579 million Euros. The German government paid a large sum of the money, while the Kenyan government reportedly paid just a fraction (reportedly 0.16 million Euros, about $225,000 -though this figure has not been confirmed by government officials). It aimed at helping poor women get access to affordable reproductive health services and maternal care to reduce maternal mortality.

It targeted a total of 140,656 women in five project sites that included three rural districts, and two slum settlements in Nairobi. A poverty tool was used to screen the women for eligibility. It graded them on a scale of 1-3, based on indicators such as the kind of housing, accessibility to water and sanitation and health services, garbage disposal, number of meals per day and daily income.

Safe motherhood vouchers were provided at a subsidised cost of Ksh 200 (about $2.5), allowing the women to access antenatal care visits, delivery by normal or caesarean section and a post natal care visit within six weeks after delivery at public or private facilities accredited by the National Hospital Insurance Fund.

Clients could also purchase family planning vouchers at a subsidised cost of Ksh 100 (about $1.3), entitling a client to access contraceptives from the accredited health facilities.

Besides the two vouchers, the project also provided for clients who were in need of gender-based violence recovery services, including clinical examination, treatment and counselling.

The safe motherhood vouchers recorded remarkable success, with accredited facilities showing a 20 percent increase in the number of women seeking care during pregnancy.

The cost of delivering a baby in a government hospital ranges from 20 to 65 dollars. This prompts many poor women to seek the services of traditional birth attendants, who will charge around 13 dollars. They may also accept payment in the form of an animal such as a goat for delivering a baby.

The Reproductive Health – Output Based Approach (OBA) programme is an attempt to overcome maternal deaths by making hospital births affordable.

Initiated in June 2008, the project allows poor women to purchase a safe motherhood voucher for 200 shillings – equivalent to about $2.50 – which entitles them to give birth and access ante- and post-natal care at accredited clinics.

The project was piloted in five areas including Kisumu, Kiambu and Kitui, in western, central and eastern Kenya respectively, and in Korogocho and Viwandani slums in Nairobi. Its first phase, which ended October 2008, recorded a massive turnover of pregnant women seeking skilled care.

Francis Kundu, programme officer of the National Coordinating Agency for Population and Development, which is overseeing the overall implementation of the project, said accredited facilities saw a 20 percent increase in the number of women seeking professional care during pregnancy.

At the Marie Stopes Clinic in Kisumu, one of the accredited health points, the number of deliveries jumped from less than 50 a month to 150 with the onset of the voucher system. The private clinic – part of the international family planning non-profit organisation – had to employ new staff and construct a new ward to cope with the influx of patients.

“We saw women coming from far and wide; from the remotest of villages in Kisumu. Some had never set foot in a hospital before,” Dr Charles Ochieng’ told IPS.

“The vouchers dignified the poor. The women came to the clinic, some even barefoot, and they would tell us, ‘We have never felt like this before, so this is what means to come to a hospital?” said Ochieng’.

Thanks to a voucher, Gladys Owino was able to deliver her fourth child in July last year at the New Nyanza Provincial General Hospital in Kisumu.

“I was so overjoyed that I could access maternity and post-natal services at such a big hospital, and be treated by skilled caregivers. My previous births were conducted by a traditional midwife, and one was so complicated that I almost lost my life,” she said.

A natural childbirth at the Marie Stopes clinic costs 100 dollars; a caesarean section costs $455. The cost of delivering at the government’s hospitals ranges from 20 to 65 dollars for natural birth and caesarean section respectively.

Poverty – 46 percent of Kenyans are classed as poor – has been the main reason why women like Owino have earlier failed to turn up even at cheaper government facilities.

Other reasons for low turn out have included poor quality of service including claims of aggressive attitudes towards patients by health workers, particularly at public facilities.

The voucher system is transforming this as well given that it is based on reimbursement – the more clients a facility gets, the more money it brings in. Public health staff have been motivated to change their attitudes in order to bring in more money to improve services.

At the end of the month, each accredited service provider is submits claims for services rendered, which are then processed and reimbursed by PriceWaterhouseCoopers, the voucher management agency.

This has resulted in increased competition between public and private health facilities.

“It has called for improved services and increased standards of health care delivery. If you have no quality you do not get clients,”Kigen Bartilol, deputy head of the Division for Reproductive Health under the Family Health Department within the Ministry of Public Health and Sanitation told IPS.

“Most facilities have been forced to change their attitudes to win clients. If you do not change, you do not get clients and therefore you do not get paid.

“There was so much success, particularly with clients seeking safe motherhood services. Because of the competition, public hospitals improved services and recorded increased figures in the number of pregnant women seeking hospital deliveries as well as post natal services,” he noted.

Phase two of the project, which will roll the voucher programme out to other parts of the country, is scheduled to commence in July. However, concerns are emerging about how the Kenyan authorities will sustain it, should the German government, which has contributed most of the funding, pull out.

The pilot project was undertaken at a total cost of about 9.2 million dollars. According to Josephine Kibaru, head of the Family Health Department, the government is currently in the process of undertaking a study to ascertain how much nationwide coverage will cost.

“We had asked for Ksh 100 million (about 1.3 million dollars) for the scheme, and should we not be given the whole amount, then whatever is allocated can be increased over time,” Kibaru observed.

There was increased funding for health in Kenya’s latest budget, read on Jun. 11, but at the time of publication, officials were still waiting for a breakdown of how the money would be spent to be certain the voucher programme’s future is secure.

 
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