Healthcare service providers’ and facility administrators’ perspectives of the free maternal healthcare services policy in Malindi District, Kenya: a qualitative study

Healthcare service providers

Twelve healthcare service providers were recruited (Table 1). Ten of them were midwives working in different departments within the reproductive
health units in all the five facilities. Of these midwives, five work in Malindi district
hospital and two work in Ganda dispensary. Gede health centre, Watamu dispensary and
Kakoneni dispensary had one midwife each. The two additional service providers included
a consultant obstetrician/gynaecologist and a medical officer who work in the reproductive
health unit.

Table 1. Characteristics of Service Providers

Healthcare facility administrators

Six administrators were recruited four of whom were Nursing Officer In-charges and
two were facility administrators. Table 2 shows the range of facility administrators involved in the study and the number of
years they have worked.

Table 2. Characteristics of Facility Administrators

Themes

Three emergent and often inter-linking themes were identified from the narratives
obtained from both the service providers and the facility administrators. These included:
(i) perceived benefits of free maternal health services by service providers and administrators,
(ii) perceived barriers and/challenges to free maternal health care service policy,
and (iii) future management of free maternal services in Malindi District.

Perceived benefits of free maternal health services by service providers and administrators

Before the introduction of this policy, the maternity departments were overcrowded
with mothers who overstayed in the facility due to pending hospital bills. This was
reported as a significant cause of stress to health care providers. The free service
policy has alleviated this problem as women can go home immediately upon their discharge.

‘Overall I can say that free maternity service is doing a good thing for example,
we used to have so many mothers crowded in the maternity ward because they were waiting
to clear the bills but nowadays, they deliver and go home depending on the mode of
deliver, if normal delivery they stay in the facility for 24 hrs, if caesarean section
we discharge them on the 3 ^rd post-operative day.so we never have mothers overcrowded in the department like we
used to. This has eased the pressure on the health care workers’ (IDI with service
provider 2).

The health care providers also perceived the policy as addressing the use of skilled
care during pregnancy and delivery in Malindi district. One service provider stated
that women who never before visited the facility during pregnancy and delivery as
a result of the user fee were now able to seek skilled care services.

‘Free maternity services will be a solution to the problems in maternal health, for
example, the mothers who never used to come to the hospital because of the funds are
now coming to the hospital,’ service provider 5.

The service providers realised a rise in the number of antenatal care services visits
as well as number of facility based deliveries following the introduction of the policy.

‘Another difference I have seen after the free maternity service is that many people
are coming to deliver at the hospital as compared to the previous time they could
wonder where are they are going to get the money to deliver at the hospital, so they
preferred delivering at home. So now I can say that the turn up is big and is good’.
Service provider 4

‘With the free maternity service, the mothers in the clinic have really increased,
like right now, the antenatal care clients are still coming for the service but when
you compare this numbers in maternal and child health clinic and those in maternity,
they are not tallying so that means that yes we are giving the services in the antenatal
clinic, but when you look at the maternity despite the increase in deliveries, their
numbers are still few’ service provider 6

Other service providers stated that the free maternal health care service had already
impacted the maternal health outcomes including a reduction in the number of maternal
mortalities following the implementation of the free maternity service:

‘The outcome I can say it is good, eh, the mortality has gone down, because there
are times when we had many mortalities, although it was mainly caused by referrals
from the rural health facilities, but I can say that after the free maternity service,
we have not been having many mortalities,’ service provider 2.

‘The maternal deaths are very few, we can stay even up to three months without a maternal
death,’ service provider 1.

The timing of the women seeking these services had also improved. Following the inception
of the policy, women were seeking maternal health service sooner than they used to.
However, although there was an increase in the uptake of some services, other services
were not necessarily accessed. This included the family planning services where the
uptake was stated to be very low despite the services being free.

‘The numbers of pregnant women attending the antenatal visits have increased but the
uptake of family planning is very low. The future of our community is good with this
free maternity service, however the success lies on preventing these pregnancies as
well,’ consultant.

Barriers and/challenges to free maternal health care services policy in Malindi.

Despite the positive outcomes of the policy significant challenges and barriers in
its implementation existed. These included; “uncompensated loss in fee revenue while
patient volumes simultaneously increased”, “inadequate human resource”, “shortages
of commodities”, and “demotivation of health care providers”. For example, failure
of the national Government to reimburse the facilities promptly was reported to contribute
to shortage of drugs and supplies, which negatively affected the quality of care provided.
One service provider stated that they were at times forced to improvise or ask the
relatives to buy the necessary supplies in order to facilitate service provision in
public health care facilities.

‘Free maternity service is very hectic for the midwives and mothers because when the
mother comes to the facility usually we don’t have the supplies and the maternity
is usually very bare so we go to some facilities to borrow some supplies.at times
we are forced to improvise in order to provide care. We do not get some uterotonics
drugs, we do not have delivery packs, and the supply is really low. It is very hectic.’
Service provider 4

The uncompensated loss in revenue was perceived as a source of frustrations to the
administrators who feared that the continuity of service provision may be jeopardised
if this challenge persisted. The lack of supplies, drugs and equipment was not only
viewed to affect the facility administrators and health care workers, but was also
seen to be affecting the other parallel programs that aimed to improve the utilisation
of service that had skilled care. For example, TBAs were being given a token for every
mother they brought to the facility to deliver. The small token seemed to encourage
the TBAs to bring the mothers to the facility instead of conducting the deliveries
at home. This initiative seemed to have strengthened health facility’s linkages with
the TBAs. As a result, there was improvement in the uptake of delivery services in
a facility resourced with skilled attendant. However this has since stopped due to
failure to sustain the program soon after the introduction of free maternity services.

‘We had a meeting with the community to sensitize them on free maternity services
and the numbers really increased but we have been having challenges with the loss
of revenue because previously we had an arrangement as a facility to reimburse the
TBAs when they bring the mothers but now since we have not been having the funds to
support this move the TBAs have not been bringing the mothers.’ Service provider 1

Failure of the government to involve health providers and administrators in the development
of this policy was also perceived as barriers to effective implementation of the program
in specific facilities.

‘There was no form of involvement before the rolling out of the program. I think this
had an effect in the implementation because if we were involved for example as a medical
officer probably we would have talked of the areas that would have been of emphasis
like planning of it, and probably we would have ideas on how to implement it well.’
(IDI with a Medical officer)

On the other hand, facility in charges expressed concerns about the quality of the
services provided which they felt was compromised by the high patient volume amidst
shortage of staff and supplies.

‘Free maternity service is a good program, we are happy it is there but the only problem
is that it’s quite hectic for us because of the hardships we are facing and, it’s
quite hectic for us because we are not offering that quality service that we want
to give. Workload has also increased and staff remain constant. This has been a very
big challenge hence you end up not giving the quality service due to burnout,’ facility
in charge 1.

The consultant and one service provider stated that sometimes the outcomes are not
very good not because the service provider was not there but because the number of
women needing a particular service at a particular time significantly outnumbered
the service providers.

‘Sometimes outcomes are not very good for example one nurse who has to deliver 5 mothers
cannot monitor 5 mothers all in labour,’ consultant.

‘Because of the shortage of staff at times the clients overwork the service providers
and maybe complication could occur not because the mother did not come to the facility
early but because the midwives have so many mothers to attend to.’ Service provider
2

As a result of poor quality of the services and the shortage of supplies and drugs,
it was also noted that the number of women seeking the service was diminishing over
time. This was experienced a few months after the initial implementation of the program.

‘When it started, the first few nights we got very many mothers coming to the hospital,
like the first 3 days we were delivering up to 17 at night but with time it started
going down and this is because in our facilities especially at night of which you
know many mothers deliver at night we have only 2 midwives in maternity and 1 medical
officer intern, so when they come 17 of them you can imagine what would happen…’ Facility
Administrator 2

Apart from the concerns in the quality of the services provided, the medical officers
made an observation that the motivation and morale of the service providers was declining.
This was perceived to be attributed to the increase in workload amidst shortage of
staff.

‘There is also the challenge of personnel which is highly affected by the workload
and you will find that the people offering the service are few and I have noticed
lack of motivation on the part of the health care workers that is general in the entire
hospital,’ medical officer.

Prior to the introduction of the fee free policy, the health care system had just
been devolved from the national government to the county government. This meant that
budgeting for health care and decision making functions were to be conducted at the
County/regional level. The devolution was perceived as a challenge to the implementation
of the free maternity health services due to a number of administrative and logistical
challenges including those related to the transfer of funds from national government,
inadequate funding for implementation of the free maternity services and lack of a
clear procurement plan for the purchase of medical supplies.

‘The free maternity started when we had not devolved health services to the counties,
so we don’t know whether the running will be left to the counties or the central government.
We are now wondering that now that health services were devolved was this project
also devolved, what exactly happened. There is no any feedback that we are getting
to say that this is the way forward,’ facility administrator 1.

Poor referral system and operation time for facilities serving rural areas seemed
to have affected the implementation of the free maternal health care services in Malindi
District as well. For example, concerns on delays in referring mothers for further
management and emergencies from the rural facilities to the district hospital were
reported to be potential challenges to the reduction of maternal mortality and morbidity
in Malindi. The existence of only one ambulance serving 36 facilities within Malindi
district seemed to be the main contributor to the weak referral system.

‘We also have a challenge in the referral system hence handling emergencies is hard
and the referral needs you to be an accompanying nurse and if you are alone it is
a challenge hence you are forced to send the mothers with their own transport. Also
the ambulance is a challenge as we only have one ambulance in the whole district serving
the rural areas and hence it delays emergencies’ service provider 9

‘We do not get any mortality because if we get any complication we just refer but
usually the line of referral is delayed for up to 5 hours,’ service provider 4

Most dispensaries in Kenya (the main facilities serving rural areas) are poorly staffed
and lack adequately trained skilled workers. This limits the functioning of the facilities,
including the operation times of the facilities which was perceived as a challenge
to maternity service provision and utilisation.

‘We also have a challenge where we don’t open at night due to insufficient human resource
and naturally most deliveries occur at night. This issue has led many women to still
deliver at home.’ service provider 9

Future management of free maternal health care services in Malindi

In addition to airing their success and challenges, participants proposed strategies
that could improve the implementation of free maternal health services in Kenya. These
included:

Sensitising the general public on both the user fee removal policy and the importance
of seeking skilled care during delivery.

‘We need to sensitize the community on why free maternity services. we also need to
sensitize the community on why deliver at the hospital, let them know about the high
numbers of maternal mortality and why we need to fight for the mothers to stay alive,
a home without a mother is nothing, this task is beyond the health care worker only’
facility in charge 2.

Motivating the health care workers through increased remunerations and sponsorship
to trainings programs.

‘There is a need to have something for the service providers because most programs
come with the view of the community and the clients but nothing for the service providers.’
Service provider 7

‘The free service is for the mothers, but even the midwives should get some form of
motivation. Despite the workload and shortage, they will get motivated, for example,
through sponsorship to school and trainings. The health care workers should also get
good salaries. If they give us good salaries and they motivate us, we will work.’
Service provider 1

Improving drugs and supplies in the facilities in order to cope and address increased
service utilisation.

Effectively communicating with health workers and managers about the policy vision,
goals and activities required for effective implementation of the policy.

There should also be a link between the top level and the people in the periphery
to be able to understand what is happening for a successful implementation of the
free maternity service,’ service provider 6.

Increasing human resource for health to facilities in order to address workload issues.

‘Our plea is to the government to give us necessary equipment and staff so that we
may be able to give quality services, so if we will get everything we are good to
go.’ Service provider 1

Involving the community especially through working with TBAs in order to enhance the
uptake of the skilled health care.

‘With our community they rely so much with the TBA. We need to collaborate with the
TBA, and you will see the mothers will come to the clinic for ANC and for the deliveries.’
Service provider 4