Recruitment:
In all counties, according to the respondent consumers who had come for clinics, they had been recruited to access “Linda Mama” services during the first ANC visit and were registered. A woman had to be pregnant to register. All mothers who came in and were pregnant were eligible. They needed a photocopy of the first page of their identification (ID) card, was photocopied and filed, In the absence of own ID card they could use the ID of spouse or mother. Adolescents without IDs carried their guardians’ ID. Some of the women were registered through the community health volunteer (CHV) who referred them to ANC and other services then they were registered. For some without IDs, they use ANC numbers.
Kisumu providers reported the use of phone numbers (self or spouse or mother). They also used mobile phones /smart phones, applying a system in which they would dial (*263#) on Safaricom and it would bring options leading to registration. The community health volunteers (CHVs) could also register the women using their mothers’ mobile phone by dialing (*263#) then referring them to the facility. Registration could also occur at health facilities during any visit or even during delivery when the mother had not been registered in any facility. After registration mothers were given an m-number at the health facility. That notification number was written in their ANC booklet, and would enable them to obtain maternity services and post natal care anywhere in Kenya. Phone numbers were required for follow-up of mothers by the facility to reduce ANC defaulters. They were formally admitted in the maternity or postnatal register. “Once a mother has M- number then she can deliver anywhere in Kenya” a manager explained.
Dissemination of “Linda Mama” information was reinforced through community awareness, opinion leaders, service providers informing mothers, and clients also informing one another, telling them to visit the facility. “When expectant mothers visit hospital, there is a staff in charge of registering them, registration is free, there are two nurses doing the registration”. Explained a service provider from Homabay.
Benefits of the initiative
According to the consumers the majority of the benefits were realized during delivery, although they started to be realized as soon as the clients were registered. “You are treated free of charge, you are given good drugs free even when you are old and for children up to 6 months, we don’t pay for services received by ourselves and our children” explained discussants from Kisumu county. Another consumer said “It has not helped me at the moment but I hope to get help from it during delivery, I will also get free health services up to 6 weeks of delivery” explained Homabay antenatal discussant.” It eases life for mothers particularly for those who do not have money at the time of delivery, they can still just go and deliver at the health facility” explained Siaya discussants. According to some respondents even the rate of abortions had gone down and explained “May be a mother do not have money to deliver in the hospital and so she thinks of aborting but because of this program she will keep the pregnancy because delivery is free, and the care of newborns and infants up to 6 months are free” a discussant clarified.
Services were accessed by more clients by reducing the cost of seeking care to a minimum at the time of need. Free services encouraged mothers to seek services in time. Free ANC resulted in high turn up of mothers, improved general health of mothers and babies, increased knowledge level for mothers as they attended education during clinics, at the health facility. “Those who were delivering at home are now coming to the facility, before people just used to come for the first ANC visit and disappear, but now it has increased skilled delivery “ Siaya service provider explained. It is to be noted that dispensaries were not as involved in “Linda Mama” initiative as higher levels of care “Mothers hardly come here for deliveries because it’s a dispensary and we don’t work at night, the effect is felt in bigger facilities” claimed a dispensary respondent from Siaya County.
According to the managers, “Linda Mama” initiative had improved health seeking behavior in terms of improved ANC attendance four visits or more, increased health facility skilled delivery, as the population of mothers delivering in the hospital shot up because of the initiative. There was increased PNC attendance, and Family Planning and other services as well such as immunizations, given at birth, (BCG and birth polio), because of the non-payment by users at the point of use. Complications identified at any stage of pregnancy, during ANC, at admissions for delivery, and peri-natal period were all taken care of free of charge, which was a great relief to users. According to some respondent managers, it covered mothers and their children up to 2 years but after that all children under five years of age receive free treatment in public health facilities. They stressed that the initiative had greatly reduced home deliveries, complications, and hence reduced peri-natal morbidity and maternal mortality as well as neonatal morbidity and mortality. According to service providers “Malaria in pregnancy has improved because we give them nets at early stage. They go to term pregnancy because cases of Malaria are reduced. In addition the CHVs get supported by the facility in their activities e.g community dialogue and action days” explained a service provider from Homabay.
Maternity and MCH services improved as a result of the funds received by health facilities for reimbursements. “The money for “Linda Mama” helped to purchase drugs, reduced work load in the facility, improved quality of care to mothers, and are able to get more information regarding their health and that of their babies, and we use part of the funds to renovate our hospital”, explained a hospital based service providers from Kisumu County. Managers and service providers brought the fact that the benefit of “Linda Mama” initiative was all round, both health facility and the clients benefitted at the same time. In this way the initiative had improved the quality of service provision, by empowering the facilities in service availability, by making financial resources available to take care of health facility service provision needs. It had thus improved service readiness (stocking of pharmaceutical and non pharmaceutical items, the required infrastructure, the range of services provided, and quality of services and hence service delivery outcomes. “It is good people accept because it is free it has increased number of clients seeking care better as compared to UHC, “Linda Mama” is better, the money reimbursed helps in improving the facility, supply of commodities” remarked a respondent manager from Kisumu county.
It had improved quality of care for the mother and baby, by reducing the cost of referring mothers for specialized services such as ultra-sound services. “It has a great impact to provision of services. It has enabled acquisition of equipment. It has improved infrastructure in the facility. Part of the Linda mama funds have been used for renovations, repairs, electricity and hiring of a security firm in the facility” explained a satisfied Kisumu service provider. Consumers testified that the initiative had helped them a great deal “it is totally free, the only requirement needed is a photocopy of the ID, in addition, there were incentives given after delivery such as pampers, basin, socks, sanitary towels and soap” explained post-natal discussants from Homabay county. “It helped me when I was to deliver I did not pay any bill at all” explained Kisumu discussants. Siaya respondents added their voice “It has not helped me yet because I have just registered but I know delivery will be free”.
Impact on health facility delivery attitudes
The initiative seems to have influenced the attitudes and practices of women with regard to health facility delivery through four pathways that have emerged from our findings that should be considered in the implementation of Universal Health Coverage (UHC) which is the ultimate goal of the Kenyan Government:
Policy and information dissemination
It appears that clear policy guidelines were disseminated and explained to service providers and managers and were also accessible in the NHIF website for consultation. Sensitization was done well. The Linda mama benefits were disseminated to mothers during visits, at maternity, and at ANC and maternity open days. Mothers benefitted also from baby packages, group ANC- porridge given to the mothers. Most of the women delivered at the hospital through the m-card. “As when I was delivering I stayed in the hospital for 4 days after delivery and we were about 20 mothers who delivered and all had Linda mama cards” Kisumu county, consumer testified.
Enhanced health facility capacity to handle the patients’ needs had regained confidence among consumers on the services at health facilities. From the revenue generated the health facilities were able to pay their bills to suppliers and hire additional staff as needed for improving access to timely quality of services in terms of structure, process and outcomes, summarized on Table 1 services. While increasing the volume of customers served the initiative had reduced workload for service providers, as nurses were able to work in shifts. It was very effective especially for mothers as they were able to get a range of critical services like ultra sound, caesarean section, and even in patient services during pregnancy and the childbirth up to the expiry date of the card, free. Consequently the consumers were convinced that delivery at the health facility was much safer than the alternative providers as complications arising during delivery would be effectively handled.
There was substantial quality improvement, environment was good, equipment, doctors and essential commodities were available, at secondary referral hospitals. Consumers added their testimonies “We no longer go to the TBAs, because we are afraid of the complications which might occur during delivery e.g. over bleeding. Moreover, delivery at the health facility is totally free as compared to other places like TBAs. Even less fortunate mothers are able to access care at the health facility. In case a mother is HIV + ve, the TBA cannot prevent the child from being infected hence but health facility does, and is best in my option” Explained Homabay discussants. Hence it would appear the attitude of consumers had changed, they preferred hospital because it was safe and could solve problems for mothers and for the babies when they arose. “Mothers now love to deliver at the hospital because the services are good” expressed Kisumu county consumer.
Eased family economic burden on health
The program reduced costs for the consumer to the minimum, while not undermining their autonomy and choice for the service provider, where to seek care and to deliver. It lifted the economic burden of care from the consumers. This motivated mothers to seek services and enabled early referrals. In addition the consumers enjoyed incentives of mother-baby packages (basin, slippers, soda, napkins, pads, cotton, tissue, soap, baby shawl, net). Mothers were able to get tea, porridge and meals after delivery. “Mothers are given adequate well cooked food, beverages, hot bathing water which make them come in large numbers to deliver here, home delivery is almost nil” according to a Kisumu service provider “From January up to now (March) only one home delivery has been reported to the facility, brought by CHV after home delivery” explained a service provider from Homabay. Similarly, Siaya respondents echoed similar sentiments that the scheme had had a huge impact, because of availability of services free. “We are having more clients, those who were delivering at home are now coming to the hospital, mothers are motivated to deliver at our facility, they are coming all the way from far because of free, friendly services, mothers no longer come with old “leso” (fabric) to the facility because they will be given a baby shawl” explained a service provider from Siaya. ”We don’t pay anything when we come to deliver, many mothers are delivering in hospital because it is free, as compared to before when most mothers were afraid of the bills” explained Kisumu focus group discussants.
Community engagement
The routine household visits by the CHVs to sensitize households, and output-based incentives for referring mothers, seemed to have led to good performance in specific villages where the CHVs are active. They sensitized the community about mother and baby packages and linked households with health facilities. It worked positively both for the facility and the community. However, Siaya respondents stressed the fact that so many mothers still did not know about the “Linda Mama” scheme.
Main challenges and emerging lessons
Many consumers reported few challenges with the scheme. However a number of challenges were mentioned by respondents the main ones included: The requirements of the national identification number (ID) in the registration process had the potential to affect access to care among those most in need. This risk was recognized and some alternatives were introduced to cover everyone, such as young people without ID, so that no one would be excluded. A lingering issue was that mothers were asked to pay for photocopying which introduced a cost to consumer, potentially a barrier to accessing services at the time of need!
According to the managers and service providers the main challenge was the delay in disbursement of funds to the facilities. The process of claiming was described as tedious. Refund period was not consistent and took too long because the money was channeled through the county government, and processing took too long. It made transport for monthly report submission to the NHIF problematic. The delay affected the motivation among providers and managers “Right now, in March, we are still waiting for reimbursement for December, January and February” explained a manger. They explained that delayed reimbursement affected work as often they would not have money to buy bundles for internet access, needed for registration and other data processing activities. Service providers complained of a mismatch between service demand and available resources to provide services, many respondents mentioned increased workload. “It’s quite involving and requires additional staff for effective data capture on a daily basis” explained Homabay respondents. “Doing photocopying of ID and registration documents involve a lot of work and the maternity services such as delivery beds were often too few for the number of deliveries being conducted” explained Kisumu service providers. Some mentioned the importance of having a photocopier within the health facility “Photocopying registration form outside the facility is tiresome and could lead to some mothers being lost or having delayed access to care” interjected a Siaya service provider. They noted that the online procedures during registration and other visits required computers and access to internet, as well as constant availability of bundles, affected by reimbursement delays.
Consumers complained of inadequate care when one delivered at night, “there is minimal attention given to the mothers by the health providers as they usually wait and come when the baby is almost out” this could be addressed by a regular quality assurance mechanism. They mentioned that sometimes incentives packages run out, and mothers go away without. Some customers were unaware that registering and having the m-card enabled one to deliver in another county. Others had been turned away from certain private hospitals. Consumers felt that the period of free care was too short and needed to be lengthened. Such issues needed to be clarified.
Respondents cautioned against over reliance on “Linda Mama” as “without it everything can come to a standstill, if it stops then the indicators will go down again” exclaimed a manager. There was increasing dependency among mothers those were no longer putting enough effort in preparing for their babies’ deliveries because they knew that they would be given everything during delivery. High expectations appeared to be increasing and needed to be handled with care. High expectations seemed to be expressed also by managers and service providers. Some managers were of the view that the basic package covered was not comprehensive enough since it did not cater for X rays, routine ultra sounds to be done during ANC as these could not be covered in the Kenya shillings 600 reimbursed. In their view, lack of these diagnostic services affected adequacy of timely diagnosis of some conditions during ANC.
Not all health facilities were implementing the initiative, for example some dispensaries did not operate at night and hardly conducted deliveries, which respondents thought was a is a missed opportunity to provide easily accessible services to local populations. In addition, many facilities did not work during weekends making hospitals to be overwhelmed during weekends. Respondents also mentioned inadequate sensitization about the initiative at the grassroots leading to a knowledge gap among mothers regarding the initiative and its importance. Community engagement element was inadequate in all the three counties.