Background
Maternal morbidity and mortality have been a major public health concern across the globe and more so in developing countries. Globally, more than 800 maternal deaths are reported per day with 99 % of these deaths occurring in low and middle income countries [
1].
Pregnancy related conditions in Africa have been identified as significant causes of deaths in women between the ages of 15–44 years. A woman in Africa has a 1 in 39 lifetime risk of dying from pregnancy compared to 1 in 4000 in high income countries [
2]. Compared to other parts of the world, maternal deaths are higher in Sub-Saharan Africa where approximately 165,000 women are reported to die annually due to pregnancy and its related complications [
1].
Kenya is evolving from a low to a middle income nation but despite this economic milestone, Kenya is still ranked among the ten countries that contribute to the 60 % of global maternal mortality – Kenya records over 6000 maternal deaths annually [
3]. High costs of maternal health care, especially deliveries, coupled with continuing high maternal mortality rates, have led to a debate about optimum health financing strategies for maternal health, [
4] and questioned inequities in health service accessibility brought by user fees [
5]. User fee on health care services was introduced in Kenya in 1989 as a health financing strategy [
6], however this strategy has since been seen to contribute to inequity in the utilisation of health care services as the poorest households were found to utilise less of the fee charging facilities compared to the rich in the society [
7].
It is well recognised that a significant proportion (56 %) of women in Kenya especially those who live in rural settings do not deliver their babies within a health facility or assisted with a skilled birth attendant [
8]. For those who deliver at home, 28 % are reported to do so with the help of a Traditional Birth Attendant (TBA), one-fifth deliver with a relative, and nearly one tenth of the women deliver alone [
9,
10]. Culture, poverty (including pregnant women’s inability to pay for skilled care services) and distance to a health facility [
8] have been recognised as factors that lead to women delivering their babies outside of the health care facilities.
In order to improve this poor situation, the government of Kenya has taken several measures to address issues of poor maternal health outcomes in the country. One of these measures include the introduction of a fee free policy on maternal health services since June 2013 [
6].
The fee free policy aims to improve the accessibility, and utilisation of quality maternal and newborn health care across all demographic groups in Kenya as well as reduce the unmet maternal health needs [
8]. Additionally, the introduction of free skilled care delivery services intends to improve access to health services for disadvantaged communities, [
5] by reducing the financial barrier of accessing skilled care. [
4]
The World Health Organisation (WHO) defines skilled care as ‘
quality care to a woman during pregnancy,
childbirth and postpartum period by a skilled personnel supported by an enabling environment (
necessary equipment,
supplies and medicines and infrastructure)
and a functional referral system [
11].
At the centre of skilled care is a skilled attendant who is a health professional (
midwife,
nurse,
doctor)
educated and trained to proficiency in the skills needed to manage normal pregnancy,
childbirth and the immediate post-
partum and in the identification and management or referral of complications.’ [
11]
The fee free policy aligns with other international strategies to reduce maternal mortality rates including the Millennium Development Goal 5 (MDG5) that calls for a reduction in maternal mortality by three quarters by 2015. [
4,
8,
11].
As far as is known, there have not been any studies that have investigated how the policy stakeholders perceive this policy. This paper is part of the larger study to explore and triangulate the perspective of all stakeholders of this policy. The research sought the views and perspectives of a wide range of individuals who represent service providers, facility administrators and service users from Malindi District. The aim of this paper is to report perspectives of health service providers and facility administrators about some of the factors that act as barriers and facilitators to the implementation and provision of the free skilled maternal health services introduced in Malindi District. Data analysed for this paper are taken from interviews from these selected stakeholders to highlight their understanding and inform practice (policy implementation and service provision) and policy (policy planning and feedback) in order to improve overall maternal health outcomes in the district.
Methods
Study setting
The study was conducted in Malindi district, a sub county within Kilifi County in the Coastal parts of Kenya. Malindi district covers an area of 7750 km
2 and has an estimated population of 424,081people with nearly half (47 %) of the population being below the age of fifteen years [
12]. The district is served by 37 government owned health facilities. Thirty six (97 %) of these facilities are equipped to offer Basic Emergency Obstetric Care (BEOC) which includes; antenatal care with early detection and treatment of common problems of pregnancy, as well as first aid for complications of pregnancy and labour. The other facility (Malindi district hospital) is the only government owned facility in the district which is equipped to offer Comprehensive Emergency Obstetric Care (CEOC) to include the provision of BEOC, blood transfusions and caesarean sections [
13]. The current Maternal Mortality Ratio in Malindi district (MMR) is at 428 per 100,000 live births [
14] with an equally high fertility rate of 6.1 children per woman, higher than the national fertility rate, of 4.6 children per woman [
15].
Theoretical framework
The study espoused the Realist Evaluation Framework introduced by Pawson & Tilley [
16].
This theoretical framework identifies and provides the lens through which to understand the best practical method or methods in approaching or causing change whilst giving consideration to the context. Realism begs the question, ‘what works for whom, in what circumstance and in what respects and how?’ [
16,
17]. Realism is also said to be an ‘open system’ in that, it acknowledges that the program is prone to being affected by external factors. Therefore, one cannot assume a program to take a constant state but has to acknowledge the fact that a program changes throughout its cycle for it to remain viable [
16]. Realism explains the programs failure and/or success [
16,
17], enabling the planners to know whether a program can be applied in another setting or not and goes further to give an explanation as to why so or why not. Realism appreciates the fact that the program is active and works around active recipients hence the choice of the evaluation methodology ought to fit in this active arena [
16].
Realism not only focuses on the effects of a program but also on the inner workings and operations of a program and how they are connected, which is often obscured from those who observe the outcome patterns. These workings and operations have been termed as the Context Mechanism Outcome (CMO) configuration. Mechanism forms the pivot point in realist evaluation [
17]. Context on the other hand is not only linked to the place but also the systems, relationships, biology, technology and economic status. Context elements are those factors that are external to the intervention, present or occurring even if the intervention does not lead to an outcome, and which may have an influence on the outcome. It describes those features or the conditions in which programs are introduced that are relevant to the operation the program mechanisms. Mechanism is built on the premise that it is not the program that works but the action elicited by the target audience or stakeholders equipped with the right resources and capabilities offered by the program is what makes the program work [
16].
A realist approach looks for mechanisms at individual, group, organizational and societal levels .In the case of the current study the mechanism is the actions or change elicited and experienced by the, providers and facility administrators following the elimination of user fee on maternal health services.
Applying this evaluation framework, the study aims at identifying what works for whom, in what circumstance and in what respects and how, with reference to the user fee elimination program on maternal health services in Malindi district.
Data collection
A qualitative inquiry was employed to explore the perceived impact of free skilled maternal healthcare service provision in Malindi district. Purposive sampling was used to recruit the study participants. The inclusion criteria for the study was that one had to be a health service providers (nurses, doctors, and consultants) or a facility administrator (facility in-charges and hospital administrators) who has served in Malindi District for at least two years or more. Fifty introduction letters requesting their participation in the study were sent out to the potential participants’ offices, departments and stations within Malindi District. The letter clearly described the study’s aim, and informed the potential participants that their interest to take part in the study was absolutely voluntary and there was no consequence if they choose not to participate. The letter also bore the researcher’s telephone contacts where the potential participants were to send a text message to the researcher upon their acceptance to participate in the study. The potential participants were informed that the study was to be conducted in an interview format, and the interview would take approximately one hour.
Of the fifty introduction letters sent out, 18 potential participants sent text messages to the researcher indicating their interest to take part in the study. Information sheets and consent forms were sent to the 18 participants together with a letter inviting them for an interview to be held at their health facility. The participants returned the signed informed consent form on the interview day. An interview was scheduled with each potential participant at a time and date favourable to them in order to ensure that the service provision was not disrupted in any way. The participants were assured the information they provide was and would remain anonymous. To preserve and protect confidentiality of the participants, each participant was assigned a unique Study Identification Number (SID). At the completion of the study, the identification numbers were de-linked from personal identifiers. This procedure ensured that no data was linked back to an individual.
Semi structured interview guides [
18] were developed by researchers and pretested on non-participating district service providers and administrators. Eighteen individual interviews were undertaken with study participants from Malindi District hospital, Kakoneni dispensary, Watamu dispensary, Ganda dispensary and Gede health centre between January and March 2014. An iterative approach was adopted, in that the forthcoming interviews were informed by what arose out of the data collected [
19]. The interviews were conducted in English, digitally recorded (with consent of participants) and transcribed by the principal researcher (EL).
Some of the topics that were addressed in the interview guide included “the views, opinions, attitudes and experiences of the participants on the fee free maternity services; the barriers and facilitators of the fee free maternity services and; their commendation and recommendation on the service following the introduction of the policy.”
Data analysis
All transcripts were repeatedly read by both authors, and subsequently independently analysed thematically using ‘Framework analysis by Ritchie and Spencer [
20]. Framework analysis make use of systematic method to manage data giving qualitative data consistency and structure [
21]. To minimize the possibility of losing relevant themes, repeated themes of text were identified, allocated headings conferring to the context and coded to numerous important categories. Sub-headings were then identified from the thematic analysis [
21]. This method leads to a greater transparency, rigor and validity of the process of systematic analysis. Analysis was both deductive, with categories derived from prior knowledge, and inductive, with categories emerging purely from the data [
22].
Triangulation of narratives of different individuals at different levels of health system, and different settings contributed to the validity of the data and highlighted any conflicting views and widely shared themes across the group.
Ethical consideration
Ethical approval was obtained from the Social and Behavioural Science Research Ethics Committee, Flinders University (approval number 6331) and formal permissions obtained from the office of the Director of Health Kilifi County (Ref no: ST.HP/KRCHS/VOL.II/152).
Data were collected once the participants had signed an informed consent. The participants were also informed that their participation was voluntary and they could withdraw from the study during the interview if they so wished [
23,
24]. Anonymity of participants was maintained including through one-on-one interviews. No incentive was given.
Discussion
Several studies conducted across the world on the elimination of user fee policy on maternal health services have supported this policy as it does increase the usage of skilled care during pregnancy and delivery [
6,
25‐
30]. They also acknowledge that barriers still exist and if not addressed could compromise the success of this policy. The current study further demonstrates that the elimination of user fee is beneficial notably to the financially disadvantaged populations where it was seen to increase their access to skilled care during pregnancy and delivery. These findings are supported by a number of studies that have documented success on user fee removal in low and middle income countries. The successes documented are; an increase in use of these services especially in poor and uneducated women, [
31] an increase in the number of institutional deliveries, [
26,
27] an increase in elective caesarean section rates [
4,
28], and an increase in antenatal visits [
29].
Despite the positive outcomes of the program, the health care workers and administrators experienced challenges in the implementation of the program. The main challenges aired were; uncompensated loss in fee revenue while patient volumes simultaneously increased, high patient volume and inadequate human resource, shortages of inputs like drugs and supplies, a sense of demotivation among the health care providers which was attributed to the increase in workload on the few staff, and compromise to the quality of the service provided. These challenges were not only unique to Malindi but were seen to have affected other areas where the free maternity policy and program has been initiated. In Ghana for example, [
32] delayed reimbursement by the government to cater for the loss of user fee revenue at health facilities following initiation of free maternity services led to stock-outs of drugs and supplies, which negatively affected the quality of care provided and resulted in some facilities reinstituting user fees. This was also reported in Burundi where the lack of preparation for the new policy resulted in critical negative consequences for healthcare providers, including stock- outs of drugs, reduced quality of services, disruption of the referral system, and reduced motivation of health workers [
33].
The health care workers also expressed their concerns and dissatisfaction in the quality of the services provided which they felt was compromised by the high patient volume amidst shortage of staff. The poor quality of free services was perceived to affect the maternal health outcomes and the consumers’ perception towards the services. For instance, it was noted that the number of women seeking the service had reduced and stabilised at a figure slightly above what was there prior to the initiation of the program. This was experienced only a few months after the implementation of the program. According to Thaddeus and Maine, quality of service is one other factor considered by service users prior to seeking care [
34]. Hatts’ standard economic theory on user fee elimination policy further states that, if the interaction between price and the quality of services provided is complicated by fewer revenues to purchase key inputs like drugs and supplies coupled with a short staff, then the quality of the health services on offer may change as the price drops. And if both quality and the price drop simultaneously, the effects on quantity demanded are unknown [
25,
30].
The health providers participating in this study observed decrease in staff morale and performance following the implementation of free maternity service which they attributed to the increase in workload amidst having shortage of staff. Demotivation of staff was also reported in Nigeria, where the health workers complained of increase in workload yet there was no increase in remuneration or the number of health workers [
30].
The devolution of the health care services was perceived to affect the implementation of the free maternity service. The devolution of health care services was understood to lack clear cut procedures for ensuring adequate oversight on the funding, procurement of medical supplies for the health services, and the delivery of these services. This gave rise to administrative and logistical challenges to the provision of the free service. [
35]
In addition, weak referral system also posed as a challenge to the program where lack of adequate ambulatory facilities was said to be the major challenge facing the district. Without adequate and proper interventions the weak referral system could pose as a potential challenge to maternal health outcomes. Thaddeus and Maine, [
34] have argued that not getting adequate care in time is an overwhelming reason why women die in low and middle income countries. It was also found that the facilities serving the rural areas, mostly the dispensaries, were only operational during the day despite the fact that most deliveries are known to occur at night. As such it was perceived that the women in Malindi district do not fully enjoy the benefits associated with the user fee elimination policy.
According to Thaddeus and Maine three delay model [
34], it is plausible to argue that the main challenges facing free maternal health care service policy in Malindi revolve around the third delay, which is the delay in receiving adequate and appropriate care once in the facility. Such inadequacies may be characterized by shortages in supplies, equipment and lack of trained personnel, incompetence of the available staff, demotivated staff or uncoordinated emergency services.
To address the above challenges, several strategies were proposed by the participants. This included: (i) the need to sensitize the general public on both user fee removal policy and importance of seeking skilled care during delivery. This can be done through public information campaigns and meetings with village leaders to communicate the policy vision and goals to the general public including finer details of what users can expect to experience at facilities; (ii) the need to plan for adequate drugs and supplies to cope with increased utilisation, and plan how to tackle wider drug and supplies problems in the longer term; and (iii) the need to motivate the health care workers as a strategy in achieving successful implementation of the program through sponsorship to school and trainings and giving good remunerations to the health care workers. The health care providers serve as the first point of contact of patients in the health facility, as such, if they are not rewarded and motivated the end result will be patients complaining of being mistreated. This has been documented to be one of the barriers to hospital utilization [
36]. Another important aspect is the need to involve and communicate clearly with health workers and managers about the policy vision and goals, as well as about what and when actions will be taken [
25,
36]. It is recognized that leadership, supervision, information dissemination and communication are major mediators and moderators of the quality and effectiveness of health care [
37]. It is also important to increase human resource strength in the facilities in order to address workload issues and improve quality of services that will attract and retain the high number of mothers seeking skilled delivery following the initiation of the program.
As narrated by some study participants (see service provider 1&4), the need to involve the community in order to enhance the uptake of the program by the community through forming linkages with the TBAs and the community health workers is necessary. It has been recognised that community participation is fundamental in the success of any public health intervention [
38,
39] and so would be in the reduction of maternal mortality. The engagement of the women (women of child bearing age, mothers, grandmothers and mother-in-laws) in their health decision making at the grassroots level ensures that their concerns and expectations are addressed, their physical, mental, psychosocial wellbeing are protected and above all their health outcomes before, during and after pregnancy and childbirth are secured thereby reducing maternal mortality [
40]. Community health workers are commonly known as the engines of health systems in much of the developing world, and are a tremendous asset, as they connect the patient to the system. They are often the patient’s first point of contact, and play an important role in diagnosing, counseling and triaging what level of facility a patient should be sent. With incentives and proper training, they can counsel a pregnant woman to go for her antenatal care visits, ensure that she gets proper nutrition and is tested and treated for HIV, and help her arrange transportation prior to delivery at a health care facility by a skilled practitioner. All these are important steps in preventing newborn and maternal deaths. [41]
Strengths and limitations
The use of a qualitative approach in this study provided an in-depth and highly contextualized information and insights into pertinent issues including those that may affect policies and programs. It also covered a wide range of settings involving five facilities within Malindi district that varied in their catchment area, location and level of care which gives an in-depth understanding of events in the program. The study limitation includes the study’s inability to offer a full and complete picture of the user fee elimination policy and program as it was conducted early in the implementation phase of the policy and only 18 interviewers were included to represent service providers and facility administrators. However the useful information gathered from this study could improve the program at this phase and make the later phases a success. Further studies are recommended to evaluate the policy and its implementation at a later stage so as to identify the long term effects on maternal health utilisation, outcomes and service provision.
Acknowledgement
I wish to acknowledge to Dr. Stephen Chireah of Malindi district Hospital and Eunice Okyere, PhD student of Flinders University, South Australia for providing language help and proof reading assistance for this article.
My sincere thanks goes to the government of Kenya through the Director of Health Kilifi County, Dr Anisa Omar, the then Medical superintendent of Malindi district hospital, Dr Moris Buni and the Nursing officers in charge, Mrs Esther Mwema who accorded me with the necessary administrative support and permission to conduct this study.
Competing interest
The authors declare that they have no competing interests.
Authors’ contribution
EL: Designed, undertook a systematic search, reviewed literature, acquisition of data, data analysis, wrote and revised the manuscript. LM: supervised the overall study design including literature search strategy, qualitative inquiry, reviewed the literature and co-wrote the manuscript. Both authors read and approved the manuscript.