The Challenge

Kenya has made impressive progress in reducing the under-five and infant (< 1 year) mortality rates over the last decade. However, despite the strong political will and an enabling policy environment with commitment from the Kenyan government on universal health coverage, as outlined in Kenya’s Vision 2030 and the Kenya Health Policy (2012-2030), the achievement of targets is still elusive. For example, only 44 percent of women delivered in a health facility in 2008/09 nationally with 28 percent of the deliveries being conducted by traditional birth attendants and 21 percent by relatives. Not surprisingly, both the maternal mortality ratio and neonatal mortality rates remain unacceptably high at 400 maternal deaths per 100,000 live births and 31 neonatal deaths per 1000 births. The major cause of maternal death is post-partum haemorrhage accounting for 34 percent of all maternal deaths, sepsis accounts for 9 percent of maternal deaths and hypertensive disorders contributing 19 percent.

On June 1, 2013, the Government of Kenya took action to address this problem by initiating a policy of free maternity services in all public facilities. This would help all expectant mothers access maternal care and would also help reduce maternal deaths. By July, the Director of Public Health and Sanitation estimated a 10 percent increase in deliveries across the country, with increases of 50 percent in certain counties. In some facilities, these numbers have been even higher. According to representatives of Kenyatta National Hospital (KNH), within a month the number of pregnant women seeking maternal care had increased by 100 percent.In addition, Ksh 60 billion was allotted to county governments providing for new institutional frameworks and management arrangements in which the counties are responsible for community health services, primary care services and county referral services; thus creating an immediate need to support the newly-established county health management systems and structures to manage health service delivery.

Inequity by location (rural/urban) and by wealth status is particularly clear where delivery occurs and whether a skilled birth attendant is present. 63 percent of births in rural areas occur at home in contrast to 25 percent in urban areas. The most common reason for this is the distance from a health facility and lack of transport. Not surprisingly, only approximately 20 percent of the poorest quintile of women will have a skilled birth attendant at delivery in contrast to approximately 80 percent of the richest quintile of women. In fact, the Kenya Health Sector Strategic & Investment Plan (2012-2018) also estimates that current staff levels meet only 17 percent of minimum requirements needed for effective operation of the health system. Women who do not have access to a skilled birth attendant are often assisted by a traditional birth attendant, untrained relatives or friends. The poor quality of service in facilities is also well-known among potential patients and acts as a significant deterrent to engaging with the public health system. For example, women in North Eastern cited the poor quality of service and lack of female providers as some of the key barriers preventing them from delivering in health facilities, more so than cost of delivery.