There is a rampant and pessimistic notion that people build too many walls and not enough bridges. Try to imagine a world where the opposite of this happens.

For decades, the healthcare system in Kenya has been under scrutiny. Onlookers bear the same sentiments: the government is simply not doing enough to offer equitable and affordable healthcare to its citizens. There is some truth to the assertion, but it presents, at best, a grim one-sided picture of a country no one should want to inhabit.

The full picture is far more encouraging than the bleak future such an opinion forces us to accept. At Open PHENCES, we have embarked on a journey to unmask the positive stories of public and private healthcare collaborations within our county health systems.

By shedding light on these stories, we look forward to seeing more of such partnerships. Although small-scale now, these county-led initiatives have the potential to transform the Kenyan healthcare system within the next five years.

Background: The Linda Mama Health Cover

The Government of Kenya has made large strides in improving maternal and child health (MCH) outcomes among poor, vulnerable, and/or rural populations. Most notable is the free Linda Mama Health Cover spearheaded by the President and First Lady, Her Excellency Mrs. Margaret Kenyatta.

Literally translated to “Protect the Mother”, the Linda Mama programme offers free antenatal care, delivery care, and some post-natal care (post-delivery complications and immunization). The programme aims to increase access to maternal medical care during pregnancy and after delivery, decreasing maternal or infant mortality and other adverse outcomes.

However, many vulnerable women (such as in slums and rural areas) still do not know about the Linda Mama Programme. These women stay away from hospital during pregnancy and delivery, fearing the hefty cost of proper antenatal care. Instead, they rely on Traditional Birth Attendants (TBA) for prenatal care and delivery, when the time comes.

It is against this backdrop that Sikhendu Medical Clinic and St. Raphael’s Medical Centre in Trans Nzoia County began their initiative.

Trans Nzoia County: Sikhendu Medical Clinic and St. Raphael’s Medical Centre

Sikhendu Medical Clinic (a private for-profit) and St. Raphael’s Medical Centre (faith-based organization), both level 3A facilities, decided to leverage the existing TBA network within their coverage area. They enrolled TBAs in the community with the intent of transforming their role to birth companions.

The TBAs’ main task is to map out all women of reproductive age in the community and refer expectant women to either facility for antenatal care, skilled delivery and other post-delivery services. The women are registered with the Linda Mama programme, after which the birth companion is expected to support their compliance with ANC visits, and any other condition that may have been established until delivery.

At the time of delivery, the TBA accompanies the woman to the clinic and assumes the role of birth companion. She will be with the mother throughout the labour process, while midwives or nurses attend to her.

The TBA, a person the mother trusts, serves to provide psychological support and non-medical pain alleviation like back rubs. She assists the mother to walk around and even assists the midwife to position her correctly for easy delivery.

The clinics have identified specific motorcycle riders (popularly called boda boda, who transport people for money) to help transport the women to hospital for delivery and back home.  The registered birth companions are attached to specific riders based on proximity to where the mother lives. The riders’ fees are paid by the clinic through the Linda Mama programme.

After delivery, the birth companion follows up on the woman to ensure she accesses postnatal, child welfare, and family planning services. Registered birth companions have been sensitized on danger signs during pregnancy and post-partum as well as danger signs for the new-born. Therefore, they can assess and refer the woman to hospital promptly in case of any danger.

For every referral (delivery only), the birth companion receives a stipend of KES. 500, also catered for under the Linda Mama cover through NHIF (National Hospital Insurance Fund).

Challenges of the TBA-Maternal Referral Initiative

Thanks to the invaluable contribution of community birth companions, Sikhendu Medical Clinic reports an average of 70 deliveries per month. In 2019, the facility ranked third in the entire Kiminini Sub-County of Trans Nzoia County.

However, there have been challenges that hindered the scaling of this initiative since its inception. The biggest challenge has been delayed payment of the Linda Mama claims to the clinic. This in turn delays payment of the stipends to the birth companions.

The majority of TBAs relied on income from their work attending births. In referring the women to hospital, they essentially give up their livelihood and so they solely depend on the stipend for their livelihood. If their payment is delayed, these women (TBAs) lose the incentive to refer expectant mothers to the clinic, and may resort to their former way of operation.

The outbreak of the COVID-19 pandemic created another significant challenge. Imposition of curfew and movement restrictions made it difficult for mothers and their birth companions to get to the clinic.

To address this challenge, Sikhendu Medical Clinic gave uniforms and identification badges to their registered birth companions and riders. Using their IDs, they moved easily during curfew hours to get expectant women to hospital when they needed medical care.

Teenage pregnancy is another challenge reported in the area. TBAs have inadequate knowledge on adolescent sexual and reproductive health, which limits their ability to handle issues pertaining to teenage expectant mothers.

On average, a third of all deliveries conducted in the clinic involve adolescent mothers (10-19 years). The birth companions feel that if sensitized well on Adolescent Sexual and Reproductive Health (ASRH) matters, they will be better able to support young people in the community to reduce the incidents of early pregnancy.

Conclusion: Collaboration for a Healthier Nation

Despite the challenges reported, the TBAs are grateful for the stipend they receive for their service. One birth companion reported that she used this money to pay school fees for her two children in secondary school. Many reported that the support they receive from the officer in charge of the clinic motivates them to work tirelessly even when there is no payment.

This is only the first of what we expect to be hundreds of stories around small-scale public and private healthcare collaborations throughout the country. We hope that, by highlighting these stories, counties will be able to learn from one another and apply these lessons to improve their own health systems.

Dr. Masibo shares Trans Nzoia Co-creation insights with participants from other counties at the PHENCES co-creation in March 2022