Private hospitals should participate in the free maternity services scheme

Last week I had a discussion with an obstetrician who works with a referral facility in Nairobi about her views on the effect of the free maternity services policy. While the public domain is awash with reports of its success, her account of her experience since the policy came into force is not rosy at all. The doctor who is a specialist in maternal health has been called upon many times to repair torn delivery canal, a rare complication which has now become familiar at the maternity ward. It left us wondering whether the government is ready and willing to tie up all the loose ends to avoid these common bottlenecks that other countries have run into while they experimented with the strategy.

The provision of free maternity services is a politically correct policy, but there is a bit more to it than that. Low delivery in hospital is a multifaceted problem attributed to cost barriers, poor attitude towards public services, geographical inaccessibility, lack of information and poor quality services. The scrapping of user charges for maternity services offered in government facilities cannot address all the aspects of this problem. However, the presidential directive presents a window for stakeholders in the health sector to come together, craft and implement strategies that would translate into reduced suffering and deaths among the mothers who give birth in this country. Which are these potentially vulnerable aspects of this policy?

For one, the decision to exclude the private hospitals, civil society organizations and nursing homes is a conspicuous weakness of the policy as it goes against well known orthodoxy that for universal and equitable coverage for health services to be attained both private and public hospitals should participate. Countries like the Nepal, Taiwan, U.K and New Zealand have successfully adopted a integrated healthcare delivery system. The private and mission hospitals, which account for more than 50% of all hospitals in the country, are equal partners in health services provision in the country and should be treated as such. Under the current implementation practice free choice will be sacrificed as the mother is denied the opportunity to decide whether to give birth from a public, private or mission hospital.

Suppression of free choice will limit the patient power a key driving force for improving the quality of care and patient outcome. As noted by the Kenya Service Provision Assessment Survey (2010), poor quality of care is the single most important reason why majority of our mothers prefer home births. The policy is unlikely to address this concern. It’s devoid of any incentive or disincentive that can influence the behavior of the healthcare workers. Even more detrimental is that the public hospital managers have not been given a free hand to deal with human resources issues that might arise as they attempt to maintain quality in the face of increased demand. Following the new price signals mothers are likely to flock to the public hospitals in search of cheaper services but oblivious of the quality of services to expect. As noted by the Kenya National Union of Nurses (KNUN) the employment of 30 nurses per constituency is a far cry from the actual number required to maintain a fair quality of services.

There is yet another dimension that’s completely missing from the policy; complementary investments. How will the entire health system gain from this new policy? It appears that the policy action is too committal to tax financing which negates potential investments by private providers in maternal health. The financing modality that has been adopted to pay for maternal services will further fragment the healthcare financing landscape and is likely to delay establishment of social insurance in the country which was a strong running point for the current administration. In absence of a significant input by the private sector towards the maternal health program, the government financial support for the initiative will carry a huge opportunity costs and is unlikely to improve in real terms in the future. The centralized planning and provision of maternity services is likely to result in inefficiencies and wastage. There is a good chance that the failure to leverage on the well established NHIF infrastructure for disbursement of funds might result in delays in reimbursement of funds.

While there is no doubt that the policy will benefit clients at the bottom of the pyramid, these omissions might result in suboptimal effects. In the spirit of a people centered approach to health, the Ministry should work with stakeholders to formulate an appropriate legislation and a new implementation strategy. At the very minimum the NHIF and the private hospitals should be accorded the opportunity to play their role. The focus should be on both the mother and the baby. With an intention to improve the quality of maternity services as well as newborn care in the country. To ease the implementation of this policy; the maternity services package to be funded should be defined, the eligibility criteria enumerated and a partnership platform capable of exploiting all the available capacity in the country developed.