Linda Mama: The free service mothers are paying for

BY NATION TEAM

The one thing that stood out in Jubilee’s 2017 manifesto was the healthcare promise to Kenyans: the provision of free maternity services.

The highly-hyped programme was meant to bridge the financial gap that stopped many women from accessing maternity services. The programme was was later transitioned to Linda Mama under the National Health Insurance Fund (NHIF).

Linda Mama was to reach out to women and children from poor backgrounds. Under this package, the government promised to pay Sh6,000 per woman covered. Expectant mothers were entitled to at least four antenatal, delivery and post-natal checkups.

All the women had to do was to register with NHIF and be issued with a card they could use whenever they were seeking the service. The card was to take care of antenatal and post-natal services (six months after delivery). The mother would walk in and walk out with her bundle of joy.

While there were gains in the free maternity area with the reduction of maternal and child mortality, management of the programme has been marred by challenges.

According to the Health ministry, between 2013 – when the free maternity services were introduced - and 2016, slightly above 2.3 million women had benefited from the programme at a cost of nearly Sh12 billion. These women got access to theatre and midwife services, medication, as well as access to free counselling and family planning options.

As a result, hospital deliveries increased from 461,995 in 2012/2013 to 627,487 in 2013/2014. Between 2014 and 2015, about 811,645 women delivered in hospitals free of charge, while in 2015/2016 another 911,959 gave birth under the programme in public facilities, shows data from the ministry.

In addition, user fees, usually paid as registration card charges by patients, were scrapped. There is no doubt, therefore, this plan has significantly reduced maternal mortality, defined as the death of a woman while pregnant or within 42 days of termination of pregnancy.

BUDGET CUT

The war, however, is not won yet as nearly 14 women die from pregnancy-related causes daily, according to the statistics. These deaths are as a result of severe bleeding, infection, hypertensive disorders, obstructed labour, malaria, diabetes, hepatitis and anaemia. Experts attribute this to the shortage of funds, lack of equipment and drugs, and delays by the government to reimburse hospitals that offer free maternity services.

Despite the programme having reduced home deliveries, hospitals have not been able to offer the services optimally due to lack of funds.

A spot check by the HealthyNation team revealed that most of the promises made have not been kept.

For instance, an investigation by our team revealed that none of the women we talked to in different county hospitals was provided with a Linda Mama card and women are paying for post-natal care in most facilities. Public hospitals complained of late disbursement of funds and lower rates of reimbursement for deliveries from NHIF.

So bad is the situation in some hospitals that the mothers are being discharged six hours after giving birth and being asked to pay for basic items because the hospitals are not reimbursed on time.

Mothers are forced to share beds, with up to three sleeping in one bed because of the huge number of women. In some cases, the women opt to sit to give their children sleeping space, despite the risks involved especially for those who deliver through Caesarean section.

The situation has now triggered questions on the programme’s budget.

In the 2016/17 financial year, the government had set aside Sh6 billion to that effect, which was later cut by the Treasury to Sh4.1 billion for the year beginning July, exposing hospitals to a funding crisis. The allocation has since been reduced to Sh3.2 billion.

Jason Lakin, an economist with the International Budget Partnership, terms the reduction trend worrying. Already, hospitals have been complaining that the amount allocated per mother is too low to cater for the services.

QUESTIONABLE RATES

Under the programme, public health centres are supposed to receive Sh2,500 per person, Level 4 and 5 hospitals Sh5,000, and referral hospitals Sh17,500 for both normal delivery and CS.

Reimbursement for private hospitals is set at Sh17,000 for CS and Sh6,000 for normal delivery. “There have been concerns about whether the free maternity grant is big enough and now it’s being cut further. That doesn’t address the concern,” Lakin had earlier said.

In interviews with beneficiaries and the management of hospitals, what came out was that despite the idea being noble, the funding crisis negates the gains made. “I heard about Linda Mama when I gave birth to my secondborn in 2015. It was awesome. I paid nothing,” says Nancy Okumu*

When she was admitted, she was only asked for Sh50 for bookkeeping records. She gave birth through CS.

When she went back to Pumwani Maternity Hospital last year to deliver her third baby, her husband had to buy cotton wool and razor blades. “I thought these were necessities that a hospital should not lack, but being asked to pay means there is something wrong. Thank God I had the money. What of that mother who walks into a hospital without a single cent knowing the hospital will pay for everything?” she asks. “The government needs to relook at the programme if it wants to achieve Universal Health Coverage.”

A senior doctor, speaking on condition of anonymity because of the sensitivity of the matter, says whenever they ask for money from the county, they are told it is illegal to be given cash.

In the previous system, each hospital drew its budget and sent it to the provincial director of medical services. In case of an emergency, the hospital’s medical superintendent would send another budget to the provincial director.
Every cent the hospital collected was deposited into an account, and if the provincial director authorised the release of the money according to the budget the hospital drew, the facility would get a refund.

LINDA MAMA CARD

When HealthyNation contacted NHIF acting CEO Nicodemus Odongo on the late disbursement and low allocation to counties, he blamed the institutional framework. “We normally send the money to counties on time, but this goes to a county revenue account. It is after the counties have appropriated the amount that it is disbursed to hospitals. This is now beyond us,” he said.

The only alternative is for the counties, he said, was to come up with a plan on how the money can be disbursed on time. On the rates, Mr Odongo said they were working with the government rates. “Linda Mama is a government programme and the rates for reimbursement are as per the government policy. There is nothing we can do about this. We give what the government gives us,” he said.

A report released late last year echoes HealthyNation’s findings. The report by Open Society Initiative for Eastern Africa reveals women were discharged prematurely to prevent them from sleeping on the floor due to lack of space. The report was done in Kilifi, Nairobi and Migori counties.

“In all the cases, there was no proper accountability for the flow of resources. Since the reimbursements were not forthcoming, facilities provided poor quality services and lack of basic supplies forced providers to refer clients to private health facilities where they were expected to pay for the services,” states the report.

The report recommends that the reimbursement amount be raised to Sh16,000 for normal delivery and Sh30,000 for CS.

In Kwale and Mombasa counties, expectant mothers are forced to buy items like cotton wool, spirit and razor blades.

An employee of Tiwi Rural Training Centre, who did not wish to be named because he is not allowed to speak to the press, says women are still suffering. Hospitals are not getting money in time and the little they get, is being diverted to other areas, not maternal health, the employee says.

In Mombasa, the situation has triggered an uproar. “When you go to Port Reitz Sub County Hospital for delivery, you must buy gloves, among other essentials. We beg county health officials to come to the ground and see for themselves what we’re going through. We even buy medicine,” says Caroline Oduor, a Changamwe resident.

Mombasa chief health officer Khadija Shikely, however, says the crisis has been worsened by mothers failing to carry their ID cards during hospital visits.

“Women must have their national identification cards to access Linda Mama services. If they come for maternity services without their ID, NHIF will refuse to refund us the money we spend. At the moment, NHIF owes us Sh80 million for just one facility,” he says. “How will we develop if you don’t pay?”

Coast General Hospital, the largest specialized health facility in the region with a capacity of over 700 beds and serving Taita-Taveta, Kwale, Kilifi, Lamu and Tana River, has also seen an influx of patients from Garissa and Mandera counties since the introduction of Lind Mama.

DRUG HITCH

Things are not any easier for those who give birth in private hospitals. “I gave birth at a private hospital in Mikindani and I was forced to pay Sh9,000 despite having the Linda Mama card,” says Lynne Anyango, a mother of one.

In Kisumu, Jaramogi Oginga Odinga Teaching and Referral Hospital CEO Peter Okoth confirms the delays by the government to reimburse money. “When the Universal Health Coverage (UHC) pilot was launched in 2018, reimbursement funds were scrapped. Kisumu is one of the UHC pilot counties,” says Dr Okoth.

The Ministry of Health was to supplement the county health budgets for foregone user fees with Sh877 million for the one year of the pilot. To date, Kisumu has only received Sh418 million.

Emily Anyango, a mother of two, who gave birth at Kisumu County hospital last year says she was asked to buy cotton wool and medicine before her admission.

Prof Judith Miguda, the county executive committee member for Health, blames Kenya Medical Supplies Authority (Kemsa) for the drug hitches in public hospitals. “Kemsa has been a thorn in the flesh. It has not supplied the equipment and drugs needed,” says Prof Miguda.

In Nyeri, mothers at the Nyeri County Referral hospital are also forced to share beds due to a surge in the number of women giving birth there.

According to the hospital medical superintendent Robert Ngunjiri, once the UHC plan was launched, the Linda mama programme ended. “There was some sort of duplication,” he says, adding that mothers, however, do not pay the hospital after delivery.

Mothers in Uasin Gishu County complain they have been forced to buy personal items to use after giving birth. “The beds were limited and we had to share a bed. The programme has, however, made many mothers safe,” says Carol Yator.

Uasin Gishu Sub-County Hospital medical superintendent Peter Okiriamu says they do 120 deliveries per month “This programme has made maternal care accessible,” says Dr Okiriamu.

Their biggest challenge is lack of space and inadequate workers to handle the growing numbers.

In Nakuru, the in-charge of Margaret Kenyatta Mother-Baby Unit at Nakuru Level 5 Hospital says since the launch of the Sh450 million facility, there has been a tremendous increase in the number of patients.

With Linda Mama, the head of the department says the facility has exceeded its bed capacity with over 300 patients admitted.

However, all is not gloom as in Taita-Taveta County, despite the challenges, mothers continue to access free services.

Mary Mwangima, who recently delivered her child at Moi County Referral Hospital in Voi, says she only carried her baby’s essentials and a roll of cotton wool. “I was discharged after one day. I was given enough food and I was never asked to pay anything,” she says.

Another beneficiary from Mwatate, Lucy Mwasaru, says she stayed at Kambi ya Punda hospital for five days after developing post-delivery complications and was discharged without paying anything.

By Angela Oketch, Winnie Atieno, Fadhili Fredrick, Lucy Mkanyika, Irene Mugo, Edith Chepngeno and Phyllis Musasia