In a sparsely decorated mud hut in Matungu, a small town in Kakamega county in western Kenya, 26-year-old Esther Echesa was preparing to feed her family ugali. Clothes for her toddlers, Sheila and Bravine, were strung up on a wire stretched from wall to wall. It was a pleasant March morning, and her husband, Hamisi, dressed in a Manchester United jersey, had just returned from market with a small bagful of sardines, to be sprinkled over the thick maize porridge for flavour. The ugali, a Kenyan staple, was to be the family’s only meal of the day. The Echesas cultivate maize, cassava and sweet potatoes on a small patch of land. In a good month, they make as much as 600 Kenyan shillings—about $6—selling some of their crop.
Echesa delivered her firstborn, Sheila, at her parents’ home, assisted by her mother, who had never helped deliver a child before. She told me she had been “afraid to go to the hospital,” because “people say you get beaten up and treated badly.” An international study published in 2014 found that women in labour regularly face rude and violent behaviour—including pinching, slapping and thrashings—from staff at Kenya’s government hospitals. Sheila remained unwell for weeks after the delivery. When Bravine was due, about a year ago, Echesa decided that “I must deliver my second baby in the hospital.” She paid 50 shillings for a ride to the nearest one on a motorcycle taxi.
At the entrance to the hospital’s maternity ward, Echesa was asked a series of questions, mostly to determine her income level. She was identified as a “very poor and needy mother,” and enrolled in OparanyaCare, a conditional cash transfer programme launched last September to improve maternal and child health in Kakamega—Kenya’s second most populous county, with about 1.7 million of the country’s almost 45 million people. By the latest census data, from 2009, Kakamega has a maternal mortality rate of 316 deaths per 100,000 live births—an alarmingly high figure, even if it is lower than the national average of 495. Under OparanyaCare, mothers who deliver at government hospitals are eligible to receive 12,000 shillings, or about $120, in six equal instalments, each conditional on fulfilling certain requirements. The programme is influenced by South Asian schemes that have successfully increased the numbers of women delivering in government health facilities, or under the supervision of trained health workers. But, as experts point out, those schemes have not achieved significant reductions in maternal or infant mortality rates. The provisions of OparanyaCare look to break that pattern, and the programme is a small but telling test of whether the gains of the South Asian schemes can be replicated in East Africa, and whether a modified approach can overcome their limitations.
At the Kakamega county referral hospital, I spoke to Catherine Vugutsa Shiyenji, a 48-year-old nurse who was among the first trained to enroll women in the programme. She sat at a registration desk that was bare except for an Indian training manual on maternal health, with drawings of women in colourful saris. At the start of the scheme, she said, “I was concerned that women and girls will see it as an incentive to get pregnant,” and so would turn away from family planning. “But the effect of the programme surprised me. It ended up assisting the needy.” She was happy that staff now interact with every expectant mother who comes in, and can talk through the issues each woman faces—something they didn’t do before. “The hospital records 25 to 30 deliveries a day,” she said, “while previously it was 10 to 15 deliveries.” Across Kakamega, over 4,500 mothers were enrolled in OparanyaCare in its first six months.
There are challenges in administering the programme. “Most pregnancies in this county are accidents, which works against our targets,” Shiyenji said. Under OparanyaCare, expectant mothers are ideally registered early in their pregnancy, and receive a first payment for making four antenatal visits to a hospital. But “women realise they are pregnant sometimes only after four months, which is well into their second trimester,” Shiyenji explained, and so miss some stipulated visits.
But there seemed to be some flexibility to that requirement. Melissa Nanjira, a 17-year-old mother, gave birth at just about the time OparanyaCare was rolled out. When I met her, also in March, she had received 6,000 shillings—2,000 for delivering in a government hospital; another 2,000, retrospectively, for antenatal visits she did not complete; and 2,000 again for having herself checked up and receiving a dose of vitamin A a month after the delivery.
As per procedure, Nanjira was paid via M-Pesa, a ubiquitous mobile-based money transfer service, using a SIM card issued as part of her registration for the programme. For the third instalment, for instance, shortly after she visited a government clinic, her phone buzzed with instructions for collecting the money due. She headed to an agent in one of the small, green M-Pesa kiosks dotted across Kenya, initiated a withdrawal though a special menu on her device, showed her national identification card, and claimed her cash.
With her daughter now six months old, Nanjira was due to take the baby to a clinic for a dose of vitamin A, so as to qualify for the next payment. To receive the final two instalments, she was to complete a schedule of immunisations for her daughter by the time she reached nine months of age, and then present the child for a further series of check-ups, doses of vitamin A and measles vaccines.
Just before my visit to Kakamega, I visited a zonal UNICEF office in the city of Kisumu, an hour’s drive south of the county and on the shores of Lake Victoria. UNICEF provides technical support and advice on OparanyaCare to the Kakamega government, and I wanted to ask its officials how the programme had taken shape. An initiative to address high maternal and child mortality was first mooted by Kakamega’s governor, Wycliffe Oparanya, who later named the final scheme after himself. Oparanya envisaged providing expectant mothers with formula milk and cash, but UNICEF’s assessments offered a more precise understanding of Kakamega’s situation, and suggested the need for a more carefully tailored solution.
Susan Momanyi, a social-policy specialist in the Kisumu office, told me UNICEF found that as little as 27 percent of deliveries in Kakamega were being handled by trained health workers. Kenya already offered free maternity care, but “it was evident that mothers did not have enough money,” she explained. “With the little they did have, it was cheaper to pay for a traditional delivery at home than pay for transport to visit a facility. On the off chance they did make it to a facility, they seldom took their children back for vaccinations.”
Joanne Bosworth, who heads social-policy work for UNICEF in Kenya, told me over Skype from Nairobi that the organisation started looking for ways to address these behaviours. They considered existing, voucher-based Kenyan schemes to incentivise the use of reproductive health care, but these were too costly. Bosworth’s team started looking at relevant schemes across the world, and zoomed in on a study of maternal health programmes in India, Pakistan, Bangladesh and Nepal.
One programme appeared especially pertinent. “The evidence from India’s Janani Suraksha Yojana showed reduction in neonatal deaths,” Bosworth said, as well as an increase in deliveries conducted by trained health staff. “Which was the main thing we were trying to incentivise in Kakamega.” The Indian scheme offers cash rewards to women who deliver in government health facilities across the country, as a way to reduce financial barriers to accessing institutional care. Currently, it is the largest conditional cash transfer scheme in the world, with over 10 million recipients since it was launched a decade ago. UNICEF suggested a modified approach for Kakamega, using cash to incentivise both institutional deliveries and formal prenatal and postnatal care, and the county government agreed.
For all the promise in the Janani Suraksha Yojana’s approach, though, there’s no guarantee that it will address Kakamega’s crisis of maternal and infant mortality. Abhay Bang, an expert in community health in rural India, pointed me to evidence that though the Indian scheme has significantly raised the number of deliveries at health facilities, the increase hasn’t led to a significant drop in maternal mortality. “In India, institutional deliveries were at 39 percent when JSY was first introduced, and today it stands at 70 percent,” he told me on the phone from Gadchiroli, in east Maharashtra. The increase in institutional deliveries has not led to “a faster decline in maternal mortality rate over and above the declining trend in the previous 15 years,” he said. “This probably is due to the quality of service provided at the healthcare facility.” Simply put, getting more people to health facilities is one thing, and equipping those facilities to treat them adequately is another. Bang also warned of governments’ tendencies to get preoccupied with individual programmes to the detriment of overall health needs.
Bosworth told me that UNICEF is monitoring OparanyaCare’s effectiveness, but it is too early for any certainty over whether the Kenyan programme will face, or overcome, the difficulties of its South Asian counterparts. Echesa, for her part, was thankful for the money she had received, and told me she had already used OparanyaCare money to buy clothes for Bravine and pay for medical expenses for Sheila. But it was scant respite from the family’s desperate poverty. What she would really like, she told me, was “to be part of a scheme that will guarantee employment.” Shiyenji, having spoken to hundreds of women enrolled into OparanyaCare at the Kakamega county hospital, echoed that view. It would be helpful, she said, “to link this programme to a scheme that will help Kakamega’s mothers earn a living, and not cut off the payments when the child is a year and a half.”