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.