International Journal of Current Business and Social Sciences IJCBSS Vol.1, Issue 3, 2015

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1 IMPLEMENTATION OF FREE MATERNITY SERVICES POLICY IN KENYA: HEALTH WORKERS ATTITUDE AND INVOLVEMENT Author: Emmanuel Wekesa Wamalwa Co-authors: Ben Osuga, Maureen Adoyo CITATION: Emmanuel Wekesa Wamalwa. (2015). Implementation of Free Maternity Services Policy in Kenya: Health Workers Attitude and Involvement. International Journal of Current Business and Social Sciences, 1 (3), ISSN w w w. i j c b s s. o r g 240 ISSN

2 ABSTRACT Kenya has a high maternal mortality rate. Free maternity services program was implemented to improve access and utilization of maternal health services and ultimately improve maternal health. The implementation of the policy in Kenya was done through a top-down approach, with health workers being called upon to implement the formulated policy. Evidence shows that involvement of health workers is critical for ownership and successful implementation of the policy. There is no evidence of involvement of Kenyan health workers before implementation of the policy. This study was carried out to determine the involvement of health workers in the policy process as well as their attitude towards the policy. The study was conducted in Nakuru County at the Rift Valley Provincial General Hospital and Bondeni Maternity. All health workers at Bondeni Maternity and all health workers at the Maternity Unit of the Rift Valley Provincial General Hospital were included in the study. The objective of the study was to determine the level of involvement of health workers in policy process and the attitude of health workers towards free maternity services policy. This was a descriptive cross-sectional study. A census was used to select the respondents from the sampled facilities. A total of 110 respondents were sampled and a 90.9 response rate was achieved. The study found that the policy was popular among respondents with 80% reporting that the policy was necessary and 72% reporting they like the policy. All respondents (100%) indicated that they were not involved in any way in the formulation of the policy. Majority of respondents knew about the policy through the media. There was a significant difference in attitude between the two facilities (p=0.008). The study concluded that health workers like the policy but they were not involved in formulating it. Their lack of involvement may hinder successful implementation of the policy. Key Words: policy, free maternity services, health worker s attitude, health worker s involvement. INTRODUCTION Pregnancy-related complications are a leading cause of death among women in the reproductive age (15 49 years) in developing countries (Witter et al, 2009). Reducing maternal mortality and reaching the Millennium Development Goal (MDG) 5 target by 2015 has proved challenging for Kenya. According to the Kenya Demographic and Health Survey (KDHS) report, the national maternal mortality ratio is 488 per 100,000 live births. Delivery under skilled birth attendant is seen as one of the crucial ways of reducing maternal mortalities. However, many factors can influence the rate of skilled birth attendants including the cost of care which, especially for emergency obstetric care can be catastrophic for households (Campbell & Graham, 2006). About 43 percent of births in Kenya take place in a health facility while 53 percent of deliveries take place at home (KNBS & ICF Macro, 2010). Ensuring all women give birth with a skilled birth attendant and access to emergency obstetric care is accepted as the most crucial intervention for reducing maternal and newborn deaths (Campbell & Graham, 2006). Unfortunately, studies have shown that this strategy is largely hampered by user fees in low and middle income countries. Findings of studies on exemption policy in Ghana confirmed that introduction of free delivery care policy is associated with an increase in facility deliveries (Dzakpasu et al, 2012). Many w w w. i j c b s s. o r g 241 ISSN

3 other low and middle-income countries have initiated user fees exemption policies as a method of increasing financial access to health care. The Government of Kenya rolled out free maternity services program on 1st June, 2013 to encourage women to give birth at health facilities under skilled personnel. This was in keeping with the resolutions of the African Union favoring pointof-service user fees exemptions for pregnant women and children under the age of five years (African Union, 2010). The policy aims at reducing maternal complications as well as maternal mortality by increasing access and utilization of maternal health services. The program is meant to eliminate all the charges for intra-partum care in public health facilities. The success of the policy depends on successful implementation which is greatly influenced by health workers who are the policy implementers. Involvement of health workers is critical of successful implementation as evidenced by findings from countries who have implemented such a policy (Campbell et al, 2009). Health workers attitude also influences their motivation to implement the policy. There is no evidence of involvement of health workers in the policy process before it was implemented in Kenya. The objective of the study was therefore to determine the involvement of health workers in the policy process as well as their attitude towards the policy. The findings of this study will help improve the implementation of the current policy and inform approach to implementation of such policies in future. Statement of the Problem The maternal mortality rate for Kenya is considered to be high. According to Kenya Demographic and Health Survey (2009), the maternal mortality rate for Kenya is 488 per 100,000 live births. Successful implementation of free maternity services policy will lead to an increase in the proportion of deliveries under skilled personnel and ultimately lead to a decrease in maternal and neonatal morbidity and mortality. It is however recognized that the success and realization of the benefits of such a policy is largely determined by its implementation. Effective implementation of user fee exemption policies requires involvement of frontline providers. The implementation of the policy of free maternity services in Kenya was done in a top-down approach, with health workers being called upon to implement the policy that was formulated at the national level. The health workers who implement the policy largely determine the success of the implementation of the policy. However, there is no evidence of involvement of health workers in policy formulation and planning. This study aims determining the involvement of health workers in the policy process and their attitude towards the policy. General Objective The study was carried out to obtain the perspective of the health workers regarding the free maternity services policy in Kenya with the aim of improving its implementation. Specific Objectives To determine the level of involvement of health workers in the implementation of free maternity services policy. To determine the attitude of health workers towards the free maternity services policy. w w w. i j c b s s. o r g 242 ISSN

4 LITERATURE REVIEW Involvement of Health Workers in the Policy Process In top-down approach to policy implementation, the health workers are only involved in the implementation of the policy. However, some investigators observe that through dialogue and active engagement of implementers, good ideas can be elicited on how to implement policy effectively as well as enhance the acceptability of the new policy and maintain morale (Osborne & Brown, 2005). Evidence on the removal of, or exemption from, user fees confirms the need to focus on human resources for health, ensuring that health workers are engaged in the implementation arrangements (Campbell et al, 2009). For instance, user fee exemption policy was implemented in Burundi with minimal involvement of frontline managers. It was largely a political agenda, without the involvement of technicians. The results were unsuccessful implementation and failure to realize intended outcomes (Nimpagaritse & Bertone, 2011). Investigators such as Witter and Adjei (2007) have therefore recommended a more participatory approach and wider discussions with all actors, including those in the field as a better way to formulate and implement policies and reforms. The implementation of the policy of free maternity services in Kenya was done in a top-down approach with health workers being called upon to implement a policy formulated at central level. This study therefore sought to bring the views of the health workers into the policy process by obtaining their views on possible barriers and implementation strategies that will contribute to the success of the policy. Health Workers Attitude towards User Fee Exemption Policies Some studies concerning health sector reform have focused on the effect of front-line workers behavior in the policy implementation process with a number of studies focusing on different aspects of this area. A study done in Burundi recommended that political leaders should better involve technicians and frontline actors in the preparation of such radical reforms. Those peripheral actors usually have information on system functioning and health facility management that can effectively guide the implementation of the reform (Nimpagaritse and Bertone, 2011). A study on street-level bureaucracy in South Africa showed that while nurses supported the broad policy principles in free care policy, implementation of the policy had significant negative professional and personal consequences for them (Walker & Gilson, 2004). A study done in Ghana by Witter et el (2007) reported that health workers motivation to implement such policies included opportunity to serve the community (66%), social status attached to the profession (8.3%), opportunities for training (4.3%) and allowances (3.8%). In Burundi, health workers were on one hand professionally motivated as the policy allowed them to treat patients for free and contribute to the health of the population. On the other hand, they were frustrated by the few patients who take advantage of the system (such as women who arrived at the hospital two weeks before their due date), by the increased administrative workload and the reduction of financial resources available to purchase necessary items such as drugs, recurrent and capital equipment (Nimpagaritse and Bertone, 2011). A study in Afghanistan showed that health workers workload increased after removal of user fees. The morale of the health workers reduced due to loss of discretionary revenue (Steinhardt et al, 2011). Similar findings were noted in Niger (Ridde and Diarra 2009). w w w. i j c b s s. o r g 243 ISSN

5 Theoretical Framework The underpinning theory of policy analysis offers two main theoretical approaches: top-down and bottom-up perspectives. Top-down approaches see implementation as a rational process that can be pre-planned and controlled by the central planners responsible for developing policies. The requirements of implementation are presented as a generalized list of conditions, which if met, will enable effective implementation (Hogwood and Gunn, 1984; Sabatier and Mazmanien, 1979). Implementation failure, seen as the gap between policy objectives and achievements, is, therefore, the result of failing to plan adequately for implementation. Meessen (2009) noted that a top-down process can be a frustrating experience for technicians and can lead to multiple challenges in the implementation stage. The bottom-up perspective (Hjern and Porter, 1981), however, sees policy change as a much more dynamic and interactive process. This perspective emphasizes the need to understand implementation systems and the actors responsible for implementation in order to understand why policies do not achieve expected outcomes. The gap between objectives and outcomes is a demonstration of how policy is re-created through the process of implementation, rather than an implementation failure (Hill, 1997). Bottom-up theories are generally judged to have particular relevance to the delivery of social services, such as health care, because those providing these services must have discretion in taking decisions that allow them to respond effectively to variable client needs (Rothstein, 1998). Michael Lipsky (1980) termed such providers Streetlevel Bureaucrats. In the 1970s, Michael Lipsky coined the term street-level bureaucracy to denote bureaucratic public service organizations that deal face-to-face with citizens or clients. Bureaucracy, as defined by Weber, refers to a hierarchical organizational structure designed rationally to coordinate the work of many individuals in the pursuit of large-scale administrative tasks and organizational goals (Slattery, 2003). Consequently, the term street-level bureaucrats refers to all frontline workers within such organizations who interact with citizens in the course of their jobs, and who have substantial discretion in the execution of their work (Lipsky, 1980). Streetlevel bureaucrats work within tightly scheduled and fragmented systems that often do not allow enough time to sufficiently deal with the needs of clients and, due to a lack of continuity, frequently do not support workers to take responsibility for their clients. Examples of street-level bureaucrats are teachers, social workers, police officers and healthcare workers. Lipsky (1980) and Prottas (1979) argue that the organizations that employ these workers possess significant similarities which shape both the processes through which they conduct their work and the dilemmas they face in attempting to fulfill the competing demands of the organizations and their clients. These demands, to provide services efficiently to a large number of people, while also providing individualized attentive service, form what Lipsky (1980) deems the fundamental service dilemma of street-level bureaucracies. The major concern for the street-level implementer is how to control the stress and complexity of day-to-day work. Out of this concern grows a whole range of informal routines that students of street-level bureaucracy call coping mechanisms (Elmore, 1978). Lipsky (1980) argues that these practices of street-level bureaucrats effectively become public policy, rather than the intentions or objectives of documents and statements developed at a central level. According to this theory, implementers have a crucial role of determining the final outcome of the policy. Even w w w. i j c b s s. o r g 244 ISSN

6 with this recognition, few studies have examined the influence of implementers over policy change (Atkinson, 1997). Conceptual Framework Independent Variables Health workers attitude towards the policy Involvement of health workers in the policy formulation and implementation planning Dependent Variable Effective implementation strategies MATERIALS AND METHODS Study Design A descriptive cross-sectional study design was employed in this study. Study Area and Population The study was conducted in two health facilities in Nakuru County (The Rift Valley Provincial General Hospital and Bondeni Maternity). The target population was the health workers who are involved in implementation of the policy. They included doctors, clinical officers and nurses. All the health workers who are stationed at the maternity unit of the Rift Valley Provincial General Hospital were included in the study. All the health workers in Bondeni Maternity were included in the study. The Medical Superintendent in charge of the Rift Valley Provincial General Hospital as well as the Nursing Officer in charge of Bondeni Health Center were also included in the study as key informants. Sampling Purposive sampling was used to sample the facilities for the study. The Rift Valley Provincial General Hospital was purposely sampled because it is the largest and main referral hospital in Nakuru County, offering comprehensive obstetric care. Bondeni health center was purposely w w w. i j c b s s. o r g 245 ISSN

7 sampled because it is one of the largest health centers in the county recording the highest number of deliveries compared to other health centers. Only public health facilities were included in the study because the policy is meant to be implemented in public health facilities. A census was used to select the respondents from the sampled health facilities. All the health workers who are stationed at the maternity unit of the Rift Valley Provincial General Hospital were included in the study. All the health workers in Bondeni Maternity were included in the study. The Medical Superintendent in charge of the Rift Valley Provincial General Hospital as well as the Nursing Officer in charge of Bondeni Health Center was also included in the study as key informants. The sample size comprised of 110 respondents obtained from the two health facilities. Health Workers Rift Valley Provincial General Hospital Bondeni Maternity Total Sampled Total Sampled Doctors 12 (12.8%) 12 (12.8%) 0 (0%) 0 (0%) Clinical Officers 19 (20.1%) 19 (20.1%) 0 (0%) 0 (0%) Nurses 62 (66%) 62 (66%) 15 (93.8%) 15 (93.8%) Personnel Incharge 1 (1.1%) 1 (1.1%) 1 (6.2%) 1 (6.2%) of facility TOTAL 94 (100%) 94 (100%) 16 (100%) 16 (100%) Data Collection and Analysis The data was collected from 22 nd April, 2014 to 23 rd May, Questionnaires were used to collect data from all the respondents except the key informants. An interview guide was used to conduct interviews on key informants. Analysis of the data was done using SPSS software and Microsoft Office Excel. The degree of association between responses from the two facilities was tested at 95% confidence interval with a p-value of <0.05 being taken as significant. Logistical and Ethical Considerations The codes were used to identify respondents and their identity remained withheld. Consent was obtained from all the study participants. Ethical Clearance to carry out the research was obtained from Kenya Methodist University s Board of Scientific and Ethics Review Committee. A written permission to conduct the study at the Rift Valley Provincial General Hospital was given by the Medical Superintendent following perusal and approval by the research committee of the facility. A written authorization to conduct the study at Bondeni Maternity was given by the Nakuru County Director of Health. Characteristics of Respondents RESULTS w w w. i j c b s s. o r g 246 ISSN

8 A total 100 (91%) respondents participated in the study out of the sampled 110, giving an overall response rate of 91%. The respondents included doctors, clinical officers and nurses from the Rift Valley Provincial Hospital and Bondeni Maternity. Majority of the respondents were nurses, accounting for 72% (n=72) of all the respondents. This is because majority of the maternal health services in health facilities are offered by nurses. Majority, 85% (n=85) of the respondents were females. This is because majority of the respondents were nurses who were female. Regarding the experience of the respondents in the provision of maternal health services, majority, 48% (n=48) had the experience of more than five years. Others had an experience of 1-5 years (29%) and less than one year (23%). Attitude of Health Workers towards Policy The attitude of the health workers greatly influences the implementation of the policy. Majority of the respondents, 80% (n=80) indicated that it was necessary to introduce such a policy in Kenya. Likewise, majority of the respondents, 72% (n=72) indicated that they like the policy while others (13%) indicated that they do not like the policy. Table 2: Differences in attitude between the staff of the two facilities Facility p-value Nakuru PGH BondeniMaternity 66 6 I like the policy (79.5%) (46.1%) 11 2 I don't like the policy (13.3%) (15.4%) Not sure (7.2%) (38.5%) Total There was a significant difference between the two facility on how the staff regarded the policy of free maternity services in general (p=0.008). In Nakuru PGH, 79.5% (n=66) of the respondents liked the policy of free maternity as compared to 46.1% (n=6) of the respondents in Bondeni Maternity. Only 7.2% (n=6) of staff in Nakuru PGH said they were not sure about the policy compared with 38.5% (n=5) of staff in Bondeni Maternity (100%) (100%) Regard for policy Health Workers Involvement in the Policy Process Health workers involvement in the policy process helps to achieve ownership of the program and better implementation. There was no documented evidence of involvement of health workers in the policy process, before the policy was implemented. This study sought to determine the involvement of health workers in the policy process. All the respondents, 100% (n=100) reported that they were not involved in any way in the policy process. The opinion of the health workers on how the program should be formulated and implemented was not sought. However, all health workers (100%) indicated that there is need for health workers to be involved in formulation and implementation of such policies in public health facilities. w w w. i j c b s s. o r g 247 ISSN

9 The free maternity services policy was implemented in a top-down approach. The health workers were called upon to implement the policy already formulated at central level. Majority of the health workers (73%, n=73) received communication regarding the policy through the media and only 25% (n=25) received official communication regarding the policy for instance through their supervisor. In addition, 2% (n=2) of the respondents received communication regarding the policy from colleagues and workman. Source Through official communication from supervisor Through the media Through colleagues and workmates (informal) Through community members TOTAL Frequency 25% (n=25) 73% (n=73) 2% (n=2) 0% (n=0) 100% (n=100) The data collected above indicates a large percentage of the respondents (73%) came to know about the policy on free maternity through the media, 25% through official communications from their supervisors and 2% from informal sources including colleagues and workmates. DISCUSSION The study found that majority of the health workers (72%) like the policy and only 13% did not like the policy of free maternity services. Likewise, 80% of the respondents indicated that it was necessary to introduce such a policy. This implies that the health workers regard as a good intervention to improving maternal health in Kenya. It also implies that given the necessary support, health workers are likely to be committed to policy implementation. These findings are consistent with evidence from other countries who have implemented such policies. That health workers support implementation of user fee exemption policies as an intervention to improve affordability of healthcare. However, issues such as loss of revenue and increased workload may cause frustrations among health workers. For instance in Burundi, health workers were motivated to implement the user fee exemption policy. However, they were frustrated by the few patients who take advantage of the system (such as women who arrived at the hospital two weeks before their due date), by the increased administrative workload and the reduction of financial resources available to purchase necessary items such as drugs, recurrent and capital equipment (Nimpagaritse and Bertone, 2011). A study conducted in Afghanistan showed that the morale of health workers reduced following implementation of user fee exemption policy due to loss of discretionary revenue (Steinhardt et al, 2011). Similar findings were noted in Niger (Ridde and Diarra 2009). A study on street-level bureaucracy in South Africa showed that while nurses supported the broad policy principles in free care policy, implementation of the policy had significant negative professional and personal consequences for them (Walker & Gilson, 2004). This evidence suggest that although health workers support implementation of user fee exemption policies, implementation challenges can cause loss of morale and frustrations which can negatively affect the policy implementation. Implementation of free maternity services policy in Kenya was done in a top-down approach, with health workers being called to implement an already formulated policy. This is evidenced by the study findings that all the health workers (100%) were not involved at all in the w w w. i j c b s s. o r g 248 ISSN

10 formulation of the policy. This approach differs from the recommendations of previous investigators who recommended a bottom-up approach of policy implementation for health care services (Rothstein, 1998). Evidence from other countries shows that failure to involve health workers in formulation of such policies can potentially lead to implementation failure. For instance, user fee exemption policy was implemented in Burundi with minimal involvement of frontline managers. It was largely a political agenda, without the involvement of technicians. The results were unsuccessful implementation and failure to realize intended outcomes (Nimpagaritse & Bertone, 2011). The study further found that majority (73%) of the respondents knew about the policy through the media. This is an indication of minimal involvement of health workers in the policy formulation process. It implies that there was no evidence of formal discussion between the policy makers and the policy implementers at the time of commencement of implementation. Conclusion Regarding involvement of health workers in the policy process, this study concludes that health workers were not involved in the formulation of the free maternity services policy, but were called upon to implement a policy already formulated at central level. Lack of involvement of health workers may lead to lack of policy ownership and may be a source of implementation challenges. On health workers attitude towards the policy of free maternity services, this study concludes that majority of health workers found the policy necessary and they liked the policy in general. The health workers are likely to be committed to policy implementation if motivated to do so. Recommendations The study recommends that health workers should be motivated to implement the policy of free maternity services in Kenya. The National Ministry of Health should seek the views of health workers on various implementation issues since the implementers are better placed to understand the challenges and offer solutions. This can be done through the various stakeholder forums. In addition, feedback channels can be created to obtain feedback from health workers (implementers) regarding implementation progress and challenges. This will ensure that implementation challenges are minimized and the policy is implemented successfully. REFERENCES w w w. i j c b s s. o r g 249 ISSN

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