Designing a referral scheme for maternal health in Kenya

In March 2015, Transaid was asked to provide technical support to the MANI project (Maternal and Newborn Health Improvement project in Bungoma County, Kenya) to assess transport barriers to maternal health services as well as design an appropriate referral system to facilitate the transfer of pregnant women from their homes to health facilities. The MANI project is being delivered by a consortium of organisations and other partners including: Marie Stopes International, Options Consultancy Services, AMREF, CARE, the Institute of Health Policy, Management and Research, KPMG IDAS, MannionDaniels, and the Population Council.

The aim of the MANI project is to strengthen core health systems in Bungoma County in Western Kenya and to increase the survival rate of mothers and newborns by enabling poor women to access affordable and quality health services throughout the county.

During a one month project Transaid conducted a transport mapping exercise in a sample of communities in Bungoma to confirm what types of transport are available and what the obstacles to pregnant women using them are. This was followed by a review and strengthening of the initial design of the project that proposed a transport voucher scheme. Transaid also made recommendations for potential innovative transport solutions to be funded through the challenge fund in Bungoma and other similar counties in Kenya.

A combination of qualitative and quantitative data was collected through stakeholder meetings, focus group discussions and individual interviews with key stakeholders. This led to a recommendation to establish an Emergency Transport Scheme (ETS) which would reduce the cost and delay associated with organising transport from the community to the health facility.

The ETS will commence with the recruitment of Boda Boda riders (motorcycle taxis) from each identified Community Unit. Recruitment will be undertaken by a group consisting of community members, Community Health Volunteers (CHVs), Village Elders and local Chiefs. Only riders of good standing, who own their own motorcycle, a license, a phone and helmet will be eligible. With support, these riders will develop strong linkages between communities and health facilities; working with CHVs, ETS riders will become aware of who the pregnant women are, where they live, and when they are expecting to give birth. Riders will get to know the woman and her family so that, if at the time of labour the woman needs to be transported on credit, the ETS rider will do so knowing that he will be able to collect funds later. CHVs will be the liaison person between the pregnant woman, the ETS rider and the health facility.

With agreement from the riders, communities and the riders’ representative association, prices for transporting pregnant women will be fixed at a rate as close as possible to the market rate. A day rate and a night rate will be agreed in order to cease any exploitative pricing by Boda Boda riders for transporting pregnant women. Phone numbers of ETS riders will be shared with communities, and will be available at dispensaries, health facilities and will also be carried by CHVs.

For selected communities in specific Community Units, a Tapered Voucher Scheme (TVS) will be implemented. The TVS will provide vouchers to pregnant women and, for the first 12 months, will cover the whole cost of referral from their community to the health facility. For the second 12 month period the vouchers will cover 50% of the cost of using the ETS to reach a health facility. Frontline SMS (or a similar system) can be used as an SMS platform for managing and verifying the voucher system.

Transaid has a long experience in managing community transport systems. Similar programmes operated by Transaid in Uganda and Nigeria have already highlighted the potential for establishing formalised referral schemes using private sector transport resources. In Kenya, the impact of the proposed approach is expected to achieve a reduction in maternal and stillbirth/neonatal deaths as a result of delays in reaching health facilities.