How digital transport vouchers are helping women safely deliver their children
In November 2015, Musengy’a, who lives in Ilatu in Makueni County, Kenya, was into her 2nd trimester and was worried whether her impending delivery was going to be alright. While this is normal for any expectant mother, Musengy’a had particular reason to be concerned: she had skipped several antenatal clinics, so knew little about the health of her unborn child.
Her nearest clinic, at Ilatu market, was 10 kilometres away. For many, that does not pose a problem, but for Musengy’a, the cost of transport was a major barrier. A boda boda (motorcycle taxi) to and from the clinic cost KSh 400 (USD 4). Her family did not consider it wise to spend that much money on ante-natal visits rather than other pressing needs, such as food, so antenatal care was not prioritised.
Some of Musengy’a’s neighbours had given birth to stillborn children, and, in some cases, the mother had bled to death. Musengy’a’s husband, a casual labourer, could do little to reassure her. As evening gave way to nightfall, while gazing absentmindedly at the distant Chyulu hills, Musengy’a felt a sense of darkness creep over her. What would destiny hold? She knew she was right to be afraid: in Makueni, 452 in every 100,000 women die in childbirth – one in 200– and only 53% make it to a skilled birth attendant.
Then she came to hear about the work of an organisation called PharmAccess, which was piloting digital transport vouchers for pregnant mothers through Community Health Volunteers (CHV). A voucher qualified you for free transport to one of two health facilities in Makindu sub-county, the Illatu Community Dispensary and Makindu Sub-County Hospital.
Musengy’a decided to enrol for the program – and it helped her to deliver her second baby boy safely.
PharmAccess is a non-profit foundation dedicated to improving access to health care in Africa through innovative financing mechanisms. It mobilizes public and private resources to benefit the health sector through insurance, loans to doctors, clinical standards and quality improvements, private investments and operational research.Financial Sector Deepening, Kenya (FSD) funds its research.
The digital vouchers were part of a digital m-Health wallet developed by PharmAccess and its partners, and carried out in partnership with the sub-county health team. The m-Health wallet allows the customer to pay, save or remit for healthcare purposes only. It also allows third-party payers (such as the county, donors, insurers) to allocate money for healthcare to the beneficiaries’ m-Health wallets. The m-Health wallets’ back-end system, CarePay, provides real-time data on payments, use of health services , and any other data relevant to the donor.
The main objectives of the test were:
1. To evaluate the optimum model and processes for the implementation of the digital transport vouchers
2. To establish whether facilitation of transport to health care facilities results in increased antenatal profiling visits and increased number of skilled deliveries at health facilities.
CHVs working in the county were identified, and the CHVs then recruited a total of 73 pregnant women to participate in the test. The identified mothers enrolled and received the transport voucher on their m-Health wallets. The team also recruited two boda boda (motorcycle taxi) riders, who were trained by Riders Kenya, a private driving school with expertise in defensive riding on bikes with vulnerable passengers.
The CHVs encouraged the pregnant mothers to contact a designated rider to take them to their antenatal visits and for their delivery. The women then paid the boda boda driver using their m-Health wallet voucher.
Initial baseline data among the selected mothers-to-be – asking them, when applicable, where their previous delivery had occurred – indicated that 47% of the mothers registered in the program had previously delivered their children at home.
After the introduction of the m-transport voucher, the number of home deliveries reduced to 20%, and the number of skilled deliveries increased from 53% to 80%. Although these significant gains cannot be fully attributed to digital transport vouchers alone, qualitative surveys conducted after the deliveries suggested that the vouchers contributed greatly.
When interviewed, pregnant mothers said that the reasons they chose to deliver at home were a lack of funds, the long distances involved in health centres, and the negative perceptions of delivering in health facilities.
“We could not afford delivering our child in a health facility”
“The health facility was too far and I could not walk”
‘’ I was informed that mothers are mistreated at the facility so I opted to deliver at home where I would be comfortable”
“I delivered at home because I did not know about the dangers of home delivery”
“My labor pains started all of a sudden thus I did not have time to get to the facility”
Despite the percentage increase of deliveries at the facility, some mothers enrolled in the trial faced challenges when trying to use their transport voucher. The most common reasons for not using vouchers were:
• the birth took them by surprise
• they did not have their phone at the time of birth
• they faced social pressure from family members who did not want them to go to a health facility
Some mothers preferred delivering their children at home, despite having transport vouchers. According to the CHVs, some mothers would lie and say they were not experiencing labour pains so they would not be encouraged to use transport to the facility.
“Unfortunately when I went to the facility for the ANC visits, the expected delivery date that I was given didn’t coincide with when the baby came. At the facility the expected date of delivery was recorded as to be on the 21st February 2016 yet the baby came on the 2nd February 2016.”
“At the time of delivery, my husband who was in custody of the only phone we have at our home was away working as a casual laborer. (…) I really wanted to deliver at the facility. If only I had my own mobile phone then I would have called the boda boda rider and paid to be taken to the hospital and back. This situation has made me feel bad as a woman because just for once I could have experienced facility delivery.”
“Unfortunately during the time of delivery, my husband did not allow me to visit the facility for delivery because he said there was no cash to buy the things needed for the baby while at the facility. I was helped by my mother-in-law during the delivery”.
The availability of the riders (the two riders were sometimes overwhelmed) and lack of choice offered by the riders (some mothers preferred others) were also barriers for some women in using the vouchers.
The main learnings from this small-scale test were as follows:
- 1. Introducing mobile transport vouchers had a direct impact on skilled deliveries (an increase of 43%).
- 2. It is important to give the mother a choice of different transporters (it is not advised to restrict them to a few).
- 3. The transporters need to be managed by a third party to ensure availability and quality of services rendered (e.g. county referral transport).
- 4. Adaptation to a new technology (such as m-Health wallet) takes time and practice; CHVs, transporters and healthcare providers need training so they can show mothers how to conduct transactions.
- 5. Social and cultural barriers, including the perceptions of services at health facilities, need to be addressed to further increase the number of skilled deliveries.
The beneficiaries of the test recognized the benefits of the transport voucher and appreciated the efforts of those who implemented it. These key learnings will now be applied during the larger-scale rollout of the transport voucher scheme in Samburu County.