Free maternity care: Is it going up or down, or simply round and round? No one knows

Thursday April 20 2017



In his budget speech this year, Cabinet Secetary Nicholas Rotich touted Kenya’s free maternity programme.

He later “agreed” with “Ms. Cherotich from Baringo County” that we need to “invest more in health, especially in maternal healthcare, to enable women… to give birth with… skilled birth attendants.”

In the past, the administration has taken credit for substantial increases in deliveries with a skilled birth attendant; in 2015, the government claimed that the share of such deliveries had risen from 44 per cent before free maternity to 66 per cent. The 2017/18 budget puts “uptake” of the programme at 77 per cent in 2015/16.

No source is given, but this is close to the figure one gets by taking the 1.2 million births mentioned in Rotich’s speech and dividing it by the 2015 “expected births” in the last Economic Survey: 1.57 million.

However, the 2017/18 budget also puts the target for deliveries handled by skilled birth attendants at just 59 per cent, rising to 63 per cent by 2019/20.

This suggests the budget is rather unambitious on the matter of increasing access to free maternity. As usual, these figures are a confusing morass both across and within documents.

More remarkably, there is no acknowledgement that, in 2015/16, the last full financial year for which we have data, the free maternity programme underspent by Ksh1 billion. This underspending is not explained in any official document.

Perhaps there is a logic here: If our target for 2017/18 is lower than what we achieved in 2015/16, maybe we don’t need all the money the government has put in this programme.

That would also explain why the Ksh4.3 billion set aside in 2017/18 has never been adjusted upward for inflation: It was Ksh 4.3 billion in 2015/16, then fell to Ksh4.1 billion in 2016/17, and now is rising back to Ksh4.3 billion.

The consumer price index has risen by 12 per cent between July 2015 and February 2017 (according to the budget’s statistical annex).

It will rise further by July 2017, when we start implementing the budget. But using 12 per cent, a conservative estimate is that the maternal grant should have risen to Ksh4.8 billion today to be worth what it was in 2015/16.

In any case, the Ministry of Health claims, in its Sector Working Group (SWG) report, that it actually requires Ksh6.5 billion to implement the programme, so it is doubtful that it has too much money.

What would an objective third party observer conclude from all of this? Surely not that free maternity is a priority for the government. And this is to say nothing of the lack of a proper diagnosis of the problem. Free maternity removes user fees at clinics and hospitals.

If that has led to an initial increase in use of facility-based maternal services, but then a plateau (or even a decline, as this data might suggest), then perhaps cost of services is not the binding constraint.

Could it be that women still find the facilities too distant, or too unfriendly to use, or lacking in key staff or equipment? Or is it that the official price is not the final price, after women are charged for supplies, or forced to “facilitate” their care in some way? I see no reflection in official documents (and yes, that includes in the Health Sector Working Group report, before a clever government officer claims otherwise) on these possibilities or what they mean for resolving the issues raised by Ms Cherotich.

I have focused on free maternity here because it is a programme that the government has made a big deal out of since 2013; Rotich said in his speech that it was a “key initiative.” But if this is how a flagship programme is treated — with inconsistent data, lack of clear vision, and apparently underfunded — what should we expect from less high profile programs?

Lest my readers think these challenges are confined to health, let’s examine a proper economic variable: The deficit. The CS said that the budget deficit would fall from 9 per cent of GDP to 6 per cent of GDP in 2017/18.

This sounds good, but in the statistical annex to the budget speech, this year’s deficit is actually estimated to be 10.4 per cent.

Should you find quibbling over 1.4 per cent of GDP petty, it is worth noting how fickle these numbers are: The original budget had a deficit of Ksh775 billion in July 2016. This fell a few months later in the BROP to Ksh618 billion, and then again a few weeks later in the BPS to Ksh548 billion, which was 7.4 per cent of GDP. It is now back up to Ksh743 billion.

Swings of this magnitude in such short periods force us to ask whether we should take any of these numbers seriously.

Jason Lakin is Kenya country director for the International Budget Partnership. E-mail: [email protected]