Feasibility of Service Delivery Redesign for Improved Maternal and Newborn Survival in Kakamega County, Kenya

Abstract

Maternal and newborn mortality remain high in many low- and middle-income countries despite significant increases in the rate of facility deliveries in these countries. The Lancet Global Health Commission on High Quality Health Systems in the Sustainable Development Goals Era proposed “service delivery redesign” (redesign) as a systems-level approach to improve outcomes. For maternal and newborn health, redesign means all deliveries occur in hospitals that can provide immediate, definitive care for complications while quality antenatal and postnatal care occur in primary care facilities. This would happen along with inter-sectoral investments to ensure quality, improve access and increase demand for quality. Redesign is not just a clinical intervention, but also a political decision to improve population health. This project developed a strategy for and operationalized a feasibility assessment of maternal and newborn health service delivery redesign in Kakamega County, Kenya, the first such feasibility assessment for the new concept. The methodology included consultations with health system stakeholders, assessments in 49 health facilities, 151 health provider surveys and 16 community focus group discussions. Feasibility was assessed along four dimensions: geographic access, hospital infrastructural capacity, human resource capacity and acceptability. The key findings were that: 1) there was a good spread of hospitals in Kakamega County, but there was a challenge with availability and cost of transportation. 2) Maternity beds would need to be increased by a third for redesign, and surgical capacity, blood transfusion services and sick newborn care services would need to be extended to all the earmarked delivery hubs. 3) Current human resource available is only half of the need and the available staff numbers would need to be increased fourfold for redesign. 4) More than 80% of health providers were supportive of redesign. Healthcare users were also supportive of redesign, once respectful, dignified care was assured. The results show a strong base of stakeholder acceptability and infrastructural capacity for redesign, but also identifies health workforce gaps and transportation challenges that need to be addressed. After assessing the evidence, the Kakamega County Government has committed to implementing service delivery redesign, demonstrating the primal role of politics in policy change.