From free deliveries to detained mothers: The fallout of Linda Mama's scrapping

Politics has taken centre stage in maternal health, with the Kenya Kwanza administration clashing with former President Uhuru Kenyatta over free maternity services.

Speaking on Friday, Uhuru expressed regret that the Linda Mama initiative, which significantly improved the quality of maternal healthcare, was scrapped by President William Ruto’s administration.

“The gains we had in my administration have been eroded. Linda Mama and others have been replaced by new, untried and untested schemes,” he said.

Uhuru said that while the country waits for these experiments to work, Kenyans suffer and progress is retarded.

“In health, our Linda Mama, the removal of maternity fees in our healthcare, brought great improvement in maternal health and reduced mortality rates,” he said.

This debate comes amid public outcry over mothers and newborns being detained in maternity wards across the country for failing to pay delivery fees.

In a quick rejoinder, the Kenya Kwanza administration has defended its approach, saying Linda Jamii, provided under SHA, guarantees women quality care during pregnancy, delivery, and postnatal periods.

Over the weekend, Deputy President Kithure Kindiki said the scope of maternity has been expanded under the Linda Jamii initiative.

Kindiki, who spoke in Dadaab, further dismissed Uhuru’s concerns about scrapping free deliveries, maintaining that it was not abolished but rather is active and has been enhanced under SHA.

“The Linda Mama programme that used to take care of pregnant women has now been expanded through SHA,” said Kindiki.

“It’s no longer just Linda Mama. It protects mothers, the elderly, the youth, and children. We now call it Linda Jamii, not just Linda Mama, because if you only protect mothers and leave out the youth, the elderly, and children, that’s not right.”

But free deliveries have since been scrapped under the Kenya Kwanza administration, which has established the Linda Jamii initiative.

According to the Social Health Authority Act, 2023, every pregnant woman must register as a member of the Social Health Authority Fund (SHIF), and pay annual premiums of 2.75 per cent to enjoy antenatal clinics (ANC), deliveries, and post-delivery care.

The benefits package under SHA includes ANC at Level 2 and 3, deliveries at all levels, and Caesarean Sections (CS) at some Level 3, 4, 5, and 6.

Postnatal care is also offered but only covered at Level 2 and 3.

The Anti-D serum under SHA was increased to Sh6,000, which NHIF did not have. But many women do not access care at Level 2 and 3 facilities, because Anti-D requires monitoring by specialists, who are only available at Level 4, 5, and 6, where ANC is not covered.

The Anti-D serum is an injection given to rhesus-negative mothers to prevent cross-sensitisation of the baby.

Under SHA, Anti-D serum is only covered by SHIF and not PHC, only provided at ANC, and requires specialist monitoring. ANC is not a benefit at hospitals with specialists—Level 4, 5, and 6.

“Anti-D is the only improvement that SHA has brought, different from what NHIF was offering. Women, however, face challenges accessing the service as it is limited to only Level 2 and 3, under ANC,” Rural and Urban Private Hospitals Association of Kenya (RUPHA) chairperson Dr Brian Lishenga explained.

Individuals who did not have NHIF would be moved to Linda Mama. Under NHIF, payment was capped at Sh500.

Fees for normal deliveries were capped at Sh10,000 and Sh30,000 for Caesarean Section (CS).

Under SHA, vaginal (normal) deliveries are offered at all levels and Caesarean Sections at some Level 3, 4, 5, and 6 facilities, provided under SHIF.

“This remitting of premiums is a key bottleneck for maternity services for vulnerable women,” said RUPHA chairman Dr Brian Lishenga in an interview with The Standard.

Additionally, under SHA, ANC and postnatal care are provided under the Primary Healthcare (PHC) Fund at Level 2, 3, and selected Level 4 facilities. The services are limited at some Level 4 and all Level 5 and 6.

There is, however, no direct reimbursement to hospitals, as calculation is done as part of primary healthcare.

“ANC and PNC are falling behind. Patients incur costs due to the PHC funding model and lack of access to the service at Level 4, 5, and 6,” said Lishenga.

Under NHIF, normal deliveries were capped at Sh3,500 at Level 2 and 3, and Sh6,000 at Levels 4, 5, and 6, whereas CS was Sh17,000 in private and faith-based facilities, and Sh10,000 in public hospitals.

The services were free for all Kenyan women with proof of birth in Kenya or citizenship.

Lishenga said the vulnerable and the poor constitute a significant proportion of Kenya. “Economic disenfranchisement of women is still real,” he said.

Linda Mama targeted vulnerable, poor, and needy women.

“There is nothing similar to Linda Mama under SHA,” said Lishenga.

Even as the Kenya Kwanza administration defends the Linda Jamii initiative, shocking cases have emerged of women being detained in maternity wards for failing to clear bills.

Last week, Moi Teaching and Referral Hospital (MTRH) detained more than 26 women who had not cleared their maternity fees.

Some had been held for up to three months, either because SHA had not paid on their behalf, or they had not paid annual premiums.

The women were released after videos of their plight went viral, prompting civil society organisations, including the Machozi ya Mwisho Initiative, to intervene.

A similar situation was reported at Thika Level 5 Hospital, where at least 19 mothers were detained.

“Some of the women detained at MTRH and Thika had not registered for SHA, so it could not pay for them. The real problem is poverty. Many mothers cannot afford even the Sh500 monthly premium,” said Lawrence Omondi, Executive Director and Co-Founder of the Machozi ya Mwisho Initiative.

Omondi expressed concern that among those locked up were teenage mothers, with some held for more than a month.

“In my view, maternity care should be completely free. The level of poverty is too high, and that is why mothers are not registering for SHA,” Omondi said.

At MTRH, some women were sharing beds while others slept on the floor.

Asked about solutions to the challenges facing women in search of maternal health, Director-General for Health, Dr Patrick Amoth, said the Ministry of Health has engaged development partners to secure funding to support mothers who are unable to pay their premiums.

“We have had a shift in health financing architecture, focusing not on an individual but on the entire household. When one is given insurance, it is able to cover the mother, child, siblings, and spouse. We are ensuring that nobody is left behind,” said Amoth.

But he maintained there was no significant difference between the Linda Mama and Linda Jamii initiatives, describing it as simply a change of name.

“So, it is just a change of name, but the resources have increased. Linda Mama used to receive Sh4.2 billion, but now, for primary healthcare services, we have over Sh8 billion this financial year. In addition, we have extra resources under the Emergency Fund,” said Amoth.

He added: “The scope of funding has actually increased compared to what it was before.”

Amoth noted that the Primary Healthcare Fund, which has been allocated Sh8 billion in the current financial year, caters for maternal services including consultations, ANC, and deliveries at primary healthcare facilities, with the money coming directly from the exchequer.

Additionally, the Emergency, Chronic and Critical Illness Fund, according to the DG, also supports maternal care and is fully funded by the government, in addition to indigents’ sponsorship launched by President William Ruto.

“We are working with SHA and healthcare facilities to ensure that no mother is denied services simply because she cannot pay for social health insurance,” said Amoth.

Support, he said, will also be extended to teenage mothers who may lack identification documents.

The Linda Mama programme was introduced in 2016.

Since its introduction, the number of women delivering in hospitals has increased.

Before free hospital delivery, the majority of women from poor households sought help from traditional birth attendants, an issue that contributed to high maternal and infant deaths. For example, in 2008/9, Kenya’s maternal deaths stood at 488 per 100,000 live births.

But even as debates on free deliveries continue, Director of Health Financing at the Ministry of Health, Elizabeth Wangia, told the National Assembly Committee on Health in May last year that only indigent women will be considered for free delivery under SHA.

The committee had questioned why the Ministry of Health had slashed the Linda Mama budget, under the 2024/25 financial year, from Sh4 billion to Sh2 billion.

“As much as Linda Mama will be a stand-alone fund, we will identify pregnant women as provided in the Act. If indigent, they should be assisted to get service,” Wangia explained to Robert Pukose, lead committee chair.