Seventy-three individuals participated in the study, including 43 women who were pregnant in 2017 (mean age 28), 22 CHVs (mean age 47), and eight health facility managers (mean age 38). Both CHVs and facility managers were predominately female (80%). Five health facility managers were nurses, two were public health officers, and one was a community health extension worker (a formal, paid position based at a facility that includes managing a team of CHVs and is usually trained as a nurse or public health officer), with five working in public facilities and three working in private facilities in 2017. CHVs had a median of 11 years of experience (range seven to 30 years) while health facility managers had a median of four years of experience (range two to 33 years) in their position.
Participants identified several important barriers to maternal and child health care not related to strikes, including cost of care, long distances to and wait times at facilities, understaffing and drug stockouts, and disrespectful maternity care. Decision making related to facility-based care was complex with women making tradeoffs between care at facilities that they thought was of higher quality, particularly in emergencies, and care from traditional birth attendants that was more likely to be compassionate, confidential, and less expensive. Another challenge to maternal and child health care was confusion about costs of services and what services were covered under new initiatives like Linda Mama. In many cases it was unclear to women and even CHVs whether fees charged for various maternal and child health services were legitimate or whether they were informal charges or even bribes to providers. These “everyday” challenges were important factors in shaping care seeking decisions and quality of care, and they existed apart from issues of strikes.
Experiences of maternal child health care during strikes
While “everyday” challenges were important, the majority of participants identified strikes by health care workers as the most significant barrier to maternal and child health care in 2017. Participants said that many pregnant women during the strike could not access or delayed ANC, were less likely to deliver in a health facility, and that women who did were more likely to deliver in private facilities. Some women’s experiences during pregnancy were deeply traumatic and chaotic, including several stories of family members or friends dying in childbirth or losing their child during the strike. As one woman said of her community’s experiences during the strikes, “[they] will be in our memories for a long time to come,” (FGD with women, Group 2, Participant 8). CHVs and health facility managers noted the psychological toll the strikes took on health workers as well, with one facility manager remarking,
“I really suffered as a person because there was so much suffering, and they come to look at you, you are to solve everything…So me, personally I could not even sleep.” Interview with facility manager, Participant 5
Women and CHVs often did not differentiate between health care worker cadres when speaking of strikes, however, there was an understanding that maternal and child health services were “nursing”
duties and were generally not performed by other cadres of health care workers even when nurses were on strike. This made pregnant women especially vulnerable during nurses’ strikes, with several CHVs and health facility managers referencing spikes in maternal and child deaths and mother-to-child transmission of HIV due to decreased utilization of ANC. As one facility manager said,
“The strike really affected people from my community, especially the pregnant mothers because maybe she attended her first ANC visit but when she came back for her second, there was the strike. So, she didn’t come for the third, and she defaulted and never met the fourth ANC visit… There were mothers supposed to deliver in the facility accompanied by their birth attendant, but as soon as they heard of the strike, they opted to deliver at home and [this] really affected [their] health.” Interview with facility manager, Participant 1
Strike-related inequities in maternal child health services
Strike-related barriers to care were not equitably distributed across communities, and participants highlighted that it was poorer women and children who were most negatively affected by strikes since they were less likely to have the resources to access care in private facilities where most services remained operational. Inequities in terms of the impact of strikes on maternal and child health was a major theme – i.e., that the poor were often left completely without access to care during strikes while a better off minority was largely unaffected because they could pay for care in the private sector. As one facility manager said,
“It was hell in the community…Because most people affected are the common ones, the poor ones, the common “mwananchi,” [they] are the most affected because you will find the fairly well-off people are able to access services elsewhere. But now you find the local community suffers the most,” Interview with facility manager, Participant 8
Participants also highlighted the significant economic impact on some patients and communities from payments for care that had the potential to push families deeper into economic insecurity and poverty. One CHV described strikes as “creating poverty” because sick family members could no longer work, and households spent livelihoods and savings to access care in private facilities:
“The strike came and even created poverty in the community because now the person is sick, they take their land and they lease, they lease the land even when the person lives there, there is no food at home, children are unable to go to school. This thing largely affected [the community].” FGD with CHVs, Group 2, Participant 2
Relational dimensions of strikes in the health system
Another major theme that emerged was how strikes impacted key relationships in the health system, including patient-provider and community-CHV relationships. Health facility managers and CHVs spoke at length about their efforts to build relationships and trust with communities that were essential to improving maternal and child health services and affecting decisions about care seeking, particularly for pregnant women. Strikes by health care workers strained and sometimes severed these relationships between the community and health system. As one facility manager put it,
“When you work in a hospital, you create a relationship with the community…but when there is a strike, they don’t understand why you cannot assist…they tend not to trust us again…It really affected me. We have invested so much in community health…but because of the strike the relationship that we had built was broken, [and mothers] went back to the traditional birth attendants.” Interview with facility manager, Participant 7
CHVs felt they were put in impossibly difficult situations during strikes, receiving little guidance from their supervisors about what services remained open and directions for referring patients to care. One CHV described their experience with a woman who was delivering during the strike, saying,
“I had to take the responsibility of taking her to a Mission hospital, but I was told by the doctor in charge that there were no free services and we had to pay at least some money. Since I wanted to help her, I had to use my own money so that she could deliver safely… I had to help her because the community trust in me. When I help them in good and bad times, they will continue trusting in me just the way she did.” FGD with CHVs, Group 1, Participant 2
Strategies for maternal child health care during strikes
There were no coordinated strategies at the County or national level that participants identified to keep maternal and child health services in the public sector operating during the 2017 strikes or to make services in the private sector accessible. Participants described ad hoc efforts often led by individual health care workers, CHVs, and by communities themselves. For health facility managers, this included waiving fees and hiring more staff at private (mostly faith-based) facilities, coordinating services, referrals, and supplies between public and private facilities, and delivering services at public facilities in secret or outside of the facility. For communities and CHVs, this often meant raising money or using their own money to pay for services for family members, friends, and community members.
Health facility managers and CHVs alluded to several strategies that could mitigate the negative impact of strikes in the public health sector, including for maternal and child health services. Several health facility managers suggested more formal links between public and private health facilities be established, and that this coordination could help in sharing resources across institutions and referring patients during times of crisis like strikes. CHVs advocated for more formal training and coordination so that they could better support their communities during strikes. Additional strategies to prevent future strikes included policy reforms to revert management of human resources back to the national government and addressing issues of corruption in the health system.
Perspectives on the legitimacy of strikes by health care workers
Participants expressed mixed feelings in terms of the legitimacy of recent strikes by health care workers. Some women and CHVs supported health care workers in their fight for “what was rightfully theirs” (FGD with women, Group 2, Participant 3), and believed they were fighting to ultimately improve the public health system and not just serving their own interests. Others were skeptical of striking health care workers for a variety of reasons, including health care workers “valuing money more than lives” (FGD with women, Group 3, Participant 3) and suspicions that physicians in particular benefitted because they owned private hospitals and clinics that profited from increased demand during strikes.
Several CHVs used the opportunity in discussions about strikes by health care workers to highlight their own challenging work environments, that their work was not adequately valued in the health system, and that they should be formally employed and paid by the government. As one CHV said,
“The CHVs are the people who work at the ground and yet those who are paid are in the offices. We walk around villages looking for those who have defaulted medications, and pregnant mothers who need to start their ANC visits... The government should recognize our work as CHVs and they should omit the V in Community Health Volunteer and replace it with the W to be Community Health Workers as it used to be…So, you need to remember us, because we are like your pillars. If we collapse, then you will also collapse.” FGD with CHVs, Group 1, Participant 2