The Afya Credit Incentive for Improved Maternal and Child Health is a new way of encouraging pregnant women in rural Kenya to attend maternal, newborn and child health (MNCH) services, offering mothers cash payments for every visit.

Tens of thousands of mothers and babies die annually in rural Kenya, many from easily preventable causes. From nutrition support to making delivery safer to prevention of HIV transmission, malaria and other diseases, MNCH services can save lives. All too often, however, poor rural women do not use them and give birth at home with no skilled birth attendant, only seeking medical help when it is too late.

There are many reasons why women miss out on MNCH services, some socio-cultural, some practical, and cash will not solve them, but Caroline Ochieng and Matthew Fielding, the SEI researchers behind the project, believe the Afya scheme could just tip the balance.

How the Afya credits work

On her first visit to the health centre, a mother receives a card worth 1000 Kenyan shillings (around US$11). She can redeem the card for cash at her next scheduled appointment, when she will also receive a new card worth 2000 shillings, redeemable at her next visit, and so on. Women who honour five consecutive appointments receive the highest-value card, worth 5000 shillings (around US$57).

“The cash value goes up each time because one of the biggest challenges is getting mothers to come to the whole course of visits,” says Ochieng. “The later visits – for delivery and then three months after the baby is born – are crucial, not just to complete preventive treatments but also to help with complicated deliveries and make sure the mother and child are doing well.”

Although the Afya scheme is not the first project to “pay” mothers to come to MNCH appointments, most others have offered vouchers for specific goods or services. “We think it’s better to give the mothers control of what they do with the money, because they all have different needs,” says Ochieng. “For example, some might use it to pay for transport to the clinic; others to pay someone to look after their other children when they are giving birth away from home.”

In Kenya, less than half of pregnant women go for the four antenatal care visits recommended by the World Health Organization, and even fewer give birth with a health professional present or attend post-natal follow-up. These problems are particularly acute among the poor rural population, and are one of the reasons for Kenya’s high maternal and neonatal mortality rates.

Looking ahead

The pilot phase of the Afya scheme will take place in Siaya County on the shores of Lake Victoria, a region where the maternal mortality ratio is more than twice the national average. It will explore not only whether the cash incentives raise the number of women attending MNCH visits, but also whether it changes their attitudes, so they go on to use the services in the future even without the incentive. If the model proves successful, the hope is that it can be scaled up to help more women across Kenya. The basic concept could also be adapted for other cases where populations do not readily adopt healthier behaviours and technologies, such as cleaner cookstoves and sanitation.

One of the biggest longer-term challenges for the scheme will be sustainability. The start-up phase of the project (and the cash payments) are being funded by a Bill and Melinda Gates Foundation Grand Challenges Explorations grant. After that, if the Afya scheme has the potential for scaling up, it will need a less donor-dependent funding model. This is likely to be based on trying to establish a self-sustaining market for the cards – as well as its redeemable cash value, each card is also worth 10 “credits”, which could be sold and traded.

“While we hope the Afya system will encourage and enable more mothers to use maternal health services, we’re aware that the problems are not always on the mothers’ side,” says Fielding. “The scheme should be implemented alongside government action to remove some of these barriers, for example improvements in health provision, to make sure the mothers receive high-quality, courteous, private service when they do come in.” The Afya credit incentive scheme may not be a panacea for Kenya’s high maternal and child mortality rates, but could be an important piece of the puzzle.