ObjectivesTo examine the determinants of the continuum of maternal care from an integrated perspective, focusing on how key components of an adequate journey are interrelated.DesignA facility-based prospective cohort study.Setting25 health facilities across three counties of Kenya: Nairobi, Kisumu and Kakamega.ParticipantsA total of 5 879 low-income pregnant women aged 13–49 years.Outcome measuresOrdinary least squares, Poisson and logistic regression models were employed, to predict three key determinants of the continuum of maternal care: (i) the week of enrolment at the clinic for antenatal care (ANC), (ii) the total number of ANC visits and (iii) utilisation of skilled birth attendance (SBA). The interrelationship between the three outcome variables was assessed with structural equation modeling.ResultsEach week of delayed enrolment in ANC reduced the number of ANC visits by 3% (incidence rate ratio=0.967, 95% CI 0.965 to 0.969). A higher number of ANC visits increased the relative probability of using SBA (odds ratio=1.28, 95% CI 1.22 to 1.34). The direct association between late enrolment and SBA was positive (odds ratio=1.033, 95% CI 1.02 to 1.04). Predisposing factors (age, household head’s education), enabling factors (wealth, shorter distance, rural area) and need factors (risk level of pregnancy, multigravida) were positively associated with adherence to ANC.ConclusionThe results point towards a domino-effect and underscore the importance of enhancing the full continuum of maternal care. A larger number of ANC visits increases SBA, while early initiation of the care journey increases the number of ANC visits, thereby indirectly supporting SBA as well. These beneficial pathways counteract the direct link between enrolment and SBA, which is partly driven by pregnant teenagers who both enrol late and are at heightened risk of complications, stressing the need for specific attention to this vulnerable population.

The outbreak of coronavirus disease (COVID-19) challenged the care-seeking behavior of expectant mothers and their access to quality health care. MomCare, a digital care bundle that links mothers-to-be with care providers and payers, quickly adapted and provided a suite of support services throughout the pandemic.n Maintaining or improving care-seeking behaviors and quality of care for MomCare platform users shows how public health practitioners can promote interactive, patient-driven technology that can quickly link payments with patients and providers to support and empower mothers-to-be in times of crisis.

The COVID-19 pandemic has painfully exposed the constraints of fragile health systems in low- and middle-income countries, where global containment measures largely set by high-income countries resulted in disproportionate collateral damage. In Africa, a shift is urgently needed from emergency response to structural health systems strengthening efforts, which requires coordinated interventions to increase access, efficiency, quality, transparency, equity, and flexibility of health services. We postulate that rapid digitalization of health interventions is a key way forward to increase resilience of African health systems to epidemic challenges. In this paper we describe how PharmAccess' ongoing digital health system interventions in Africa were rapidly customized to respond to COVID-19. We describe how we developed: a COVID-19 App for healthcare providers used by more than 1,000 healthcare facilities in 15 African countries from May–November 2020; digital loans to support private healthcare providers with USD 20 million disbursed to healthcare facilities impacted by COVID-19 in Kenya; a customized Dutch mobile COVID-19 triage App with 4,500 users in Ghana; digital diaries to track COVID-19 impacts on household expenditures and healthcare utilization; a public-private partnership for real-time assessment of COVID-19 diagnostics in West-Kenya; and an expanded mobile phone-based maternal and child-care bundle to include COVID-19 adapted services. We also discuss the challenges we faced, the lessons learned, the impact of these interventions on the local healthcare system, and the implications of our findings for policy-making. Digital interventions bring efficiency due to their flexibility and timeliness, allowing co-creation, targeting, and rapid policy decisions through bottom-up approaches. COVID-19 digital innovations allowed for cross-pollinating the interests of patients, providers, payers, and policy-makers in challenging times, showing how such approaches can pave the way to universal health coverage and resilient healthcare systems in Africa.

Maternal and neonatal mortality rates in many low- and middle-income countries (LMICs) are still far above the targets of the United Nations Sustainable Development Goal 3. Value-based healthcare (VBHC) has the potential to outperform traditional supply-driven approaches in changing this dismal situation, and significantly improve maternal, neonatal and child health (MNCH) outcomes. We developed a theory of change and used a cohort-based implementation approach to create short and long learning cycles along which different components of the VBHC framework were introduced and evaluated in Kenya. At the core of the approach was a value-based care bundle for maternity care, with predefined cost and quality of care using WHO guidelines and adjusted to the risk profile of the pregnancy. The care bundle was implemented using a digital exchange platform that connects pregnant women, clinics and payers. The platform manages financial transactions, enables bi-directional communication with pregnant women via SMS, collects data from clinics and shares enriched information via dashboards with payers and clinics. While the evaluation of health outcomes is ongoing, first results show improved adherence to evidence-based care pathways at a predictable cost per enrolled person. This community case study shows that implementation of the VBHC framework in an LMIC setting is possible for MNCH. The incremental, cohort-based approach enabled iterative learning processes. This can support the restructuring of health systems in low resource settings from an output-driven model to a value based financing-driven model.

Background: Maternal and neonatal mortality rates in many low- and middle-income countries (LMICs) are still far above the targets of Sustainable Development Goal (SDG) 3. Value-based healthcare (VBHC) could potentially surpass traditional input-oriented approaches to create a high-quality health system and to improve maternal, newborn and child health (MNCH) outcomes. This paper describes the implementation of VBHC in urban and rural Kenya with the aim to significantly improve MNCH outcomes.Methods: We developed a theory of change (ToC) and used an incremental cohort-based implementation approach to create short and long learning cycles along which different components of the VBHC framework were introduced and evaluated. We sought to leverage local resources and used a mobile phone-based platform to support pregnant women and MNCH providers throughout the patient journey, using the system for communication, payment and data collection. We created dashboards and used interviews and focus group discussions to gather feedback and to collect the data to describe the implementation process in this paper.Results: We implemented all elements of VBHC, starting small and expanding cohort by cohort. Short and long learning cycles between cohorts enabled implementation of the framework in a relatively short time frame. Data on outputs and outcomes show that the VBHC framework had impact on three levels: Mothers’ improved adherence to maternal healthcare, incentivizing providers to improve quality of care, and transparency of outcomes and costs. This paper describes the implementation process and while the evaluation of health outcomes is ongoing, first results show improved adherence to evidence-based care pathways at a low cost per enrolled person.Conclusion: This study has shown that implementation of the VBHC framework in an LMIC setting is possible with some adaptations to the local context. The incremental, cohort-based approach enabled an iterative learning process, which could support the restructuring of health systems in low resource settings going from a supply-driven model to a value-driven model.Trial registration: Not applicable