‘It was hell in the community’: a qualitative study of maternal and child health care during health care worker strikes in Kenya

Abstract

Background Health care workers in Kenya have launched major strikes in the public health sector in the past decade but the impact of strikes on health systems is under-explored. We conducted a qualitative study to investigate maternal and child health care and services during nationwide strikes by health care workers in 2017 from the perspective of pregnant women, community health volunteers (CHVs), and health facility managers. Methods We conducted in-depth interviews and focus group discussions (FGDs) with three populations: women who were pregnant in 2017, CHVs, and health facility managers. Women who were pregnant in 2017 were part of a previous study. All participants were recruited using convenience sampling from a single County in western Kenya. Interviews and FGDs were conducted in English or Kiswahili using semi-structured guides that probed women’s pregnancy experiences and maternal and child health services in 2017. Interviews and FGDs were audio-recorded, translated, and transcribed. Content analysis followed a thematic framework approach using deductive and inductive approaches. Results Forty-three women and 22 CHVs participated in 4 FGDs and 3 FGDs, respectively, and 8 health facility managers participated in interviews. CHVs and health facility managers were majority female (80%). Participants reported that strikes by health care workers significantly impacted the availability and quality of maternal and child health services in 2017 and had indirect economic effects due to households paying for services in the private sector. Participants felt it was the poor, particularly poor women, who were most affected since they were more likely to rely on public services, while CHVs highlighted their own poor working conditions in response to strikes by physicians and nurses. Strikes strained relationships and trust between communities and the health system that were identified as essential to maternal and child health care. Conclusion We found that the impacts of strikes by health care workers in 2017 extended beyond negative health and economic effects and exacerbated fundamental inequities in the health system. While this study was conducted in one County, our findings suggest several potential avenues for strengthening maternal and child health care in Kenya that were highlighted by nationwide strikes in 2017.

Public–Private engagement and health systems resilience in times of health worker strikes: a Ghanaian case study

“…This case study found evidence of system-level interactions between CHAG and the GoG to maintain service continuity during strikes which allowed for mostly ‘absorptive’ resilience strategies, including public announcements encouraging patients to seek care in CMIs. In contrast to studies exploring health system resilience during strikes in Kenya ( Waithaka et al ., 2020 ; Scanlon et al ., 2021a ; 2021b ; Adam et al ., 2018 ), these interactions were not ad-hoc, taken on by individual frontline managers and inconsistent but occurred on a national level.…”

“…Strike action is experienced globally but the effects are particularly severe in LMICs due to pre-existing health system fragilities ( Russo et al ., 2019 ; Waithaka et al ., 2020 ). Though there is conflicting evidence on the direct effects of HWS on population mortality ( Cunningham et al ., 2008 ; Metcalfe et al ., 2015 ), strikes in LMICs are thought to have significant health systems effects, for example leading to a decrease in in/out-patient flow, a breakdown in trust between community and health workers, decreasing health worker motivation or entrenching inequalities as strike effects are felt disproportionately by the poor ( Waithaka et al ., 2020 ; Scanlon et al ., 2021a ; 2021b ; Adam et al ., 2018 ). HWS are concerning as human resources for health (HRH) are arguably the most fundamental building block of a health system ( World Health Organization, 2016 ).…”

“…Most literature focuses on the impact of HWS on mortality and the ethical nature of strikes ( Chima et al ., 2013 ). Studies of HWS in LMICs found that alternative care options are vital for population health—but shifting care to private facilities might also have serious consequences, such as catastrophic costs for the poor or the compromise of continuity or quality of care ( Scanlon et al ., 2021a ; 2021b ; Adam et al ., 2018 ). There is currently no study of the role that private providers may play in offering health system resilience during public sector strikes in LMICs or the partnership arrangements involved therein.…”

“I don't like to be seen by a male provider”: health workers’ strike, economic, and sociocultural reasons for home birth in settings with free maternal healthcare in Nigeria

“…Evidence suggests that in 2017, the public health system was near collapse due to the health workers’ strike in Kenya. 54 This reduced hospital admissions and outpatient services, including skilled delivery. 55 Poor women are most affected by health workers’ strikes since they are least likely to afford care in private health facilities.…”

“… 55 Poor women are most affected by health workers’ strikes since they are least likely to afford care in private health facilities. 54 Despite the damaging effects of health workers’ strikes on maternal outcomes, they have become far too familiar in Nigeria since 2014. Resident doctors were on strike in Nigeria in 2021 when we drafted this manuscript, indicating that this has become a pervasive problem with dire implications for women and girls’ well-being.…”