In Kenya, 82 percent of midwives correctly diagnose their patient's condition but only 28 percent give the full treatment required, the World Bank said on Friday, highlighting the challenge of reducing maternal deaths in the country despite the introduction of free maternal health services last month.
Giving birth with the help of a trained professional is deemed a critical factor in reducing maternal mortality but the statistics, released in the first Service Delivery Indicators (SDI) survey - an Africa-wide World Bank initiative aimed at improving service delivery in basic health and primary education facilities - shows that pregnant Kenyan women aren't getting the care they need.
"There is a gap between what they [the midwives] know and what they do. So there is a tremendous discrepancy there," said Shahnaz Sharif, the government's director of public health and sanitation. "They do not do what they should be doing."
Kenya is the first country to implement SDI by surveying 5,000 teachers and healthcare providers in 600 schools and clinics nationwide.
Sharif blamed a lack of training for the gap between diagnosis and the delivery of treatment in the country.
"In the old days, we used to train midwives and then all of a sudden midwifery became a no-go subject so we taught them general nursing," he said. "We may revive the midwifery curriculum."
But a member of the doctors' union said the problem was one of lack of investment in the health sector.
"It's an indicator of the facilities and what is available and what is around them," said Wambui Waithaka, a doctor at Pumwani maternity hospital in Nairobi, the largest facility in the country.
"They are able to know what to do but they don't have the equipment and they don't have the facilities," she added.
Health workers went on strike over pay and conditions in 2011 and2012.
MATERNAL MORTALITY RISES
Kenya will not achieve the Millennium Development Goal of reducing the maternal mortality ratio by three-quarters between 1990 and 2015. The government's last demographic health survey showed that maternal mortality rose from 414 deaths per 100,000 live births to 488 between 2003 and 2008/09.
Only about half of Kenyan women give birth with the help of a trained professional, a measure deemed vital in the fight against maternal mortality.
The government introduced free maternity services in public health facilities on June 1, hoping to improve the situation. Previously, women had been forcibly detained in hospitals for months over unpaid bills.
But the survey highlights the need to focus on the quality of healthcare as well.
Similar gaps in diagnosis and treatment were found with nurses and doctors, who gave the correct diagnosis in 72 percent and 86 percent of cases respectively but only gave full treatment in 46 percent and 54 percent of cases.
"It's clearly an incentive issue because they know. Why aren't they delivering their knowledge?" said Waly Wane, a senior economist with the World Bank.
"The question that we are trying to address here with the SDI is the human capital. How can you put incentives into the health system, into the education system, so that people feel that they have to perform?"
The survey found that 29 percent of public providers were absent from health facilities, 88 percent of which was sanctioned from above.
"I could bet a lot of money that the people you didn't find in the public hospitals, you found in the private [hospitals]," said Waithaka.
In Kenya, doctors often divide their time between public and private practice because of poor pay and facilities in government hospitals and clinics. Their union says they earn around $400 a month in salary and allowances.
"Why am I coming here to be demotivated? Why don't I go to a private hospital or to a private facility where I can now practice the medicine that I was trained to practice?" asked Waithaka.
The survey also found that only 58 percent of public providers were able to diagnose correctly at least four out of five common conditions, namely pneumonia, diabetes, tuberculosis, diarrhoea with severe dehydration and malaria with anaemia.
Waithaka said medical staff often lack the equipment they need to make the correct diagnoses in public facilities.
"She wants to be able to diagnose diabetes. But she only has a thermometer and a weighing scale. She's not going to diagnose diabetes with that," she said.