Strengthening health systems is expected to guide movement towards sustainable development goals for African countries [1]. However, current literature on healthcare system strengthening is characterized, not only by lack of how system performance is measured, but also by what constitutes health system strengthening [2]. Critical healthcare supply-side issues include weak governance and management of health resources; inadequate health management information systems, weak health infrastructure, shortage of health work force, inadequate health financing and poor quality healthcare services [3]. Moreover, there is no common conceptual framework for strengthening health system building blocks [4]. Infarct, healthcare systems vary widely and regions with similar levels of income, education and health expenditure differ in their ability to achieve given health goals [5] [6]. In many situations, interventions address only one or more of the building blocks and results tend to be short-lived. For sustainability and impact, the whole system needs to be addressed because different elements of the system are inter-connected and inter-dependent. Beliefs and worldviews, attitudes and feelings held, behaviors and cultures practiced by people in given communities enhance access and utilization of healthcare. The seventh pillar involving user-side community empowerment and engagement should not be ignored. It should be part of the essential building blocks. Building resilient health systems requires a systems-thinking approach with sets of interventions that cut across all the seven health systems building blocks including sufficient community engagement [7].

The objective of the study was to examine how user and institutional factors influence access and use of Maternal and Newborn Healthcare (MNH) Services in Matayos sub-County-Busia County. This study was guided by the WHO health system building blocks that form the backbone for provision of health services in health facilities [8]. The study assessed user perspectives on Leadership and Management of health facilities, Health Management Information System (HMIS), Health Workforce, Health Infrastructure, Health Finance, Maternal and Newborn Healthcare Services and Community Engagement. This covered the seven pillars of institutional blocks needed for strengthening health systems as suggested by many writers [9].

Governance of maternal and newborn healthcare was top-down without sufficient local community participation. The National Government issued health policy while Counties were only involved in policy implementation. Community participation and partnerships in MNH services were rated poorly by 8 in 10 of Matayos sub-County respondents. Community health workers and members of health committees were imposed on citizens without sufficient community engagement. Community participation and empowerment are meant to enhance responsiveness to people’s needs and promote sustainable service provision to local communities. This has been confirmed to be the case in rural India and Nepal where use of antenatal and skilled birth attendance is universal [11]. It incorporates the power to identify, design and create own solutions to health challenges in the community as supported by evidence from Estonia [12]. This

was not the case in Matayos sub-County although governance of the health management information system (HMIS) was rated as excellent.

It is notable that three quarters (263, 75.6%) of the respondents in Matayos rated attention to maternal and newborn health services in the County as poor. Quality of care in maternal and newborn health remained unsatisfactory. Respondents who did not get information from the mass media (OR 0.5, 95% CI (0.3 - 0.8), p = 0.013) had 50% chances of not using health services. In contrast, respondents who thought doctors were experienced had nearly 4 times odds (OR 3.6, 95% CI (1.7 - 7.8), p = 0.001) of utilizing institutional delivery services.

The health management information system (HMIS) in Matayos sub-County was rudimentary and not well designed to support service delivery. This explains why respondents said computers were “not useful” in processing information at service delivery points. Well-functioning health information systems should ensure collection, analysis; production, dissemination and use of information on all the three essential domains of health system function, namely health system performance, environmental and socio-cultural determinants of health and health status of populations as suggested by Manyazewal [8]. This was not the case in Matayos sub-county.

A significant group of respondents had received health messages transmitted through loudspeakers mounted on vehicles (142, 42.5%), listened to radios or watched televisions (82, 23.5%) transmitting health messages through the mass media. However, relatively few others, had read health messages on posters on notice boards (28, 8%) and billboards (11, 3.2%), or received short messages transmitted to their personal mobile phones (7, 2%). Occasionally, some (11, 3.2%), respondents got useful health talks from outreach talks mounted by healthcare providers during outreach visits to communities. From this, one would conclude that respondents valued messages they heard or watched rather than messages they read on notice boards and billboards. This is consistent with findings in oral cultures, as is the case in Africa, where the spoken word is more effective than the written word and documentation relatively more difficult to implement [13].

In-depth interviews and focused group discussions in this study revealed that all dispensaries were closed at night and on public holidays. Staff shortages were worse at night and on public holidays. This explains why dispensaries closed at such times and illustrates the important role of the health workforce. The health workforce remains the most important resource of the 4 health resources, the other 3 being: health infrastructure, health finance and health services [14]. A well-performing health workforce is one that works in ways that are responsive to the needs of the people [15]. Unfortunately, maternal and newborn health services in Matayos did not have the required resources and were not responsive to people’s health needs.

Data gathered during interviews showed inadequate health infrastructure including medical equipment and supplies to be the weakest and the least developed health system building block in Matayos sub-County. “There were severe shortages of all types of health staff… the sick required out of pocket expenditure to travel to hospital and to buy missing supplies and reagents in health facilities in order to access health care”. According to WHO’s framework for action of 2007, health systems that function well need resource procurement and distribution systems that provide health services to those in need [16]. Efforts are made to bear on achieving better health outcomes, social security for all citizens and, most important, responsiveness to people’s health needs.

Similarly, affordability of MNH services was rated as poor, with only 5 or less out of 10 (61%) able to pay for services. Affordability presented serious psychosocial barriers to health access in Matayos for individuals who had “experienced discrimination and detention” in health facilities for failure to pay for health care as has been pointed by others authors elsewhere [17]. Governments in developing countries have acknowledged this problem and some have made it a priority to improve quality of care and make all health services more affordable [18]. This again was not the case in Matayos.

Cost has been reported to be a major deterrent in many research studies on access to health care. Both indirect and direct costs affect utilization of health services [19]. Health finance, therefore, could as well be the underlying cause of weakness in other pillars of the health system such as “severe staff shortages,poor health infrastructure,and lack of medicines and supplies” in Matayos sub-County. It was observed during this study that there were numerous private shops and pharmacies around most public health facilities in Matayos sub-County where clients paid directly for supplies missing in hospitals.

Findings of this study also indicate that maternal and neonatal health services were uniformly available and on high demand in Matayos sub-County. Demand for MNH care was high as expressed by the number of women visiting hospitals for care (99%), yet use of hospitals for delivery was only 68% and 75% for family planning. The other proportion of 25% to 32% did not access healthcare services and left with un-met needs to seek help elsewhere. The explanation is that maternal and newborn healthcare services were either not affordable in private hospitals or of poor quality in public health facilities which were poorly equipped. Accessibility was poor due to direct high transport costs from home and, sometimes indirect costs for missing drugs and supplies in hospitals. Services could not be accessed outside working hours in dispensaries; during rainy seasons with muddy roads; when the terrain was poor and were closed at night and on public hospitals. Maternal and newborn healthcare services were, in their current state, not acceptable to users in Matayos because of high costs and poor quality of care.

It is evident from these findings that users had concerns and demands, but did not realize that they needed to be partners in service delivery. This presents a major gap on the part of the users and health care providers in Matayos sub-County. Anu Kasmel, who studied Estonian Communities, recommended that empowered communities had responsibility to partner with the supply-side of healthcare in pursuit of good health [12]. This study, therefore, recommends further community engagement in Matayo sub-County in order to strengthen partnership between users and providers of MNH services and design culturally appropriate maternal and newborn healthcare services. The respondents needed to define their own role and the role of the community in strengthening health systems. This study recommends change in shared beliefs and practices by individuals, households in Matayos sub-County to enable community empowerment and followed by community engagement with the Busia County Directorate of Health for improved access and utilization of maternal and newborn healthcare services as recommended by some authors [20].

The study had both strengths and limitations. The choice of concurrent mixed method approaches, through the principle of triangulation [21], ensured increased validity and reliability of study findings. Adoption of an ethnographic inquiry design facilitated understanding of the all-important socio-cultural phenomenon common in low resource settings. However, the data were cross-sectional and cannot, therefore, be used to draw “causal” connections between outcome and predictor variables.

Culturally sensitive tailored interventions are required to influence shared beliefs and practices to inform policy to empower women so that they can access and utilize maternal and newborn healthcare.

The authors would like to thank Jack Odunga and Edwin Dindi for assistance with patient recruitment and for critiquing this manuscript.

The authors declare no conflicts of interest regarding the publication of this paper.

Nyongesa, P., Yego, F., Tonui, P., Itsura, P., Sorre, B. and Omar, E.O. (2022) Strengthening Weak Healthcare Systems for Maternal and Neonatal Care in Low and Middle Income Countries: The Missing Link. Advances in Sexual Medicine, 12, 18-33. https://doi.org/10.4236/asm.2022.121003