Influence of Monitoring Strategy on Sustainability of Maternal Health Care Projects in Public Hospitals in Kenya.

Influence of Monitoring Strategy on Sustainability of Maternal Health Care Projects in Public Hospitals in Kenya.

Masai Timothy PhD Student¹, Dr. Clive Malietso Mukanzi², Dr. Luhombo Calistus³, Dr. Julius Miroga⁴

^1,2Jomo Kenyatta University of Agriculture and Technology, Nairobi Kenya

³Catholic University of Eastern Africa, Nairobi Kenya

⁴Jomo Kenyatta University of Agriculture and Technology, Kenya

DOI: https://dx.doi.org/10.47772/IJRISS.2025.906000145

Received: 08 May 2025; Accepted: 14 May 2025; Published: 03 July 2025

ABSTRACT

Monitoring in project management is a fundamental practice in the identification of trends that fosters development and sustainability in maternal healthcare facilities Sharma et al. (2017).The study focused on influence of monitoring strategy on sustainability of maternal health care projects in Kenya. This research used descriptive correlation design. The target population is 6331 which constitute maternal mothers, maternal Nurse, civil society (HENNET), Donor agencies, NHIF officials, Ministry of Health Officials, and Hospital administrators from which a sample of 399 was determined through Slovian’s formula. Quantitative data was analysed using inferential and descriptive statistics, where stakeholder monitoring had a significant contribution to the sustainability of MHCPs in public Hospitals in Kenya. This results was interpreted as a unit change in stakeholder monitoring was likely to result in the sustainability of MHCPs in public hospitals in Kenya by -23.8 %. The study concludes that Stakeholder monitoring had a significant partial influence in predicting the sustainability of MHCPs; an indication that there was no clear monitoring strategy in the Management of stakeholders thus retarding the sustainability of the MHCPs in public hospitals in Kenya. Moderating influence of top management support was found to be significant when stakeholder monitoring was used to predict Sustainability of MHCPs in Kenya. The study recommended that Top management (Government, NGOs) to train Stakeholders and involve them fully on functionalities and formulation of monitoring strategies; plan and implementation processes using relevant tools and documents to enhance sustainability in public hospitals in Kenya.

Key Words: Stakeholder Monitoring, Top management support, Public Hospital

INTRODUCTION

Monitoring entails tracking and obtaining feedback regarding the projects and deepening the participation of the stakeholders through shared learning, joint decision making, mutual respect and empowerment.  According to the World Health Organization, maternal health projects should be monitored: the stakeholders to periodically collect the data that seek to help in fundamental decisions such as the number of midwives trained to handle emergency obstetric care. In addition WHO suggested that stakeholders must trace data over time against the desired outcomes (World Health Organization, 2024). Monitoring has evolved and gained multiple functions as people learn how to adapt, innovate, and experiment with various approaches in the monitoring process, however, very little has been practised in MHCP in public hospitals in Kenya.

This implies that the health advocators should make deliberate move to persuade the stakeholders to take up specific projects and attain a course of action that would result in an improvement in maternal and children’s well-being by regular monitoring and evaluation process of maternal health care.  However, there is no elaborate plan and monitoring strategies that have been adopted to track the stakeholders operations to achieve sustainability of MHC projects in public hospitals.

Therefore, this study aims to determine how monitoring practice has been applied to the stakeholders operations and how it has affected project service uptake on the sustainability of MHCPs in public hospitals in Kenya

Statement of the problem

High maternal mortality and morbidity rates remain a major concern among women and young children  in Kenya whose child delivery rely on unspecialised birth attendance in rural or urban slum (Mwangi, 2022).  Maternal mortality rates have remained at 362 per 100,000 which is far much higher than the Global recommended MMR  of 70 per 100,000 live births (WHO,2019) with an estimated 6,300 women dying yearly during pregnancy period or birthing process (Banke-Thomas et al, 2020 and UNPF,2022). To address this, the Government of Kenya initiated maternal healthcare services in 2013 (Owiti, 2018) whose aim was to reduce maternal death, however available statistics on the Interrupted Time Series Analysis of the Free Maternity Services Policy in Kenya reveals more than 38.2% of all births are still attended by unskilled health practitioners outside hospitals yearly (Owuor & Amolo, 2019).

Studies conducted revealed that skilled personnel’s with knowledge and skills in monitoring and evaluation that have not been formally trained (Luhombo et al, 2019).This has led to slowed take off of MHCPs resulting from lack of track and check of progress. While top management support is acclaimed to aid maternal health care projects, little is known on how its implementation has influenced the sustainability of maternal health care projects in reduction of fatalities on mortality rates. It is with this view that this study is undertaken to bring about proper monitoring procedures on implementation and sustainability of maternal health care projects in public Hospitals in Kenya.

Objectives of the study

To assess the influence of stakeholder monitoring strategy on the sustainability of maternal health care project in public hospitals in Kenya.

To establish the moderating effect of top management support on monitoring and sustainability of MHCPs in Kenya.

Research hypotheses

Stakeholder monitoring has no significant effect on sustainability of MHCPs in public Hospitals in Kenya.

Top management support has no moderating effect on relationship between monitoring and sustainability of MHCPs in public hospitals in Kenya.

REVIEWED LITERATURE

Maternal and child health has been a priority in the public health systems for decades.  Various governments and the international community have implemented various initiatives that seek to reduce the rate of morbidity and mortality of mothers and infants. The government has directed its efforts to achieve the Millennial Development Goals as well as Sustainable Development Goals that reinforce good health well-being for women and children coupled with the target to achieve Universal Health coverage.

Monitoring entails tracking and obtaining feedback regarding the projects and deepening the participation of the stakeholders through shared learning joint decision machining, mutual respect and empowerment.  According to the World Health Organization (2019), maternal health projects must be monitored: the stakeholders must periodically collect the data that seek to help in fundamental decisions such as the number of midwives trained to handle emergency obstetric care. In addition WHO suggested that shareholders must trace data over time against the desired outcomes (World Health Organization, 2024).The stakeholders should be directly involved in the carrying out sensors of all maternal deaths in areas where maternal mortality has not been directly measured as well as tracking data on every outcome for both mothers and infants in the health facilities.

Sharma et al. (2017) acclaimed that monitoring of maternal healthcare projects is fundamental in the identification of the trends and fosters the development of strategies that seek to reduce maternal mortality and morbidity in healthcare facilities.  In addition, he also suggested that monitoring of the healthcare projects in public facilities determines the required improvements and performance of the maternal health programs.  Godphrey Kyambille, Aloys Mvuma, and Dina Machuve (2023) provided an overview of maternity healthcare monitoring in developing Nations, they observed that healthcare monitoring arrangements are essential for the frequent monitoring of the mother’s and new born’ health status .They revealed  that accumulating information from the earlier projects  determines the milestones and strategies that can be adopted to sustain the projects.  Kyambille, Mvuma, and Machuve (2023) acknowledged that earlier initiatives on maternal healthcare monitoring have focused on expectant mothers during the antenatal period; however, the strategies that can be used by the stakeholders to sustain the projects remain limited. They also observed that maternal healthcare systems monitor the uptake of the projects and evaluate the clinical status and sustainability of the maternal projects.  This existing gap created gaps necessitated the study to be conducted which explored stakeholder management Monitoring strategy and sustainability of maternal health care projects.

Subsequently, monitoring has evolved and gained multiple functions as people learn how to adapt, innovate, and experiment with various approaches in the monitoring process, however, very little has been practises in MHCP.  Shirley (2020) explained that the monitoring process is built around agreeing on expected results and milestones. It defines how to track progress based on collected data and undertaking a joint analysis that results in an action framework. Moreover, the World Health Organization (2019) reported that stakeholders management must identify the indicators that need to be monitored to improve the quality of maternal and child health.

The stakeholders must perform a systematic review of the indicators for the central phrases of the maternal healthcare continuum of care such as pregnancy, childbirth, new-born care, and postpartum care.  This study concludes that stakeholders must adopt a broad choice of indicators for maternal and child health care. Furthermore, the management stakeholders focus their efforts on identifying good indicators for a comprehensive childcare monitoring system. However, this study failed to explore how the strategies can be adopted by the stakeholders to monitor the central components of maternal and child care.

In Kenya, the monitoring strategy has focused on access to health services and increasing the number of births that are attended to by qualified health personnel in the health facilities. This approach has not yielded much results in lowering the morbidity and mortality rates in Kenya, thus, this brings the foreground of the importance of sustainability of the maternal and child project.

Similarly, Doctors, Hospitals, Administrators, Policymakers, and Mothers require reliable and valid information to enhance specific project intake in various health institutions. This facilitates the process of making judgments and determines the priorities and improvement of maternal and infant care.  This informs the need to interpret, resonate, validate, and adapt to the projects to achieve the Sustainable Development Goals in Kenya. Keats et al. (2017) mentioned that the primary stakeholders are struggling to quicken the improvement towards attaining the MDGs on how easily expectant mothers can access maternal healthcare services during the prenatal and post-natal period without any difficulty. Both public and private health institutions have experienced a scarcity of healthcare professionals, particularly in the maternal healthcare points. In addition, various hospitals have developed emergency care sections to facilitate frequent hospital visits for expectant mothers and new-borns; however, a framework for monitoring these activities is missing, leaving the process of monitoring in limbo. This created gaps that necessitated a study that focused on stakeholder management monitoring strategy and sustainability of maternal healthcare projects and presented practical findings that can be adopted by private and public healthcare organizations to improve the sustainability of maternal healthcare projects.

According to the studies conducted by John Gatimu, Christopher Mwangi, and Anne Ndiritu on monitoring and evaluation practices and performance of the Nairobi County Maternal Health Programs,affirmed that there is a close relationship between monitoring of the maternal care programs and the overall outcomes of the care system in Nairobi County (Gatimu, Gakuu & Ndiritu, 2021). This study revealed that there is a strong correlation between the performance of the county maternal health programs and combined monitoring and evaluation practices. This study concluded that monitoring is an important aspect of the sustainability of maternal care projects in Kenya. This study emphasizes on the stakeholders to develop an effective methodology and approach to monitor the maternal healthcare projects as well as raise awareness of the monitoring activities in the health facilities to achieve the success of the projects. Gatimu (2022) suggested that public healthcare systems should integrate human resource challenges such as workers charged with monitoring to have technical abilities, take active roles and duties of monitoring maternal projects, and ensure sustainability. However, this study has failed to explore various strategies that could be used to monitor various maternal projects in healthcare facilities. This created gaps that needed to be explored in determining various approaches that can be used by the stakeholders to monitor maternal health care projects.  Therefore, the findings of this study focused on exploring the relevance for the creation of the monitoring strategies and systems based on the reliable quality data.  It indicated the specific aspects and levels of care and the responsibility that needs additional efforts in the construction and sustainability to monitor the maternal health care of the new born babies.

According to Gyorkos, 2003 affirmed that monitoring is a crucial part of the management cycle, where Project managers and teams are advised to integrate monitoring mechanisms and evaluation practices into the project plan and framework. Luhombo et al,, (2019) confirmed that monitoring affect the projects. However, none or limited studies have focused on monitoring and evaluation practices to achieve sustainability of projects in Kenya. The Government of Kenya has channelled a huge financial budget to improve maternal health care at the National and county levels. Monitoring of this project in which public hospitals are engaged are critical in ensuring that the fund set by the Government achieves its intended objectives. Unfortunately, it is uncertain whether hospitals implement monitoring and evaluation practices whenever they undertake projects because few studies have focused on this area where the current study seeks to bridge the information and knowledge gap.

Luhombo et al (2019) from their findings on youth funds in Bahati revealed that while the majority of the projects were managed by personnel who understood monitoring and evaluation, however, most of this personnel had no formal and structured training on project monitoring and evaluation. This study recommended that the effectiveness of monitoring and evaluation could be improved when the project teams are vast with the application of the technical and systematic methodologies when executing the project. Therefore, formal training equips personnel with the expertise to apply these methodologies effectively. However, the current study seeks to establish how monitoring of stakeholders and performance influences the sustainability of maternal healthcare projects in public hospitals. Thus, to increase accessibility and achieve lowering of the mortality rates among expectant mothers and new-borns, reduction in the long waiting time to be attended to by the maternal care practitioner, adequate scheduling during maternal healthcare services, and achieving sufficient clinical check-ups, there is need to adopt a monitoring strategy that will enhance efficiency and sustainability of the maternal care projects in maternal care facilities.

MATERIALS AND RESEARCH METHODS

This study adopted a descriptive-correlation research design which comprised of both descriptive and correlation analysis. The target population in this study is a cohort of individuals involved directly in the maternal healthcare services, this included 6,000 mothers estimated to give birth daily, 57 maternal Nurse in charge, 112 civil society (HENNET), 10 Donors agencies (KAMANEH), 47 County NHIF officials, 47 County Ministry of health officials and 57  Maternal health Project administrators of public Hospitals. Thus, the total population was 6331 respondents. . This sample was drawn from all level 4 to level 6 public Hospitals which included maternity nurses.

Sampling Size

A sample size refers to the number of units selected and the source of data obtained. Kothari (2016) indicates that researchers should ensure that the sample size is big enough to be considered as a representative of the target population. The study sample comprised of maternal Nurse in charge of maternal Health in Public Hospitals in the country who are mandated to run maternal health projects, County Health Chief Officers, and Ministry of Health Officials, County NHIF officials, maternal mothers, Donors, and Civil society. Slovin’s formula is used to determine the sample size for maternal healthcare projects for the study. The sample size required is calculated according to the Slovenian formula.  The study adopted a sample size of respondents as illustrated in Table 3.2.

n= N / [1 + N (e) ²]

n= 6331 / [1 + 6331(0.05)²]

n= 399.96, = 400

Where:

N= Target Population

n=required size

e= error term

Table 3:2: Sample size determination

Survey data (2024)

The primary data was collected using questionnaire while Documentary analysis form was used to collect secondary data. Quantitative data was analysed using both inferential and descriptive statistics. Regression model of fitness was estimated using coefficient of determination which helped to explain how closely the predictor variable explains the variations in the dependent variable. To test the significance of each individual predictor and make conclusion on whether to reject or accept the null hypotheses, the P value was used. The level of significance of 5% was used as a benchmark. If the P value is less than 0.05 at 5% significance level, the null hypotheses was rejected and accept the alternative and vice versa (Kothari, 2014). This study applied the following hypotheses generated from the model:

There is no significant influence of stakeholder monitoring strategy   on the sustainability of maternal health care projects in public hospitals in Kenya.

Top management support has no moderating effect on the relationship between monitoring and sustainability of MHCPs in public hospitals in Kenya.

Sustainability of maternal health care = f (Stakeholder monitoring strategy+ random error)

Υ = β0 + β1×1 + ε, f (x1, ε),

To address the research hypothesis, the study checked whether the regression coefficient of stakeholder monitoring strategy (𝛽1) is positive (+) and significant (p values ‹ 0.05) in line with theory and study expectations.

RESEARCH RESULTS

The descriptive research findings revealed that not all the stakeholders are trained in handling maters of maternal health care projects. This was indicated by:  Strongly Disagree=31 %, Disagreed =43.2 %, Undecided= 6.8 %, Agree= 19 % and non-Strongly Agree. The study had a Mean=2.14 and Standard Deviation= 1.06. Respectively,  respondents were not equally in agreement that the trained stakeholders for maternal health care projects strive to achieve the targeted outlined objectives Strongly Disagree=49.4 %, Disagreed =30.3 %, Undecided= 3.2 %, Agree=  17.1  % with non-Strongly Agreeing. The study had a Mean= 1.88 and Standard Deviation=1.09.The findings further revealed that the trained stakeholders do not fully participate in measuring performance of the maternal health care projects. This is indicated with Strongly Disagree=49.7 %, Disagreed =19.7 %, Undecided= 0.3 %, Agree=29  %,Strongly Agree 1.3 %  with a Mean of 2.13 and Standard Deviation=1.33.In another development the findings indicated that stakeholders do not regularly participate in monitoring  exercise on the progress of maternal health care projects  with  majority Strongly Disagreeing at 49.7 %, 19.7 %, Disagreeing, those Undecided were0.3 %, Agree=  29.0  %,Strongly Agree 1.3 %  with a Mean of 2.13 and Standard Deviation=1.33.On how stakeholders regularly participate in review the progress made on maternal health care projects. The study had (Strongly Disagree=26.1 %, Disagreed =10.3 %, Undecided= 6.5 %, Agree= 51.6 %, strongly Agree 5.5 % with a Mean of 3.00 and Standard Deviation of 1.38). This indicated that respondents agree to this argument. Respondents equally revealed that stakeholders feedback is minimal in informing the future implementation of maternal health care projects, this was indicated by Strongly Disagree=78.1 %, Disagreed = 16.8 %, none were Undecided, Agree= 5.2 % and non-Strongly Agreed. This generated a Mean of   1.32 and Standard Deviation of 0.73. Equally, respondents stated that frequent monitoring of projects in this study using M &  E tools contribute less to good project results, this was indicated by (Strongly Disagree=78.7%, Disagreed =12.9 %, Undecided= 0%, Agree= 8.4  %, Strongly Agreed with a Mean of 1.37 and Standard Deviation=0.76. Similarly it was evident that there has been frequent monitoring for the projects using M  &  E procedures with the following results indicating:(Strongly Disagree=75.5 %, Disagreed =15.2 %, Undecided= 6.1 %, Agree=  3.9  %,Strongly Agree 0.3 %  with a Mean=  1.37 and Standard Deviation of 0.76).Finally, respondents indicated that The project prepared time scheduled to track the process under M &  E guidelines is less adhered to with (Strongly Disagree=44.5 %,Disagreed =34.8%, Undecided= 11.3 %, Agree= 9.7 %, Strongly Agree 0.6 %, Mean= 1.86 and Standard Deviation=0.97).

On average, the level of Stakeholder monitoring on sustainable maternal Health care projects (MHCPs) in public hospitals in Kenya was at approximately 37 % [Mean of 1.85, Standard Deviation of 0.99].This indicated that the majority of the respondents were not in agreement with the statement that the adherence of monitoring standards on sustainability of maternal health care projects in public hospitals in Kenya was very low and therefore monitoring of projects was not fully enhance.

This findings are not consistent  with Kamau and Mohamed (2014) and Tubey (2012) who  found out that monitoring strategy was critical in stakeholder management on sustainability of maternal healthcare projects in public hospitals in Kenya because it  enhances training, participation and use of M & E tools in evaluating project progress.

Furthermore, the results do not comply with the regulatory pillars of Institutional Theory which focus on applicability of rules and laws as an enforcement mechanism in the healthcare environment (Gioia, Patvardhan and Hamilton 2013). This study has demonstrated that maternal health care projects do not carry out monitoring contrary to the theory which emphasises strict compliance of rules and regulations.

Inferential results

The second hypothesis stated that; stakeholder monitoring strategy had no significant influence on sustainability of MHCPs in public Hospitals in Kenya. The regression model shows results for the relationship between monitoring strategy and sustainability of MHCPs in public Hospitals in Kenya. To test the second objective, the study adopted Simple Linear Regression analysis approach and the findings were distributed on Table 4.50.

Table 4.1: Influence of stakeholder monitoring strategy on the sustainability of maternal health care project in public hospitals in Kenya

Predictors: (Constant), SMS

The model summary results presented on Table 4.1 shows the value obtained on the predicted variable (sustainability of MHCPs) as explained by independent variable (stakeholder monitoring strategy) revealed that R-value of .350 and the R-square for the model 0.323. This implies that a 32.3 % of the corresponding variation in the sustainability of MHCPs in public Hospitals in Kenya resulted from stakeholder monitoring strategy. Similarly, the F change statistic gave a value of (43.107, p < 0.05) which was large enough to support the goodness of fit of the model in explaining the variation in the predicted variable (stakeholder monitoring) on sustainability of MHCPs. However, on the contrary, 67.7 % variation of this sustainability could be explained by variables not considered in this model.

Furthermore, the adjusted R square (.320) fairly gives a more honest value that tends to estimate the R square for the entire population at 32.0 per cent. The model summary results with the introduction of the moderator top management support indicated that the R-square is 0.372 (R Square change = 0.372) for model 2 with 33.5 % moderated variation on sustainability of MHCPs.

Table 4.2: Influence of stakeholder monitoring strategy on the sustainability of maternal health care project in public hospitals in Kenya

The results of ANOVA as indicated in Table 4.2 revealed that the Simple Linear Regression model was of good fit to data collected [F (1, 308) = 43.107, P = 0.000 < 0.05] which implied that the19 model19 is19 statistically19significant19 to19 predict19 the19 relationship19between19 monitoring strategy on9sustainability of MHCPS in Kenya. The results of ANOVA with the introduction of the moderator top management support [F (2, 307) = 78.908, P = 0.000 < 0.05] equally indicated that the model was statistically significant to predict the relation between the moderator and monitoring.

Table 4.3: Linear Regression Results: Influence of stakeholder monitoring strategy on the sustainability of maternal health care project in public hospitals in Kenya

Equally, the results obtained in table 4.3 revealed that the unstandardized regression coefficients β value of the computed index score of monitoring strategy was found to be a negative -0.350 with a t-value of -6.566, at a significance level of p < 0.05. This implied that for every unit increase in stakeholder monitoring, there was a predicted increase in the percentage of sustainability of MHCPs, hence, the null hypothesis was rejected with the conclusion that stakeholder monitoring strategy had a significant influence on sustainability of MHCPs in Kenya.

Stakeholder monitoring had a weak negative unstandardized beta coefficient of -.238, an indication that a unit change in the Stakeholder monitoring is likely to result to a negative improvement in the sustainability of MHCPPs in Kenya. The simple linear Regression model was used to predict sustainability of MHCPs in Kenya using results of Stakeholder monitoring. This was fitted in our second Simple Linear Regression model of    Υ = β₂ x₂ + ε,     Y=f (x₂, ε),

This was as follows;

Sustainability of MHCPs= -4081(Constant)*0.238(Stakeholder monitoring) + ε.

The findings revealed that lack of monitoring on stakeholders involvement in management of MHCPs is   likely to influence negatively the sustainability of MHCPs since monitoring of projects points out strength and weaknesses experienced by managers of maternal health care projects. This result disagrees with Shirley (2020) who stated that monitoring process is built around agreeing on expected results and milestones as well as defining how to track progress based on collected data and undertaking a joint analysis (stakeholders) that results in an action framework

DISCUSSION OF FINDINGS

The stakeholder monitoring strategy has a statistically significant contribution to sustainability of MHCPs in Public Hospital in Kenya since a unit change in stakeholder monitoring is likely to result in the sustainability of MHCPs in public hospitals in Kenya by 32.3 %. The findings revealed that lack of monitoring on stakeholders involvement in management of MHCPs is   likely to influence negatively the sustainability of MHCPs since monitoring of projects points out strength and weaknesses experienced by managers of maternal health care projects in Kenya.

CONCLUSION

Regarding the influence of monitoring strategy on sustainability of MHCPs, in Kenya, the study concluded that monitoring had a significant role in steering up sustainability of MHCPs. From the results, it was observed that monitoring of projects through trained personnel, participation and use of appropriate monitoring tools was not effectively upheld in MHCPs in public hospitals in Kenya. Moreover, inspection of MHCPs was not adequately upheld as key aspects of monitoring practices were flawed. Most of the projects had not laid out framework to monitor MHCPs and ensure their ability to mobilize, utilize resources to enhance quantity and quality hence sustainable projects. It therefore concluded that the continued decline in sustainability of these projects was significantly caused by ineffective quality monitoring strategies as one of the key aspects of project management

RECOMMENDATION

On stakeholder monitoring strategy, the MHCPs should train Stakeholders and involve them fully on how to formulate monitoring strategies, plan and implementing monitoring & evaluation process using relevant tools and documents.to enhance sustainability.

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