Examining the Implementation of the Free Maternity Services Policy in Kenya: A Mixed Methods Process Evaluation

Abstract

Background: Kenya introduced a free maternity policy in 2013 to address the cost barrier associated with accessing maternal health services. We carried out a mixed methods process evaluation of the policy to examine the extent to which the policy had been implemented according to design, and positive experiences and challenges encountered during implementation. Methods: We conducted a mixed methods study in 3 purposely selected counties in Kenya. Data were collected through in-depth interviews (IDIs) with policy-makers at the national level, health managers at the county level, and frontline staff at the health facility level (n=60), focus group discussions (FGDs) with community representatives (n=10), facility records, and document reviews. We analysed the data using a framework approach. Results: Rapid implementation led to inadequate stakeholder engagement and confusion about the policy. While the policy was meant to cover antenatal visits, deliveries, and post-natal visits, in practice the policy only covered deliveries. While the policy led to a rapid increase in facility deliveries, this was not matched by an increase in health facility capacity and hence compromised quality of care. The policy led to an improvement in the level of revenues for facilities. However, in all three counties, reimbursements were not made on time. The policy did not have a system of verifying health facility reports on utilization of services. Conclusion: The Kenyan Ministry of Health (MoH) should develop a formal policy on the free maternity services, and provide clear guidelines on its content and implementation arrangements, engage with and effectively communicate the policy to stakeholders, ensure timeliness of payment disbursement to healthcare facilities, and introduce a mechanism for verifying utilization reports prepared by healthcare providers. User fee removal policies such as free maternity programmes should be accompanied by supply side capacity strengthening.

Too poor or too far? Partitioning the variability of hospital-based childbirth by poverty and travel time in Kenya, Malawi, Nigeria and Tanzania

“…The implementation of these different strategies, however, seems to face similar challenges. In Kenya, limited pre-existing health infrastructure and other supply-side capacity to match the increased workload following fee removal, insufficient referral and emergency obstetric care capacities contribute to persisting poor maternal (and newborn) health and its inequalities [51,52]. Indeed, decline in maternal/ neonatal mortality and stillbirths does not appear to have followed as a result of increase in facility utilization for childbirth [44,53].…”

Descriptive analysis of effect of uptake of comprehensive antenatal care services on neonatal mortality, Kenya

“…The results of this study show that rates of neonatal deaths in rural areas like Moyale are higher than the national average. To increase access to antenatal laboratory profiling, community health workers should be educated to promote antenatal care, basic laboratory screening services should be available at all health facilities, and antenatal profiling services should be included as part of the free maternity services that were mandated in 2013 (Tama et al, 2018). These findings have implications for neonatal health outcomes, both for Moyale specifically and throughout Kenya because they validate key national and WHO recommendations and show that provision of antenatal and laboratory services can effectively and significantly reduce neonatal morbidity and mortality.…”

“Our voices matter”: a before-after assessment of the effect of a community-participatory intervention to promote uptake of maternal and child health services in Kwale, Kenya

“…As a result of the Kenyan government’s policy of free maternity services enacted in early 2013, the bulk of rural dispensaries in Kenya established maternity delivery units [ 38 , 39 ]. These units enabled pregnant mothers to access delivery services at primary care level.…”