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.