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.