Exploring the Adaptations of the Free Maternity Policy Implementation by Health Workers and County Officials in Kenya

Key Findings

The health care workers and county officials developed 3 adaptive strategies for implementing the free maternity policy that were critical in meeting the policy objectives:

Mitigating bureaucratic processes to employ more workers and innovating complementary programs to support the utility of services

Enhancing working practices to improve referrals, clients' policy knowledge, and client communication on the policy requirements

Enhancing health care workers' professionalism and ethics by registering more mothers to uptake services, providing services to vulnerable populations excluded from the official written policy, and improving the claims process

The strategies created unintended negative consequences, such as health care workers' workload increasing and facilities discharging mothers immediately after birth, putting them at risk of complications.

Key Implication

Enhancing the roles of health care workers and county officials in policy implementation can build the flexibility and agility of the implementation process, leading to more services being provided to more mothers. Further analysis of their professional resilience in public services planning needs additional theoretical and empirical attention.

Background:

In 2017, Kenya launched the free maternity policy (FMP) that aimed to provide all pregnant women access to maternal services in private, faith-based, and levels 3–6 public institutions. We explored the adaptive strategies health care workers (HCWs) and county officials used to bridge the implementation challenges and achieve the FMP objectives.

Methods:

We conducted an exploratory qualitative study using Lipsky's theoretical framework in 3 facilities (levels 3, 4, and 5) in Kiambu County, Kenya. The study involved in-depth interviews (n=21) with county officials, facility in-charges and HCWs, and key informants from national and development partner agencies. Data were audio-recorded, transcribed, and analyzed using a framework thematic approach.

Results:

The results show that HCWs and county officials applied several strategies that were critical in shaping the policymaking, working practice, and professionalism and ethical aspects of the FMP. Strategies of policymaking: hospitals employed additional staff, and the county developed bylaws to strengthen the flow of funds. Strategies of working practice: hospitals and HCWs enhanced patient referrals, and facilities enhanced communication. Strategies of professionalism and ethics: nurses registered and provided service to mothers, and facilities included employees in planning and budgeting. Maladaptations included facilities having leeway to provide FMP services to populations who were excluded from the policy but had to bear the costs. Some discharged mothers immediately after birth, even before offering the fully costed policy benefits, to avoid incurring additional costs.

Conclusions:

The role of policy implementers and the built-in flexibility and agility in implementing the FMP could enhance service delivery, manage the administrative pressures of implementation, and provide mothers with personalized, responsive service. However, despite their benefits, some resulting unintended consequences may need interventions.

Received: March 12, 2023.Accepted: September 26, 2023.Published: October 30, 2023.

This is an open-access article distributed under the terms of the Creative Commons Attribution 4.0 International License (CC BY 4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. To view a copy of the license, visit https://creativecommons.org/licenses/by/4.0/. When linking to this article, please use the following permanent link: https://doi.org/10.9745/GHSP-D-23-00083

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