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

Document Type : Original Article


1 Health Economics Research Unit, KEMRI Wellcome Trust Research Programme, Nairobi, Kenya

2 Institute of Healthcare Management, Strathmore University, Nairobi, Kenya

3 KEMRI Wellcome Trust Research Programme, Kilifi, Kenya

4 The World Bank, Kenya Country Office, Nairobi, Kenya

5 Nuffield Department of Medicine, University of Oxford, Oxford, UK


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.

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.

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.

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


Main Subjects

"Watch the Video Summary"

  1. Kruk ME, Galea S, Prescott M, Freedman LP. Health care financing and utilization of maternal health services in developing countries. Health Policy Plan. 2007;22(5):303-310. doi:10.1093/heapol/czm027
  2. Kenya National Bureau of Statistics (KNBS). Kenya Demographic and Health Survey 2014. Nairobi: KNBS; 2015.
  3. Ministry of Devolution and Planning GOK. Millennium Development Goals Status Report for Kenya, 2013. Nairobi, Kenya; 2013.
  4. World Health Organization. The World health report. make every mother and child count. http://www.who.int/whr/2005/en/.  Published 2005.
  5. Nguhiu PK, Barasa EW, Chuma J. Determining the effective coverage of maternal and child health services in Kenya, using demographic and health survey data sets: tracking progress towards universal health coverage. Trop Med Int Health. 2017;22(4):442-453. doi:10.1111/tmi.12841
  6. Ministry of Health GoK. Kenya National Health Accounts 2012/2013. Nairobi; 2015.
  7. Borghi J, Storeng KT, Filippi V. Overview of the costs of obstetric care and the economic and social consequences for households. In: Richard F, Witter S, De Brouwere V, eds. Reducing financial barriers to obstetric care in low-income countries. Antwerp, Belgium: Instituut voor Tropische Geneeskunde; 2000.
  8. Barasa EW, Maina T, Ravishankar N. Assessing the impoverishing effects, and factors associated with the incidence of catastrophic health care payments in Kenya. Int J Equity Health. 2017;16(1):31. doi:10.1186/s12939-017-0526-x
  9. Meessen B, Hercot D, Noirhomme M, et al. Removing user fees in the health sector: a review of policy processes in six sub-Saharan African countries. Health Policy Plan. 2011;26 Suppl 2:ii16-29. doi:10.1093/heapol/czr062
  10. McKinnon B, Harper S, Kaufman JS, Bergevin Y. Removing user fees for facility-based delivery services: a difference-in-differences evaluation from ten sub-Saharan African countries. Health Policy Plan. 2015;30(4):432-441. doi:10.1093/heapol/czu027
  11. Mwabu GM, Mwangi WM. Health care financing in Kenya: a simulation of welfare effects of user fees. Soc Sci Med. 1986;22(7):763-767.
  12. Carrin G, James C, Adelhardt M, et al. Health financing reform in Kenya - assessing the social health insurance proposal. S Afr Med J. 2007;97(2):130-135.
  13. Chuma J, Musimbi J, Okungu V, Goodman C, Molyneux C. Reducing user fees for primary health care in Kenya: Policy on paper or policy in practice? Int J Equity Health. 2009;8:15. doi:10.1186/1475-9276-8-15
  14. Ministry of Health GoK. Status of Implementation of Free Maternity Services Program in The Devolved Health System in Kenya. Kenya; 2015.
  15. Hatt LE, Makinen M, Madhavan S, Conlon CM. Effects of user fee exemptions on the provision and use of maternal health services: a review of literature. J Health Popul Nutr. 2013;31(4 Suppl 2):67-80.
  16. Witter S, Dieng T, Mbengue D, Moreira I, De Brouwere V. The national free delivery and caesarean policy in Senegal: evaluating process and outcomes. Health Policy Plan. 2010;25(5):384-392. doi:10.1093/heapol/czq013
  17. Witter S, Armar-Klemesu M, Dieng T. National fee exemption schemes for deliveries: comparing the recent experiences of Ghana and Senegal. Studies in Health Services Organisation and Policy. 2008;24:167-198.
  18. Penfold S, Harrison E, Bell J, Fitzmaurice A. Evaluation of the delivery fee exemption policy in ghana: population estimates of changes in delivery service utilization in two regions. Ghana Med J. 2007;41(3):100-109.
  19. Bosu W, Bell JS, Armar-Klemesu M, Tornui JA. Effect of delivery care user fee exemption policy on institutional maternal deaths in the central and volta regions of ghana. Ghana Med J. 2007;41(3):118-124.
  20. Pearson L, Gandhi M, Admasu K, Keyes EB. User fees and maternity services in Ethiopia. Int J Gynaecol Obstet. 2011;115(3):310-315. doi:10.1016/j.ijgo.2011.09.007
  21. Witter S, Arhinful DK, Kusi A, Zakariah-Akoto S. The experience of Ghana in implementing a user fee exemption policy to provide free delivery care. Reprod Health Matters. 2007;15(30):61-71. doi:10.1016/s0968-8080(07)30325-x
  22. Witter S, Adjei S. Start-stop funding, its causes and consequences: a case study of the delivery exemptions policy in Ghana. Int J Health Plann Manage. 2007;22(2):133-143. doi:10.1002/hpm.867
  23. Boudreaux C, Chanthala P, Lindelow M. Assessing the elimination of user fees for delivery services in Laos. PLoS One. 2014;9(3):e89784. doi:10.1371/journal.pone.0089784
  24. Ridde V, Richard F, Bicaba A, Queuille L, Conombo G. The national subsidy for deliveries and emergency obstetric care in Burkina Faso. Health Policy Plan. 2011;26 Suppl 2:ii30-40. doi:10.1093/heapol/czr060
  25. Government of Kenya (GOK). The Constitution of Kenya. Nairobi; 2010.
  26. Ministry of Health GoK. Kenya Health Policy 2012–2030.Nairobi, Kenya;2012.
  27. Ministry of Health GOK. Comprehensive National Health Policy Framework 2011-2030. Nairobi,  Kenya; 2011.
  28. Commission for Revenue Allocation Kenya. Kenya County Fact Sheets. Kenya; 2011.
  29. Ministry of Health GOK. County Health Fact Sheets. Nairobi, Kenya; 2015.
  30. Ridde V, Turcotte-Tremblay AM, Souares A, et al. Protocol for the process evaluation of interventions combining performance-based financing with health equity in Burkina Faso. Implement Sci. 2014;9:149. doi:10.1186/s13012-014-0149-1
  31. Saunders RP, Evans MH, Joshi P. Developing a process-evaluation plan for assessing health promotion program implementation: a how-to guide. Health Promot Pract. 2005;6(2):134-147. doi:10.1177/1524839904273387
  32. Moore GF, Audrey S, Barker M, et al. Process evaluation of complex interventions: Medical Research Council guidance. BMJ. 2015;350:h1258. doi:10.1136/bmj.h1258
  33. Richie J, Spencer L. Qualitative data analysis for applied policy research. In: Robert BA, ed. Analyzing Qualitative Data. New York: Routledge; 1994.
  34. Tuckett AG. Applying thematic analysis theory to practice: a researcher's experience. Contemp Nurse. 2005;19(1-2):75-87.
  35. Barasa EW, Manyara AM, Molyneux S, Tsofa B. Recentralization within decentralization: County hospital autonomy under devolution in Kenya. PLoS One. 2017;12(8):e0182440. doi:10.1371/journal.pone.0182440
  36. Barasa EW, Cleary S, Molyneux S, English M. Setting healthcare priorities: a description and evaluation of the budgeting and planning process in county hospitals in Kenya. Health Policy Plan. 2017;32(3):329-337. doi:10.1093/heapol/czw132
  37. Barasa EW, Molyneux S, English M, Cleary S. Hospitals as complex adaptive systems: A case study of factors influencing priority setting practices at the hospital level in Kenya. Soc Sci Med. 2017;174:104-112. doi:10.1016/j.socscimed.2016.12.026
  38. Kingdon JW. Agendas, Alternatives, and Public Policies. Boston: Little, Brown; 1984.
  39. KNBS. Kenya Demographic and Health Survey, 2008. Nairobi; 2009.
  40. Walker L, Gilson L. 'We are bitter but we are satisfied': nurses as street-level bureaucrats in South Africa. Soc Sci Med. 2004;59(6):1251-1261. doi:10.1016/j.socscimed.2003.12.020
  41. Fafchamps M, Minten B. Public Service Provision, User Fees and Political Turmoil. J Afr Econ. 2007;16(3):485-518. doi:10.1093/jae/ejl040
  42. Kajula PW, Kintu F, Barugahare J, Neema S. Political analysis of rapid change in Uganda's health financing policy and consequences on service delivery for malaria control. Int J Health Plann Manage. 2004;19 Suppl 1:S133-153. doi:10.1002/hpm.772
  43. McPake B, Brikci N, Cometto G, Schmidt A, Araujo E. Removing user fees: learning from international experience to support the process. Health Policy Plan. 2011;26 Suppl 2:ii104-117. doi:10.1093/heapol/czr064
  44. Witter S, Khadka S, Nath H, Tiwari S. The national free delivery policy in Nepal: early evidence of its effects on health facilities. Health Policy Plan. 2011;26 Suppl 2:ii84-91. doi:10.1093/heapol/czr066
  45. Witter S, Kusi A, Aikins M. Working practices and incomes of health workers: evidence from an evaluation of a delivery fee exemption scheme in Ghana. Hum Resour Health. 2007;5:2. doi:10.1186/1478-4491-5-2
  46. Lipsky M. Street-Level Bureaucracy: Dilemmas of the Individual in Public Services. New York: Russell Sage Foundation Google Scholar; 1980.
  47. De Savigny D, Kasale H, Mbuya C, Reid G. Fixing health systems, 2004. Ottawa: International Development Research Centre:; 2004.
  48. De Savigny D, Adam T. Systems thinking for health systems strengthening. World Health Organization; 2009.
  49. Gilson L, McIntyre D. Removing user fees for primary care in Africa: the need for careful action. BMJ. 2005;331(7519):762-765. doi:10.1136/bmj.331.7519.762
  50. Nimpagaritse M, Bertone MP. The sudden removal of user fees: the perspective of a frontline manager in Burundi. Health Policy Plan. 2011;26 Suppl 2:ii63-71. doi:10.1093/heapol/czr061
  51. Witter S, Adjei S, Armar-Klemesu M, Graham W. Providing free maternal health care: ten lessons from an evaluation of the national delivery exemption policy in Ghana. Glob Health Action. 2009;2. doi:10.3402/gha.v2i0.1881
  • Receive Date: 02 May 2017
  • Revise Date: 12 November 2017
  • Accept Date: 18 November 2017
  • First Publish Date: 01 July 2018