Impact of free maternity policies in Kenya: an interrupted time-series analysis

Abstract

BackgroundUser fees have been reported to limit access to services and increase inequities. As a result, Kenya introduced a free maternity policy in all public facilities in 2013. Subsequently in 2017, the policy was revised to the Linda Mama programme to expand access to private sector, expand the benefit package and change its management.MethodsAn interrupted time-series analysis on facility deliveries, antenatal care (ANC) and postnatal care (PNC) visits data between 2012 and 2019 was used to determine the effect of the two free maternity policies. These data were from 5419 public and 305 private and faith-based facilities across all counties, with data sourced from the health information system. A segmented negative binomial regression with seasonality accounted for, was used to determine the level (immediate) effect and trend (month-on-month) effect of the policies.ResultsThe 2013 free-maternity policy led to a 19.6% and 28.9% level increase in normal deliveries and caesarean sections, respectively, in public facilities. There was also a 1.4% trend decrease in caesarean sections in public facilities. A level decrease followed by a trend increase in PNC visits was reported in public facilities. For private and faith-based facilities, there was a level decrease in caesarean sections and ANC visits followed by a trend increase in caeserean sections following the 2013 policy.Furthermore, the 2017 Linda Mama programme showed a level decrease then a trend increase in PNC visits and a 1.1% trend decrease in caesarean sections in public facilities. In private and faith-based facilities, there was a reported level decrease in normal deliveries and caesarean sections and a trend increase in caesarean sections.ConclusionThe free maternity policies show mixed effects in increasing access to maternal health services. Emphasis on other accessibility barriers and service delivery challenges alongside user fee removal policies should be addressed to realise maximum benefits in maternal health utilisation.

Perspectives of stakeholders of the free maternity services for mothers in western Kenya: lessons for universal health coverage

“…Post-natal mothers were more aware and more of them had registered, indicating inadequate communication of the initiative to potential consumers. This finding is support by the findings of Orangi and her collegues who reported lack of proper channels of communication leading to lack of awareness of the initiative, and a lack of clarity on the benefit package among both the implementers and beneficiaries [ 18 ]. There appeared to be a knowledge and awareness gap among those that had not reached the health facilities.…”

“…The concepts, principles and pathways include: involvement, partnership, community engagement, inclusive participation, equity, basic essential care package, sustainability, output-based incentives and enhanced capacity for quality service provision, easing financial burden for consumers with autonomy and respect, and pathways for attitude change. Several studies [ 18 , 21 – 24 ] have been conducted on the free maternity policy in Kenya. The main focus of our study was to find out the views and perspectives of the Linda mama implementers and consumers using qualitative research methods.…”

“…Same findings have been reported by other researchers. Orangi et alin their study reports that in some cases out of pocket payments were still being levied to beneficiaries of the Linda Mama programme [ 18 ].Cost has been shown to be a barrier to accessing care even in high income settings [ 31 ]. The registration number, the notification, written in their ANC booklets, enabled them to obtain maternity services and postnatal care anywhere in Kenya.…”

“…Phase 3 was rolled out in March 2018. It included expansion of the benefit package to include ANC and PNC care across contracted public, private and faith-based healthcare facilities [ 18 ].…”

Examining the implementation of the Linda Mama free maternity program in Kenya

“…Further, the study did not look at utilisation and user level outcomes as this was examined elsewhere. 52 We suggest that future studies can combine process evaluation of such programs with the utilisation trends over time. However, the study contributes to the literature on implementation experiences and fidelity of health financing reforms in similar low‐and middle‐income countries.…”