Implementation of the free maternity services policy and its implications for health system governance in Kenya

Abstract

IntroductionTo move towards universal health coverage, the government of Kenya introduced free maternity services in all public health facilities in June 2013. User fees are, however, important sources of income for health facilities and their removal has implications for the way in which health facilities are governed.ObjectiveTo explore how implementation of Kenya’s financing policy has affected the way in which the rules governing health facilities are made, changed, monitored and enforced.MethodsQualitative research was carried out using semistructured interviews with 39 key stakeholders from six counties in Kenya: 10 national level policy makers, 10 county level policy makers and 19 implementers at health facilities. Participants were purposively selected using maximum variation sampling. Data analysis was informed by the institutional analysis framework, in which governance is defined by the rules that distribute roles among key players and shape their actions, decisions and interactions.ResultsLack of clarity about the new policy (eg, it was unclear which services were free, leading to instances of service user exploitation), weak enforcement mechanisms (eg, delayed reimbursement to health facilities, which led to continued levying of service charges) and misaligned incentives (eg, the policy led to increased uptake of services thereby increasing the workload for health workers and health facilities losing control of their ability to generate and manage their own resources) led to weak policy implementation, further complicated by the concurrent devolution of the health system.ConclusionThe findings show the consequences of discrepancies between formal institutions and informal arrangements. In introducing new policies, policy makers should ensure that corresponding institutional (re)arrangements, enforcement mechanisms and incentives are aligned with the objectives of the implementers.

Health system governance following devolution: comparing experiences of decentralisation in Kenya and Indonesia

“… 30 44 The picture within Kenya so far appears mixed, with national government having introduced policy for free maternity services around the same time as devolution reforms were introduced, leading to increased utilisation of services. 45 However, success of this policy has been complicated by uncertainty created by devolution and poor planning, with health facilities having been inadequately compensated for lost fees, leading health workers to raise revenue from patients, with implications for the most poor. 45 Additionally, in Kenya, we found that politicians frequently gave preference to priorities deemed as popular with the electorate, such as construction of new health facilities or purchase of ambulances.…”

“… 45 However, success of this policy has been complicated by uncertainty created by devolution and poor planning, with health facilities having been inadequately compensated for lost fees, leading health workers to raise revenue from patients, with implications for the most poor. 45 Additionally, in Kenya, we found that politicians frequently gave preference to priorities deemed as popular with the electorate, such as construction of new health facilities or purchase of ambulances. 33 These were frequently referred to as ‘high vote’ priorities, meanwhile health promotion or disease prevention activities were not viewed as politically favourable.…”

Effective coverage and budget implications of skill-mix change to improve neonatal nursing care: an explorative simulation study in Kenya

“…In prior work, we have demonstrated that four public hospitals currently provide care to 71% of all sick newborns being admitted to facilities capable of providing care 24 hours a day 7 days a week in Nairobi City County 19. The national and county government finance neonatal care in these hospitals as part of a national free maternity care programme, although in one tertiary hospital copayments are required from families 20 21…”

Litigating to ensure access to quality maternal health care for women and girls in Kenya

“…The lack of certainty about the services covered under the Directive means women still have to purchase medicines and other necessities for delivery, while the service providers' workload is still greatly increased. 15…”