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

Background: In 2017, Kenya launched the free maternity policy (FMP) that aimed to provide all pregnant women access to mater-nal services in private, faith-based, and levels 3-6 public institu-tions. 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 (n1/421) 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 en-hanced 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 hav-ing leeway to provide FMP services to populations who were excluded from the policy but had to bear the costs. Some dis-charged 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 flex-ibility and agility in implementing the FMP could enhance service delivery, manage the administrative pressures of implementa-tion, and provide mothers with personalized, responsive service. However, despite their benefits, some resulting unintended con-sequences may need interventions.