The policy formulation process, and the role of actors in the policy formulation and implementation process: A policy analysis of the Kenyan free maternity policy

Kenya is one of the many African countries committed to advancing its health system reforms by providing affordable and equitable access to essential health services. In 2016, the Government of Kenya unveiled an expanded free maternity care policy called ‘Linda Mama’ to provide essential health services for pregnant women. We explored the agenda setting and the formulation of this policy to understand the processes, content and context, and the role of the actors in the formulation and implementation. We conducted an exploratory qualitative study, which involved document review, key informant interviews (KIIs) with national stakeholders, and in-depth interviews with County officials and health care workers (HCWS). We used a theoretical framework capturing the preliminary situation analysis of the policy, the processes, the content, and the stakeholders' roles in the formulation and implementation. This study was conducted in three facilities (levels 3, 4, and 5) in Kiambu County in Kenya. Data were audio-recorded, transcribed and analysed using a framework thematic approach. We found that the priorities of the policy were mainly to meet a political campaign agenda but also align them with the objectives of the country's legal and policy-guiding instruments and the global goals of SDGs that sought to improve the quality of maternal and neonatal care and eliminate financial barriers. The policy also sought to enhance access to skilled birth attendance (SBA), and its redesign filled the challenge of the previous policy. The stakeholders (bureaucrats, professional bodies, public and developmental partners) influenced the processes of the formulation and the content of the policy through their power to put forward and advocate for specific ideas through issues framed in a political and socioeconomic context. Several stakeholders played different roles in the formulation and implementation based on their interests, power and position in the ecosystem of the policy. Policy formulation or change requires the agents to work within the relevant context, stakeholder interests, power, ideas and framing of issues. ### Competing Interest Statement The authors have declared no competing interest. ### Funding Statement This study was funded by the Commonwealth Scholarship Commission [KECS-2017-266], which supported BO's PhD study. The funding agency did not play any role in the analysis, interpretation of results, and manuscript writing. ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: Ethical approval for this study was obtained from the University of Kent, the SSPSSR Students Ethics Committee and the AMREF Scientific and Ethics Review Unit in Kenya (Ref: AMREF ESRC P537/2018). Further, we received permission to conduct the study from all the healthcare facilities where the study was conducted and additional clearance to conduct research from the County Government of Kiambu, Department of Health Services (Ref. No: KIAMBU/HRDU/AUTHO/2018/10/31/Oyugi B). We also got written informed consent from the respondents before conducting the interviews, after informing them about the purpose of the study and their right to withdraw consent at any point. They were also assured of their confidentiality, and that their data would be reported in an aggregated format, and anonymised to protect their identities, throughout the course of this study. I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes All data generated or analysed during this study are included in this published article as quotations. The original qualitative data are not made available since some responses contain potentially identifiable information at multiple levels, including for individuals, health facilities, and organisations. The Institutional Review Board conditions stipulated that participants would not be at risk of identification through their responses participant consent forms did not include obtaining explicit consent regarding the possible use of anonymised data in the public domain via a data repository. For non-author contact information for enquiries about data access, please email dataprotection@kent.ac.uk