M and E Advisory Group, Nairobi, Kenya.
Centre for Health Services Studies, University of Kent, Canterbury, United Kingdom.
Glob Health Sci Pract. 2023 Oct 30;11(5). doi: 10.9745/GHSP-D-23-00083.
In 2017, Kenya launched the free maternity policy (FMP) that aimed to provide all pregnant women access to maternal services in private, faith-based, and levels 3-6 public institutions. We explored the adaptive strategies health care workers (HCWs) and county officials used to bridge the implementation challenges and achieve the FMP objectives.
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 (n=21) 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.
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 enhanced 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 having leeway to provide FMP services to populations who were excluded from the policy but had to bear the costs. Some discharged mothers immediately after birth, even before offering the fully costed policy benefits, to avoid incurring additional costs.
The role of policy implementers and the built-in flexibility and agility in implementing the FMP could enhance service delivery, manage the administrative pressures of implementation, and provide mothers with personalized, responsive service. However, despite their benefits, some resulting unintended consequences may need interventions.
2017 年，肯尼亚推出了免费产妇政策（FMP），旨在为所有孕妇提供在私立、信仰和 3-6 级公立机构获得产妇服务的机会。我们探讨了医疗保健工作者（HCWs）和县级官员为克服实施挑战并实现 FMP 目标而采用的适应策略。
我们在肯尼亚基安布县的 3 个设施（3 级、4 级和 5 级）中使用 Lipsky 的理论框架进行了探索性定性研究。研究包括对县级官员、设施负责人和 HCWs 以及来自国家和发展伙伴机构的主要利益相关者进行深入访谈（n=21）。数据以音频记录，转录，并使用框架主题方法进行分析。
结果表明，HCWs 和县级官员采用了几种策略，这些策略对塑造 FMP 的决策制定、工作实践以及专业精神和道德方面至关重要。决策制定策略：医院雇用了额外的员工，县制定了章程以加强资金流动。工作实践策略：医院和 HCWs 加强了患者转诊，设施加强了沟通。专业精神和道德策略：护士注册并为母亲提供服务，设施将员工纳入规划和预算编制。适应不良包括设施有回旋余地向政策排除但必须承担费用的人群提供 FMP 服务。一些母亲在分娩后立即出院，甚至在提供全额成本政策福利之前，以避免产生额外费用。
政策执行者的角色以及实施 FMP 时内置的灵活性和敏捷性可以增强服务提供，管理实施的行政压力，并为母亲提供个性化、响应性的服务。然而，尽管它们有好处，但一些由此产生的意外后果可能需要干预。
