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.