Kenya introduced free maternity services (FMS) in 2013 to enable all pregnant women to give birth for free in all government public health facilities. Currently, Kenya is rolling out universal health coverage (UHC), which has been acknowledged as a priority goal for every health system and part of the ‘Big Four Agenda’ for sustainable national development in Kenya. FMS is one of the core services in Kenya, but since its launch, it is not clear whether the decentralized approach chosen to implement FMS is leading to UHC. This nine-month ethnographic study in Kilifi County, Kenya, was conducted between March-July 2016 and FebruaryJuly 2017. A narrative approach to analysis was applied. In this article, we interrogate local perceptions of participation during the crafting and implementation of FMS. Findings show that FMS was detached from local realities, and this was a major inadequacy of the top to bottom approach. FMS did not consider local power relations and bargaining power which are requisites during policy formulation and implementation. The participants expressed desire for more localized control over resources from the national government. The findings suggest that as UHC is rolled out in Kenya, consultation of local stakeholders at the grassroots by the state departments would likely improve maternal healthcare outcomes. Such consultations must take into consideration differences in bargaining power and local power relations. Borrowing from the basic tenets of the recent anthropological theorization of constitutionality, this article proposes a bottom to top approach that leverages and integrates local views during policy-making process to create trust, a sense of ownership and accountability. (Afr J Reprod Health 2023; 27 [5s]: 71-81).

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Obermeyer M. The Cultural Context of Reproductive

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Health : Implications for Monitoring the Cairo

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Agenda The Cultural Context of Reproductive

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Health : Implications for Monitoring the Cairo

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Agenda. 25, (2018).

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Obermeyer, M. Cultural perspectives on reproductive

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health. (Oxford University Press, Inc., 2001).

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Ombere SO. Local Perceptions of Social Protection

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Schemes in Maternal Health in Kenya : Ethnography

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in Coastal Kenya (PhD Thesis). PhD Thesis (2018).

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Ombere SO, Haller T and Nyambedha E. Cultural Practices

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During Pregnancy and Birth Among the Giriama

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Community in Coastal Kenya : A Qualitative Study.

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Int. J. Childbirth 11, 154–165 (2021).

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Atchessi N, Ridde V and Zunzunegui MV. User fees

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exemptions alone are not enough to increase

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indigent use of healthcare services. Health Policy

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Plan. 31, (2016).

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Bolsewicz AK, Hipgrave D and Jimenez-Soto E. Public

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Engagement in Health Priority Setting in Low- and

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Middle-Income Countries: Current Trends and

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Considerations for Policy. PLoS Med. 10, 8–10

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(2013).

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Kamuzora P, Maluka S, Ndawi B, Byskov J and Hurtig AK.

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Promoting community participation in priority

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setting in district health systems: experiences from

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Mbarali district, Tanzania. Glob. Health Action 6,

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(2013).

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Salter B. Patients and doctors: Reformulating the UK health

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policy community? Soc. Sci. Med. 57, 927–936

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(2003).

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Coleman W and Pearl A. Internationalized Policy

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Environments and Policy Network Analysis. Polit.

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Stud. 47, 691–709 (1999).

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Munge K and Briggs AH. The progressivity of health-care

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financing in Kenya. 912–920 (2014)

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doi:10.1093/heapol/czt073.

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Mwabu GM and Mwangi WM. Healthcare financing in

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Kenya: A simulation of welfare effects of user fees.

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Soc. Sci. Med. 22, 763–767 (1986).

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World Health Organization (WHO). Health financing

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reform in Kenya: assessing the social health

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insurance proposal (No. EIP/HSF/DP. 06.1).

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(2006).

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Owuor HO, Asito SA and Adoka SO. The differential

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effect of the free maternity services policy in Kenya.

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African J. Prim. Heal. Care Fam. Med. 11, 1–6

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(2019).

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National Hospital Insurance Fund (NHIF). Linda Mama

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Services.

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http://www.nhif.or.ke/healthinsurance/lindamamaS

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ervices (2016).

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Masaba BB and Mmusi-Phetoe RM. Free Maternal

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Healthcare Policy in Kenya; Level of Utilization and Barriers. Int. J. Africa Nurs. Sci. 13, 100234 (2020).

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Sidze EM. Kenya maternity fee waiver is great - but there

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are still gaps in the policy. (2017).

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Ochieng BM, Kaseje M, Kaseje DCO, Oria K and Magadi

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M. Perspectives of stakeholders of the free maternity

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services for mothers in western Kenya: lessons for

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universal health coverage. BMC Health Serv. Res.

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, 1–18 (2022).

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Pyone T, Smith H and Van Den Broek N. Implementation

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of the free maternity services policy and its

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implications for health system governance in Kenya.

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BMJ Glob. Heal. 2, 1–11 (2017).

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Okungu V, Chuma J and Mcintyre D. The cost of free

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healthcare for all Kenyans : assessing the financial

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sustainability of contributory and non-contributory

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financing mechanisms. 1–13 (2017)

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doi:10.1186/s12939-017-0535-9.

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Gitobu CM, Gichangi PB and Mwanda WO. The effect of

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Kenya’s free maternal health care policy on the

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utilization of health facility delivery services and

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maternal and neonatal mortality in public health

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facilities. BMC Pregnancy Childbirth 18, 1–11

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(2018).

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Lee E, Madhavan S and Bauhoff S. Levels and variations

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in the quality of facility-based antenatal care in

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Kenya: Evidence from the 2010 service provision

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assessment. Health Policy Plan. 31, 777–784

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(2016).

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Muinde JVS and Prince RJ. A new universalism?

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Universal health coverage and debates about rights,

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solidarity and inequality in Kenya. Soc. Sci. Med.

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(2022)

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doi:10.1016/j.socscimed.2022.115258.

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Chrispinus T and Ltumbesi S. Analysis of Universal Health

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Coverage and Equity on Health Care in Kenya.

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(mysql): SELECT * FROM metadata_descriptions WHERE assoc_type = 1048579 AND assoc_id = 114957 ORDER BY metadata_description_id DESC  

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Glob. J. Health Sci. 8, 218–227 (2015).

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Chuma J and Okungu V. Viewing the Kenyan health

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system through an equity lens: Implications for

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universal coverage. Int. J. Equity Health 10, 1–14

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(2011).

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Barasa E, Rogo K, Mwaura N and Chuma J. Kenya

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national hospital insurance fund reforms:

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(mysql): SELECT * FROM citation_settings WHERE citation_id = '114964'  

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Implications and lessons for universal health

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coverage. Heal. Syst. Reform 4, 346–361 (2018).

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World Health Organization (WHO). Universal health

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coverage (UHC). https://www.who.int/newsroom/fact-sheets/detail/universal-health-coverage-

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(uhc) (2019).

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World Health Organization (WHO). WHO

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recommendations on health promotion interventions

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for maternal and newborn health 2015. (2015).

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Mulupi S, Kirigia D and Chuma J. Community perceptions

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of health insurance and their preferred design

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features : implications for the design of universal

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health coverage reforms in Kenya. (2013).

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World Health Organization (WHO). Tracking universal

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health coverage. 2017 global monitoring report.

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(2017).

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Chuma J and Okungu V. Viewing the Kenyan health

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system through an equity lens: Implications for

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universal coverage. Int. J. Equity Health 10, 1–14

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(2011).

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Chuma J and Maina T. Catastrophic health care spending

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and impoverishment in Kenya. BMC Heal. Serv.

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Res. 1–9 (2012).

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Wagstaff A. Measuring financial protection in health.

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Perform. Meas. Heal. Syst. Improv. Exp. Challenges

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Prospect. 114–137 (2008)

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doi:10.1017/CBO9780511711800.006.

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Whitehead M, Dahlgren G and Evans T. Equity and health

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sector reforms: Can low-income countries escape

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the medical poverty trap? Lancet 358, 833–836

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(2001).

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Kenya National Bureau of Statistics (KNBS). 2019 Kenya

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Population and Housing Census Volume 1:

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Population by County and Sub-County. vol. I

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(Kenya National Bureau of Statistics, 2019).

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Kenya National Bureau of Statistics & ICF International.

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Kenya 2014 Demographic and Health Survey Key

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Findings. vol. 6 (KNBS and ICF International,

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.

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Republic of Kenya. Status of implementation of free

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maternity services (FMS) program in the devolved

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health system in Kenya. (Ministry of Health, 2015).

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Tama E, Molyneux S, Waweru E, Tsofa B, Chuma J and

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Barasa E. Examining the Implementation of the Free

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Maternity Services Policy in Kenya: A Mixed

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Methods Process Evaluation. Int. J. Heal. Policy

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Manag. 7, 603–613 (2018).

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Wamalwa E, Osuga B and Adoyo M. Implementation of

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Free Maternity Services Policy in Kenya: Health

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Workers’ Attitude and Involvement. 1, 5986240–

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(2015).

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Meessen B, Hercot D, Noirhomme M and Bicaba A.

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Removing user fees in the health sector in lowincome countries : a multi-country review. (2017).

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Minkler, M. Community-based research partnerships:

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Challenges and opportunities. J. Urban Heal. 82, 3–

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(2005).

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Loewenson R, Flores W, Shukla A, Kagis M, Baba A,

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Ryklief A, Mbwili-Muleya C and Kakde D. Raising

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the profile of participatory action research at the

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global symposium on health systems research.

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MEDICC Rev. 13, 35–38 (2011).

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Kamanda A, Embleton L, Ayuku D, Atwoli L, Gisore P,

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Ayaya S, Vreeman R and Braitstein P. Harnessing

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the power of the grassroots to conduct public health

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research in sub-Saharan Africa : a case study from

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western Kenya in the adaptation of communitybased participatory research ( CBPR ) approaches.

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Haller T and Merten S. Crafting Our Own Rules:

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Constitutionality as a Bottom-Up Approach for the

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development of By-Laws in Zambia. Hum. Ecol. 46,

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Haller T, Acciaioli G and Rist S. Constitutionality:

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Conditions for Crafting Local Ownership of

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Institution-Building Processes. Soc. Nat. Resour. 29,

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Mbugua S and Kerry M. Maternal Health Indicators in

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High-Priority Counties of Kenya: Levels and

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Inequities. DHS Further Analysis Reports No.110.

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(ICF, 2018).

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Braun V and Clarke V. Successful qualitative research: A

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practical guide for beginners. (Sage, 2013).

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Rifkin SB. Examining the links between community

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participation and health outcomes: A review of the

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literature. Health Policy Plan. 29, ii98–ii106 (2014).

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Pratt B. Community engagement in global health research

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that advances health equity. 454–463 (2018)

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doi:10.1111/bioe.12465.

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Pratt B. Inclusion of Marginalized Groups and

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Siddiqui FR. Annotated bibliography on participatory

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consultations to help aid the inclusion of

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marginalized perspectives in setting policy agendas.

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of community participation in health programmes.

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Gilson L. Trust and the development of healthcare as a

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social institution. Soc. Sci. Med. 56, 1453–1468

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mean affordable : maternity patient expenditures in

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a public hospital in Bangladesh. 7, 1–7 (2005).

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Abolition of user fees: The Uganda paradox. Health

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Policy Plan. 26, (2011).

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Kruk ME, Mbaruku G, Rockers PC and Galea S. User fee

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exemptions are not enough: Out-of-pocket payments

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for ‘free’ delivery services in rural Tanzania. Trop.

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Ombere, S. Access to Maternal Health Services During the

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COVID-19 Pandemic: Experiences of Indigent

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Mothers and Health Care Providers in Kilifi County,

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Dalinjong PA, Wang AY and Homer CSE. Has the free

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maternal health policy eliminated out of pocket

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payments for maternal health services? Views of

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women, health providers and insurance managers in

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Kehr J, Muinde JV and Prince RJ. Health for all? Pasts,

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presents and futures of aspirations for universal

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healthcare. Soc. Sci. Med. 115660 (2023)

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doi:10.1016/j.socscimed.2023.115660.

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Prince R. Beyond Failure. Soc. Anthropol. Soc. 30, 56–80

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Faye P, Haller T and Ribot J. Shaping Rules and Practice

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for More Justice. Local Conventions and Local

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Resistance in Eastern Senegal. Hum. Ecol. 46, 15–

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Haller T, Acciaioli G and Rist S. Constitutionality:

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Conditions for Crafting Local Ownership of

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Ensminger, J. Making a market: The institutional

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