Equity and access in maternity care during Kenya’s transition from free maternity care to social health insurance: a mixed-methods study in Homa Bay County
This mixed-methods study in Homa Bay County reveals that Kenya's 2024 transition from free maternity care to Social Health Insurance (SHIF) has reproduced and amplified existing inequities in maternal healthcare access, particularly for adolescents, unemployed women, and users of lower-level facilities, due to barriers in timely enrolment, persistent out-of-pocket costs, and limited facility reimbursement.
Original paper licensed under CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/). This is an AI-generated explanation of the paper below. It is not written or endorsed by the authors. For technical accuracy, refer to the original paper. Read full disclaimer
In many parts of the world, the journey to motherhood is fraught with financial uncertainty. A system known as universal health coverage aims to solve this by ensuring that essential medical services are available to everyone without causing financial hardship. For pregnant women, this is especially critical because their needs are predictable and time-sensitive; missing a check-up or a delivery service can have life-or-death consequences. In recent years, many countries have moved away from simply offering free care at the point of service toward social health insurance. This model asks households to contribute money in advance, pooling their resources to pay for care when it is needed. The hope is that this approach creates a more sustainable system that protects families from sudden, crushing costs. However, the shift from a free system to an insurance-based one is complex. It raises a difficult question: does the new system truly protect the most vulnerable women, or does it create new hurdles that leave them behind?
Researchers in Kenya recently set out to answer this question during a major national transition. The country was moving from a policy called "Linda Mama," which offered free maternity care funded by taxes, to a new Social Health Insurance Fund, or SHIF, which requires contributions from households. To understand how this change played out in real life, a team of scientists conducted a detailed study in Homa Bay County, a rural area with high poverty rates and challenging health outcomes. They followed hundreds of pregnant women from their first visit to a clinic through the early weeks after birth. The researchers combined this long-term tracking with in-depth conversations with the women, their families, community health workers, and government officials. Their goal was not just to count how many people signed up for insurance, but to see if the system actually worked for everyone, especially those who were already struggling.
The study revealed that the transition was far from smooth. While the number of women with insurance grew significantly as their pregnancies progressed—rising from less than half at the first clinic visit to more than four-fifths by six weeks after birth—many women gained coverage too late to benefit from early care. The researchers found that the timing of enrollment mattered deeply. Women who were teenagers, unemployed, or lacked official identification documents faced the greatest barriers. In the old system, a young woman could often be registered using a guardian's ID, but the new rules required her own identification or a direct link to an enrolled adult. This created a deadlock for many orphans or girls without family support. Similarly, the requirement for digital registration and access to a mobile phone to receive verification codes proved difficult for women who did not own a phone or whose partners controlled the family device.
Even for those who managed to enroll, the promise of financial protection was often broken. The study showed that women with insurance were more likely to complete their recommended check-ups and give birth in a public hospital compared to those without coverage. However, they still had to pay out of their own pockets for medicines, tests, and supplies. This happened because many local clinics, particularly smaller ones in rural areas, were not yet part of the insurance reimbursement network. A woman could have valid insurance but still be turned away from a local clinic or asked to pay because the facility could not claim the money from the insurance fund. In some cases, women paid the insurance premium and then still had to buy the drugs they needed, effectively paying twice.
The researchers also uncovered how the new system changed the way women were treated. Those without insurance reported receiving a more limited package of care, sometimes skipping essential laboratory tests or supplements because they could not afford the upfront cost. In contrast, women with insurance were more likely to receive these services, but only if they were at a facility that had the right contracts and supplies. The study suggests that the new insurance model, while well-intentioned, has inadvertently widened the gap between the privileged and the vulnerable. It created a situation where access to care now depends not just on medical need, but on having the right documents, the right phone, the right money, and the right facility nearby.
The findings indicate that simply signing up for insurance is not enough to guarantee fair access. The researchers observed that the system's design features, such as strict identification requirements and complex payment calculations, acted as filters that excluded the very people the system was meant to help. Adolescents, refugees, and women in informal work found themselves stuck in a cycle of exclusion. The study concludes that for health reforms to truly succeed, they must be designed with these barriers in mind. It is not enough to have a policy on paper; the system must ensure that coverage is continuous, that local clinics are supported to serve everyone, and that the most vulnerable are not left behind by administrative hurdles. Until these issues are addressed, the transition to insurance risks deepening the inequalities it was meant to fix.
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