Written by Marissa Maggio (Communications Specialist, ThinkWell), Anne Musuva (Country Director, ThinkWell Kenya), and Nirmala Ravishankar (Program Director, ThinkWell)

Kenya’s health system has evolved significantly over the past decade; however, one goal remains unchanged—achieving universal health coverage (UHC), the guarantee that every Kenyan has affordable, equitable access to the highest attainable standard of health. And within Kenya’s commitment to this broader vision, the country has prioritized improving maternal health outcomes. As part of its strategy to achieve this goal, Kenya introduced a free maternity policy in 2013 that discontinued all fees for deliveries at public facilities, helping to remove financial barriers preventing women from accessing skilled, facility-based care during childbirth. Then, in 2017, Kenya’s Ministry of Health (MOH) delegated the implementation of this flagship maternal health policy to the National Hospital Insurance Fund (NHIF) under the renamed Linda Mama program. This program gives women who register with the NHIF access to an expanded package of maternal and newborn health services—free of charge—from NHIF-contracted public and private providers.

A recently published study by KEMRI Wellcome Trust and ThinkWell explores the gaps between the design and implementation of the Linda Mama free maternity program. To discuss the study’s key findings, ThinkWell’s Strengthening Strategic Purchasing for Primary Health Care (SP4PHC) project partnered with KEMRI Wellcome Trust and P4H to host a webinar on November 9, 2021 with experts from across Kenya’s health sector.

Moderated by Dr. Anne Musuva, Country Director of ThinkWell Kenya, the webinar included opening remarks from Mr. Claude Meyer, Coordinator of the P4H Network; presentations from Dr. Isabel Maina, Head of Healthcare Financing at Kenya’s Ministry of Health, and Dr. Edwine Barasa, Nairobi Director of the KEMRI Wellcome Trust Research Program; reflections from Mr. Wambugu Kariuki, Head of Beneficiary Management at the NHIF, Dr. Patrick Kibwana, Chief Officer of Health Services at the County Government of Makueni, and Dr. Wangari Ng’ang’a, Senior Health Advisor at the Presidential Policy and Strategy Unit in the Executive Office of the President; a live discussion led by Dr. Anne Musuva; and closing remarks by Dr. Nirmala Ravishankar, Program Director at ThinkWell.

These experts examined the progress made through Linda Mama and how addressing new challenges can inform the country’s broader UHC reform.

Where is Kenya now?

While Kenya has made strides in recent years to improve access to maternal health services, there is still more progress to be made. To highlight how far Kenya has come, experts discussed the country’s progress following the transfer of the Linda Mama program from the MOH to the NHIF. First, the number of mothers who benefitted from the program has increased, from about 321,000 in 2017-2018 to 784,000 in 2020-2021, according to NHIF data. Second, there was a notable jump in the utilization of institutional deliveries, with the percentage of mothers delivering in public facilities increasing from 44% in 2012/13 to a current rate of 79%, according to statistics tracked by the MOH. Third, the government has increased its allocation to the Linda Mama program, demonstrating the country’s commitment to advancing maternal health.

Lessons Learned

Despite Kenya’s progress, there is still room for improvement. Indeed, findings from the study by KEMRI Wellcome Trust and ThinkWell reveal that the transfer of the Linda Mama program solved for some problems—including expanded coverage and improved operational efficiency—but has introduced new operational challenges. This has caused a disconnect between how the program performs on the ground and its intended design. From the webinar discussion, four main themes emerged:

1. Strengthen communication. There is currently a gap in communication between the NHIF, local governments, providers, and beneficiaries, which has caused inconsistencies in implementation. For instance, eligibility criteria for beneficiaries, as well as which services are covered by Linda Mama, is unclear among many patients and providers. This reduces utilization of the program, since many providers and mothers are unaware of the full suite of services available. To address this challenge, lines of regular communication between policymakers, providers, beneficiaries, and frontline workers must be established.

2. Improve integration. In several counties where Kenya’s UHC scheme was piloted, some health providers were unsure about whether the Linda Mama program was discontinued. This suggests that improved integration—and reduced fragmentation of Kenya’s health schemes—is needed. Improved integration and reduced bureaucracy among parallel health schemes may also help improve the timing and flow of funds between the NHIF and public facilities, helping the NHIF to prevent delays when reimbursing facilities for services rendered. These delays deny facilities resources to improve the quality of their services and, often times, puts the cost back onto patients—contrary to the UHC vision of affordable, accessible health coverage. Conversely, encouraging integration will ensure that Linda Mama benefits are preserved, expanded, and complimentary to Kenya’s scale-up of its UHC scheme

3. Adopt a whole systems approach. Beyond health care financing, health reforms should also consider other inputs, processes, and financial barriers that may prevent mothers and newborns from accessing the care they need. For example, because some public facilities lacked access to essential medicines, patients had to pay out-of-pocket or go elsewhere to find commodities that should be free and readily available. And for those who do not live near a health facility, distance can serve as an additional barrier to access by introducing extra costs for transportation. Moreover, benefits packages should be informed by Kenya’s health needs. Currently, some key services are excluded from the Linda Mama benefits package, including coverage for ultrasounds and family planning as part of postnatal care, despite a demonstrated need for these benefits. To address these shortcomings, Linda Mama’s scope of benefits should be expanded and diverse socioeconomic needs—beyond child delivery and postnatal care—should be considered to improve health outcomes for the mother, baby, and entire household.

4. Promote evidence and learning. The NHIF should continually monitor and promote sharing of the latest evidence and learning. By tracking which facilities are staying true to the free maternity policy design and encouraging inter-county dialogue, this may enable the NHIF to move beyond its primary role as a payer to become a strategic purchaser that helps shape the health sector, the behavior of providers, and the success of the Linda Mama program.

Experts remarked at the undeniable progress that Kenya has made through the Linda Mama program to ensure better access to maternal health services. For instance, in Makueni County, the removal of user fees has contributed to a decreased poverty rate and increased quality of care, with more facilities better equipped to manage maternal complications. However, the evaluation conducted by KEMRI Wellcome Trust and ThinkWell has shown that the implementation of the Linda Mama program must continue to improve. To date, Linda Mama is the only universal entitlement program in Kenya available to every mother, regardless of their location and income status. Over time, the Linda Mama program aims to integrate under the national UHC scheme. As Kenya moves towards this goal, the country must ensure that mothers and newborns receive the benefits they need to thrive.

If you want to learn more about ThinkWell’s work in strategic purchasing for primary health care, you can read about it here. You may also watch the full webinar recording below.


Low- and middle-income countries (LMIC) are standing at the beginning of an incredibly challenging vaccine roll-out. COVID-19 vaccine delivery poses unprecedented challenges in terms of delivery volume, reaching new target populations, diversity of delivery strategies, and sometimes complex product profiles—elements that must all be managed at rapid speed if effective coverage is to be achieved. ThinkWell contributed to global level modeled estimates which indicate that the delivery cost of COVID-19 vaccines in LMIC-settings could be several times greater than for routine childhood vaccines. However, these estimates are based on crude assumptions and global level parameters, and real cost evidence from countries is lacking.

ThinkWell is conducting costing studies of COVID-19 vaccine delivery in Bangladesh, Côte d’Ivoire, and Mozambique, and 3-4 other countries to generate rapid economic evidence to support the sustainable roll-out of COVID-19 vaccines. In each country, bottom-up ingredients-based costing and top-down analysis of financial expenditure budgets and reports will be conducted to estimate the cost of delivering COVID-19 vaccines through various delivery strategies, reaching different target populations, and using products with varying cold chain requirements. The studies will also map out the service delivery process and funding flows and capture the source and use of different types of paid and volunteer health workers mobilized to deliver COVID-19 vaccines. Semi-structured interviews will also be conducted with stakeholders to assess the roll-out and its challenges. The studies will follow a common research protocol based on guidance on routine immunization costing methods and the standardized campaign costing methodology developed by ThinkWell.  You can read about previous immunization costing studies here. The first results are expected by April/May 2022.

This work is supported by funding from the Bill & Melinda Gates Foundation. To find out more about this project, please click here.