Power, interests, and maternal health care a political economy analysis of service delivery redesign in Kenya

The maternal and newborn health (MNH) service delivery redesign (SDR) in Kakamega County, Kenya, represents the country's first system-level reorganization of MNH services. The reform aimed to improve care quality and reduce mortality by centralizing delivery services at designated hubs. Using a political economy lens, we examined how ideology, political dynamics, and institutional structures shaped the agenda-setting, adoption, implementation, and sustainability of SDR. We drew on data from document reviews, stakeholder analysis, semi-structured interviews, and non-participant observation to assess the structural, contextual, and institutional factors influencing the reform. Ambiguity around SDR's purpose contributed to the community's uncertain engagement characterized by neither full endorsement nor resistance, highlighting the need for clearer communication and participation to build ownership. The interaction between formal institutions (county health governance and partnership frameworks) and informal norms (trust, shared interpretation, and relational coordination) created early momentum for implementation, particularly among health system actors. However, limited financial capacity and unclear alignment with national policy priorities undermined progress and long-term viability. Kakamega's experience demonstrates how political incentives, devolved autonomy, and local institutional context jointly shape reform outcomes. Achieving successful implementation of system-level reforms requires integrating local political leadership, strengthening community engagement, aligning with evolving national policies, and securing predictable financing. This study provides practical lessons for future MNH and system-level reforms in Kenya and similar decentralized, resource-constrained settings. Lessons include the importance of balancing formal and informal institutions to ensure both political feasibility and enduring impact.