Untangling the complexities of the implementation journey of health service delivery redesign in Kenya: a mixed-method process evaluation

Abstract Background We documented the implementation experience of a maternal and newborn healthcare reform known as Service Delivery Redesign (SDR) in Kakamega County, Kenya. This redesign aimed at improving maternal and newborn outcomes by reorganizing care delivery to encourage deliveries in facilities capable of providing definitive care during emergencies. Using an implementation science approach, we conducted a process evaluation to assess implementation fidelity, adoption, and sustainability across multiple health system components. Methods This mixed methods evaluation used data derived from facility surveys, provider assessments, emergency transport data, financial records, key informant interviews, focus group discussions, and in-depth interviews. We examined governance, financing, human resources, and service delivery aspects. Results Implementation success varied across health system components. Political support enabled successful policy development, including the facility improvement fund granting Level 4 facilities financial autonomy. Infrastructure improvements significantly increased bed capacity at Malava (22–39 beds) and Lumakanda (10–26 beds) hospitals, although gaps remained against projected targets (44–68% of long-term needs). The emergency transport system achieved a 90.3% success rate (13,401 of 14,842 cases), with 10–30 minute response times. Emergency Obstetric Care training reached 496 healthcare workers, enhancing their clinical competency. However, complex unintended consequences, including ambulance service misuse, automatic referrals without proper assessment, cultural resistance to ambulance use, diminishing trust in lower-level facilities, and power struggles over financial control, have emerged, creating reinforcing feedback loops that potentially undermine the intervention's intended hierarchical care model. Conclusion While SDR has achieved important improvements in maternal healthcare infrastructure, emergency transport, and financial autonomy, significant implementation challenges and unintended consequences highlight the intricate interconnectedness of health system components. These findings underscore the need for comprehensive health system strengthening that addresses all interconnected elements with adequate resources, robust sustainability mechanisms, and adaptive management approaches to achieve sustainable improvements in maternal and newborn healthcare in resource-limited settings.