Implementation pathways of a health services delivery redesign model to improve maternal and newborn outcomes in Kenya

Persistent high maternal and neonatal mortality rates in low- and middle-income countries (LMICs) call for system-level improvements in healthcare services. However, implementing such health system strengthening interventions presents challenges due to the complex, context-specific interactions inherent in these settings.This paper presents implementation pathways of a service delivery redesign (SDR) model in Kakamega County, Kenya, offering insights into how complex health systems strengthening interventions can improve maternal and neonatal health (MNH) outcomes at scale in an LMIC setting. Drawing on a theory-of-change approach, key factors influencing the supply and demand of MNH services were identified and organised into a conceptual framework. Causal relationships were mapped through a participatory group model-building workshop into causal loop diagrams, and strategies were proposed to address barriers and facilitators to the SDR implementation process.Several critical factors were identified along causal pathways as essential to implementation success. At the community level, building trust for expectant mothers in the health system reinforces use of quality services. Across facilities, having a well-functioning and efficient referral system ensures timely, coordinated multilevel care that improves patient outcomes. Between the facility and policy level, a delicate balance between meeting increased demand for services with available resources and available resources with supportive financial policies needs to be maintained. Across these system functions, trust emerges as a key factor initiating and reinforcing positive patterns. Prioritising efforts that encourage co-creation, ongoing coordination and engagement among relevant actors to build trust bolsters individual strategies (to increase demand, improve referral, build service readiness) and is key to improving MNH outcomes.