June 18th, 2026

What can we learn from the Lea Mama programme in Kenya regarding contexts where access to maternal and neonatal care has increased but health outcomes are inconsistent?

Across many health systems, policy and funding debates have focused on increasing access, which means increasing health care facilities and utilisation. While these steps are necessary and can be impactful, greater service volume does not automatically produce better outcomes. Kenya’s maternal and neonatal experience illustrates this tension. Sustained investments in access and utilisation have not yet yielded outcomes aligned with Sustainable Development Goal goals. This pattern appears globally, in both emerging and advanced systems, where structural incentives, provider behaviour, and care quality often matter more than mere service volume.

Responding to this tension, the Lea Mama programme came to life as a multi-sector collaboration between FSD Kenya, (a donor funded trust) and Britam Micro-insurance Company (K) Limited (an impact led insurer). The programme began with these core propositions: health outcomes improve when: i) health systems centre care around their users and prioritise outcomes over more services, and ii) healthcare users have the information and tools to follow appropriate care pathways. The programme treated many outcome gaps as system design issues—aligning incentives, information, and behaviours — rather than solely problems of clinical capability.

Reframing the challenge: Beyond the access narrative

Health system reform often begins with questions of coverage and infrastructure. While these remain important, they don’t fully address drivers of maternal and neonatal outcomes. Complications during pregnancy and delivery are highly sensitive to timing, coordination, and decision quality. Increasing contact with the health system doesn’t help if those encounters fail to deliver appropriate, respectful, evidence-based care.

Several structural factors explain the disconnect between access and outcomes:

• Variability in patient experience and engagement.
• Payment/purchasing mechanisms that reward volume rather than outcomes.
• Limited data feedback loops linking managerial and financing decisions with demonstrated clinical and cost outcomes.
• Fragmented or misaligned provider incentives.

There is need to shift focus from “more care” to “better-aligned care” to systems that support timely, coordinated, and high-quality decisions.

The value-based orientation

Lea Mama’s value-based design sought to realign relationships within the care ecosystem rather than layer on additional interventions. Three forms of alignment were central:

Collectively, these mechanisms reflect a broader insight: transformation often requires reshaping incentives and feedback loops more than adding resources.

Care-seeking patterns: early signals of change

Utilisation metrics alone don’t guarantee better outcomes, yet they can indicate meaningful behavioural shifts. Since pilot inception, Lea Mama reported:

• 76% initiated ante natal care (ANC) visits within the first trimester.
• 94% of enrolled mothers completed four or more ANC visits.
• 25% achieved eight or more visits.

High rates of ≥4 visits and early first-trimester entry suggest improved alignment with preventive goals and risk detection. Early engagement during the pregnancy journey increases the chance of identifying hypertension, gestational diabetes, anaemia, and other risks before complications escalate. Importantly, these utilisation changes were driven by education, digital prompts, and structured patient support rather than penalties, illustrating that patients respond to education initiatives, continuity, and reduced navigation friction.

Quality and cost: rethinking the relationship

Debates often treat quality and cost as competing priorities. Value-based approaches challenge this by emphasising appropriateness and predictability. In Lea Mama:

• Caesarean section rates remained close to planned targets and lower than broader system averages.
• Length-of-stay distributions tracked expected norms – deviations were typically clinically justified (e.g., neonatal complications).
• Cost variation needs contextual interpretation: not all deviations signal inefficiency—some reflect appropriate clinical responses. Thoughtfully implemented value-based care prioritises explaining cost through clinical logic, not simply minimising expenditure.
• Readmission rates were lowered across the pilot facilities showing nil 30-day all-cause readmissions against a pre-programme baseline of 1.7%. Although the small sample size (386 deliveries) and variable reporting across facilities warrants cautious interpretation, this pattern is an encouraging signal of improved care quality and continuity. Low readmission rates are particularly significant economically to Britam since avoidable readmissions had been cited as a major driver of unnecessary healthcare expenditure. Fewer readmissions typically translate into reduced hospital costs, lower claims volatility for the insurer and hence better prospects for the product’s commercial viability. Significantly, the fewer readmissions also translated to less out of pocket expenditure and emotional burden for patients.
• Overall maternity related claims decreased by 4% relative to the 2023-2024 baseline.

Delivery outcomes: interpreting early indicators

Programme delivery metrics showed:

• 386 deliveries
• 3 NICU admissions
• 0 maternal deaths
• 0 maternal ICU admissions
• 3 neonatal deaths due to birth asphyxia
• 9.4/10 NPS (80% response rate)

Again, these metrics indicate directional improvement. Pilot and network-scale datasets require statistical and contextual caution. Their broader significance which lies in suggesting improved system function: better coordination, guideline adherence, and patient experience often precede measurable population-level outcome shifts. The strong experience of care metrics achieved on the programme, sometimes dismissed as “soft’’, can be early indicators of deeper change; respectful care and clear communication which influences both clinical decisions and patient behaviours.

Provider dynamics: the adaptive challenge

Lea Mama’s experience underscores a familiar reality: the largest barriers to value-based reform are often adaptive, not technical. Identified challenges included:

• Variable familiarity with value-based concepts among providers,
• Inconsistent outcomes reporting practices, and
• Institutional resistance rooted in culture and existing workflows.

Contractual changes alone rarely produce sustained behaviour change. The desired programme changes were driven by a trust-centred engagement strategy with healthcare facilities and clinicians including:

• Joint capacity-building workshops,
• Collaboration between the clinicians, facility managers and the insurer on Programme indicators and outcomes for tracking,
• Collaborative incentive design,
• Transparent data-sharing, and
• Creation of peer learning platforms for knowledge sharing.

Intentional trust building functioned as critical infrastructure for programme success; providers were more engaged with measurement when data was framed as a tool for improvement rather than surveillance.

Data systems: from reporting to learning

Improved data sharing across facilities illustrated that measurement problems are often about incentives and governance, not just technology. When data is treated as an administrative burden, quality stagnates. When data are instruments for shared learning and visible performance improvement, participation grows. Designing feedback loops that visibly connect measurement to decisions is essential.

Lessons for funders and system leaders

Key insights from the programme’s trajectory:

• Quality is relational as well as technical: protocols matter, but so do communication, coordination, and user experience.
• Provider engagement is central: behavioural and cultural adaptation are core components of reform.
• Measurement requires humility: early indicators inform learning; over-interpretation risks misdirecting strategy.

Looking ahead: from pilot logic to system logic

Forward recommendations: Expanded outcomes-based contracting to other facilities within the pilot network, strengthened reporting frameworks, and ongoing cost–benefit analysis reflect a maturation pathway grounded in institutional learning rather than rapid replication. Sustainable transformation tends to emerge through normalisation of practices, not mere scaling of pilots.

Final reflection

Improving maternal and neonatal outcomes is frequently framed as a problem of innovation or resource mobilisation. Lea Mama points to a different emphasis: outcomes improve when incentives, behaviours, and information flows are deliberately aligned around value. Health systems rarely lack knowledge of effective clinical practices. What they often lack are alignment mechanisms enabling consistent delivery of quality. While the technical challenges are significant, it is the adaptive work i.e. reshaping expectations, relationships, and incentives, which determines programme success. Progress may depend less on discovering new solutions than on reorganising how existing capabilities are supported, measured, and rewarded.

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