A scoping review of agenda setting and implementation of the free emergency obstetric care policy in sub Saharan Africa from 2007 to 2024

Sub-Saharan Africa continues to experience the highest maternal mortality rates globally. In response, several countries have adopted free maternal healthcare policies to reduce inequities in access and utilization of services. This study aimed to synthesize existing evidence on the drivers of agenda-setting for these policies and assess the effectiveness of their implementation across the region. This was a scoping review of the literature, analyzing data from 40 studies published between 2007 and 2024 in sub-Saharan Africa. Kingdon’s multiple streams framework guided the analysis of data on the agenda-setting of free policy. Poor maternal and child health indicators were the main catalysts pushing free maternal healthcare policies onto political agendas. Francophone countries primarily adopted user fee exemptions or targeted free delivery and caesarean services, whereas Anglophone countries tended to expand insurance schemes covering a wider range of maternal and child health services. Internal political drivers included electoral dynamics, leadership changes, and the pursuit of state legitimacy, while external influences involved international advocacy and donor funding. Implementation remained uneven due to delayed reimbursements, policy misinterpretation, stock-outs, patient out-of-pocket expenses, and provider workload and demotivation. Free maternal healthcare policies in sub-Saharan Africa emerged from both domestic health challenges and global advocacy. However, persistent implementation barriers highlight the need for context-specific approaches. Strengthening policy clarity, ensuring timely financing, supporting healthcare providers, and securing essential supplies are key to achieving equitable and sustainable maternal healthcare delivery within the region.