Understanding the drivers of change in sexual and reproductive health policy and legislation in Kenya

The thesis explored the drivers and inhibitors of change in sexual and reproductive health (SRH) policy and legislation in Kenya. The overall purpose was to contribute to the limited knowledge on national-level debates that shape how developing countries adapt the SRH agenda, which originated from international processes. The thesis explains how and why some SRH reforms have been realised in Kenya amid contention, while others have been blocked. Guided by a synthesis conceptual framework that emphasised the central role of discursive power in decision-making, the thesis adopted a qualitative case-study design enriched with various anthropological concepts. Three case-studies (two bureaucratic, i.e. adolescent RH policy and national RH policy, and one legislative, i.e. sexual offences law) were deconstructed. Data collection involved semi-structured in-depth interviews with policy actors, observations and note-taking in meetings, and document review. Findings revealed that four influential narratives of SRH – the moral narrative, cultural narrative, medical narrative (with two variations i.e. ‘moralised’ versus ‘comprehensive’ medical narratives), and human rights narrative – underpinned by conflicting actor interests, mediated the interplay of actor networks, knowledge, context and institutions to determine reforms. The findings revealed that the strong entrenchment of the moral and cultural narratives in the Kenyan context (mainly public structures and institutions) was a major barrier to reforms on contested SRH issues. Even then, the hegemonic narratives were in some cases unsettled to make reforms possible. The most important factors in unsettling the hegemonic narratives to facilitate reforms included: a change in the political context that brought in new political actors supportive of reforms, the presence of knowledgeable and charismatic issue champions within political and bureaucratic institutions, the availability of compelling knowledge (scientific or lay) on an issue, sustained evidence-informed advocacy by civil society/non-governmental organisations, donor pressure, and reduced political costs (for politicians and bureaucrats) for supporting reforms. The main contribution of the thesis is three-fold. First, the thesis captures the disconnect between international SRH agreements and national-level realities, showing the need for international actors to consider national-level realities that shape decision-making. Second, its findings provide lessons for informing future SRH reform efforts in Kenya and in other sub-Saharan African countries. Third, its analysis of discursive power contributes to a major theoretical gap in health systems research in developing countries identified as lack of critical analysis of power in decision-making.