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A University of Sussex DPhil thesis Available online via Sussex Research Online: http://sro.sussex.ac.uk/ This thesis is protected by copyright which belongs to the author. This thesis cannot be reproduced or quoted extensively from without first obtaining permission in writing from the Author The content must not be changed in any way or sold commercially in any format or medium without the formal permission of the Author When referring to this work, full bibliographic details including the author, title, awarding institution and date of the thesis must be given Please visit Sussex Research Online for more information and further details UNDERSTANDING THE DRIVERS OF CHANGE IN SEXUAL AND REPRODUCTIVE HEALTH POLICY AND LEGISLATION IN KENYA Rose Ndakala Oronje Doctor of Philosophy Institute of Development Studies University of Sussex September 2013 ii UNIVERSITY OF SUSSEX ROSE NDAKALA ORONJE DOCTOR OF PHILOSOPHY (DEVELOPMENT STUDIES) UNDERSTANDING THE DRIVERS OF CHANGE IN SEXUAL AND REPRODUCTIVE HEALTH POLICY AND LEGISLATION IN KENYA Summary 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. iii Dedication To my son, Mike O. Ochieng’, for bravely bearing the brunt of my absentia during my PhD studies in very early years of his life. To my husband Mr Michael O. Adwera for supporting me throughout the PhD study period. And, to my parents, Mrs Alice N. Oronje and Mr Hannington Oronje, for their unwavering confidence in me, encouragement, and support. iv Acknowledgements This study would not have been possible without the support, cooperation, and advice of many individuals and institutions, and to all of them, I am greatly indebted. I am grateful to the Reproductive Rights Research Programme Consortium (RPC) and specifically the RPC’s Director, Prof. Hilary Standing, for nominating me for the Commonwealth Scholarship. I am also grateful to Prof. Standing for providing me academic advice and support throughout the PhD study period. I am greatly indebted to the Commonwealth Scholarships Commission for funding my PhD studies. I am grateful to the African Population and Health Research Centre (APHRC) for the career opportunity that exposed me to the field of reproductive health and opened up opportunity for pursuing this PhD programme. I am also greatly indebted to the support I have received from the African Institute for Development Policy (AFIDEP) throughout my PhD studies. AFIDEP provided me an institutional home and administrative support during my fieldwork in Kenya, without which my fieldwork would not have been successful. I am also grateful to AFIDEP’s Executive Director, Dr. Eliya Zulu, for the academic advice, support and encouragement he provided me throughout my PhD studies. I would like to thank all the people who spared their time to share their experiences, knowledge and insights with me during my fieldwork period. I am especially grateful to individuals I interviewed from various government and non-government institutions involved in the SRH subsector in Kenya. I am greatly indebted to my supervisors, Dr. Hayley MacGregor and Dr. Andy Sumner, for their critical insights and untiring support throughout the PhD process. I would also like to thank Angela Dowman for the administrative support and advice she provided me throughout my PhD studies at IDS. I would also like to appreciate the support from the larger IDS fraternity. I am particularly grateful to the IDS fellows from the VPR and KNOTS teams who provided critical insights on my thesis at different stages of the PhD. I am also grateful to fellow PhD students at IDS for the academic and emotional support, which greatly made the PhD journey bearable and less lonely. I would also like to thank the staff at the British Library for Development Studies (BLDS) for offering me a part-time work opportunity in the BLDS, which greatly contributed to meeting my financial needs while in the UK. Finally, I would like to thank my family including my son, my husband, my parents and siblings for their unwavering support and encouragement throughout my PhD studies. Their words of encouragement made a big difference in times when things seemed tough and unbearable. v Table of Contents Summary ......................................................................................................................................... ii Dedication ..................................................................................................................................... iii Acknowledgements ....................................................................................................................... iv List of Tables ............................................................................................................................... viii List of Figures.............................................................................................................................. viii List of Appendices....................................................................................................................... viii List of Abbreviations and Acronyms............................................................................................ ix Chapter 1: Introduction ................................................................................................................... 1 1.1 Sexual and Reproductive Health: Contested Origins, Contested Reality ............................ 4 1.2 Background on Kenya ............................................................................................................. 7 1.2.1 The SRH Challenge in Kenya .......................................................................................... 7 1.2.2 Policy and legal framework guiding Kenya’s health sector ............................................ 8 1.3 Research Problem................................................................................................................... 13 1.4 Chapter Outline ...................................................................................................................... 16 Chapter 2: Concepts and Methods ............................................................................................... 17 2.1. Introduction ........................................................................................................................... 17 2.2 Conceptual Framework: What Accounts for SRH Policy Change in Kenya? ................... 17 2.2.1 Discursive power ............................................................................................................. 20 2.2.2 Actor interests and networks as power ......................................................................... 23 2.2.3 Knowledge as power ......................................................................................................