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Efficiency is an important concern for health systems. This includes delivery of the health care, health financing, and investment on hospital facilities and the management of health facilities. Measurement of efficiency in health facilities is important to ensure maximum allocation and utilization of limited resources. The aim of this study was to estimate efficiency in level IV Kenyan hospitals using data envelopment analysis and stochastic frontier analysis. Panel data were collected from 27 public and faith-based hospitals between 2008 and 2012. Data envelopment analysis (DEA), a non-parametric approach and stochastic frontier analysis (SF A) a parametric approach were applied to the data. Ownership as a factor of efficiency was assessed from the collected samples. The results show evidence of technical inefficiencies across the hospitals. Based on DEA bootstrapped model, the efficiency scores was 0.7597 and 0.7751 for 2011 and 2012 data respectively. Using the cross sectional data set, SFA values were comparable to DEA with an average of 0.7919 and 0.7701 for the 2011 and 2012 data sets respectively. Based on the panel data, the SF A model gave a range of scores that were between 0.62 (Pitt and Lee and Battese and Coelli) and 0.85 (true effect models). There was no evidence of patterns in efficiency scores over time based on both DEA and SF A approaches. This data did not suggest a significant effect on efficiency based on hospital ownership. In conclusion, this study shows presence of technical inefficiencies in Kenyan hospitals. It also provides a platform in exploring further the frontier techniques and incorporating ownership when measuring efficiency in Kenyan hospitals.

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Globally, health systems accountability and engagement are increasingly claimed to be vital means to improve services by providing mechanisms for potential beneficiaries to contribute to the design, implementation, and evaluation of service delivery. In Kenya, these have taken the form of hospital boards, health facility committees, patient and facility service charters, and suggestion boxes. However, there is little information available on the factors that impact on the performance of such accountability mechanisms. This thesis addresses the shortfall, by investigating process issues that influence the performance of accountability initiatives. Primary research was conducted in a rural district through a cross-sectional survey of households clustered around four public health facilities. Following a pilot study, data on accountability mechanisms supporting service delivery were collected through a mapping exercise involving in-depth interviews and facility audits. Data on the use of these were then collected through a large cross-sectional household survey, participant observation and focus group discussions. Analysis focused on accountability mechanisms within the health facilities and on issues around the relationship between those facilities and the local community. This was supplemented by user experiences of services where this was central to an understanding of accountability structures performance. The research identified health facility committees and Service Charters as the main accountability mechanisms adopted. Further analysis showed that four main underlying factors - accessibility/proximity, trust, power and responsibility –influenced both of these. The context of the health system and cultural practices were also important determinants of performance, either constraining or enhancing their impact on service delivery. These findings suggest that emphasis on the structure of accountability and engagement mechanisms, or adopting simple measures of outcome, are unlikely to account for how and why accountability mechanisms perform as they do. Processes that sustain and are sustained by accountability mechanisms need to be considered including the selection process of health facility committee members, the use of effective communication methods with the local community, and appropriate national regulation. In addition, these efforts should always take into account the health needs of the local population, their cultural practices, and the policy context within which these mechanisms are expected to operate.

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.