Aplicaciones con el modelo DEA

In Chapter 3, the thesis identified four influential narrative framings of SRH underpinned by different actor interests, values, beliefs and ideas, which compete to influence policy reforms in Kenya. These include SRH as a moral issue, SRH as a cultural issue, SRH as a medical issue, and SRH as human rights. The moral and cultural narratives, promoted mainly by religious leaders and politicians, focus on controlling the sexuality and

reproduction of individuals (especially girls, women and sexual minorities). The medical narrative is underpinned by biomedical science and is promoted by medical professionals driven by their interests to maintain their conventionally powerful position in health policy decision-making, given their technical medical expertise. Within Kenya’s health

bureaucracy, however, the medical narrative has been moralised to exclude sensitive SRH issues given the hegemonic moral narrative. Given the medical narrative’s biomedical basis, it is presented as objective and neutral from interests, politics and ideology. However, as discussed in Chapters 3 and 8, biomedical science is not neutral since its production is influenced by contextual interests (Lock and Nguyen 2010; Pigg and Adams 2005). The dominance of the narrative in Kenya’s health bureaucracy has marginalised other types of knowledge and actors lacking biomedical expertise in decision-making. The rights narrative is mainly promoted by international-type actors (donors and UN agencies) and legal and women’s rights organisations, and is driven by the need to eliminate discrimination and control to enable marginalised groups that have no voice in policy debates to live sexual and reproductive lives of their choice. The rights narrative frames of freedom and equality are viewed by actors behind the moral and cultural narratives as threatening. Consequently, the narrative attracts strong opposition in SRH decision-making processes in Kenya. As is evident, the narratives are not entirely independent of each other and the boundaries between them are somewhat blurred as some narratives overlap to reinforce each other in facilitating or blocking reforms. The moral and cultural narratives are interconnected by their focus on controlling individuals’ sexuality and reproduction; the two narratives interact and reinforce each other to produce often overwhelming opposition to

policy/legislative proposals for addressing sensitive SRH issues in Kenya. Moreover, the moralised medical narrative is a product of the influence of the moral narrative on the medical narrative. The SRH rights narrative is at conflict with the moral and cultural narratives because it focuses on freedom and choice, while marginalising control. All the sensitive SRH issues that the narrative frames as ‘human rights’ and therefore deserving attention by government are strongly opposed by the two narratives as ‘immoral’ and

‘unAfrican’. Given the strong opposition to the rights narrative in Kenya, actors often mask the narrative in medical arguments, thus combining the medical and rights narratives. What is important is that through the narratives, different policy actors altered the frames of SRH to promote particular goals and values and justify particular policy/legislative responses to SRH challenges in Kenya as seen in the case study Chapters 4-6. The findings in the case study chapters suggest that the SRH narratives supported by contextually powerful actors and institutions – the presidency, the bureaucracy (MoH, DRH, and NCPD), parliament, and religious bodies – dominate SRH policy and legislative processes in Kenya, while marginalising alternative narratives. In the bureaucratic policy processes (i.e. adolescent RH policy and national RH policy processes), the epistemic communities within which the policies were formulated underpinned their deliberations with the ‘moralised’ medical narrative that occluded sensitive SRH issues of adolescent contraception, abortion, homosexuality, issues opposed by top government and political leaders, and religious groups. In the sexual offences legislative process, the rights narrative dominated only on non-sensitive issues of sexual violence such as rape and defilement, but was marginalised by the cultural narrative, which remains dominant in Kenya’s male- dominated parliament, on issues of rape within marriage, unwelcome sexual advances, and FGM.

The findings demonstrate how powerful narratives underpinned by actor interests, values, beliefs and ideas work through actor networks, knowledge, and context and institutions, determining which policy changes are possible and which ones are not. The moralised medical narrative that dominated bureaucratic policy networks determined which actors had access to, and could influence these networks and eventually the SRH policies the networks produced. In this case, actors who focus on sensitive SRH issues such as abortion or women’s rights were excluded from the networks that produced the bureaucratic

policies. Similarly, certain kinds of research evidence that do not support the moralised medical narrative were marginalised in the evidence base that informed the SRH policies produced. Moreover, the moral narrative influenced international funding for knowledge production, ensuring that not much evidence on sensitive SRH issues was produced in order to sustain the hegemonic status of the moral narrative in SRH policy and legislative decisions. The strong entrenchment of the moral and cultural narratives in the Kenyan context (i.e. government and political structures and institutions, and society), and of the moralised medical narrative in the health bureaucracy was a major barrier to reforms on contested SRH issues. But the findings also point to the fact that hegemonic narratives can

be unsettled (even if temporarily) by complex interactions of multiple factors, including: a change in the political context that brings 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.