The paper examines health sector reforms in Kenya at the district level based on the Government of Kenya's Health Policy Framework of 1994. The authors present the context of and historical perspective to health sector reforms in Kenya and discuss the major reform policies including decentralization to the district level. The authors then review intended policy outcomes, investigating assumptions on which the implementation and effectiveness of the reform agenda at the local level are based. The authors argue that emphasis on outcomes rather than process have not supported sustainable reforms or achieved the government's goal of improving health and ensuring equity for the citizens of the country. (C) 2003 Elsevier Science Ireland Ltd. All rights reserved.