Hospital performance is a key issue in resource constrained environments like Kenya, where national referral hospitals face enormous challenges to clinical and operational efficiency. The current study looks at the moderating role played by contemporary leadership in the relationship between strategic positioning (embracing customer service, convenience, cost and quality) and hospital performance (focusing on clinical efficiency (defined as timely, evidence-based care) and operational efficiency (defined as resource optimization)). A cross-sectional survey was distributed amongst 351 staff members with leadership responsibilities in three Kenyan national referral hospitals: Kenyatta National Hospital (KNH), Moi Teaching and Referral Hospital (MTRH) and Kenyatta University Teaching, Referral, and Research Hospital (KUTRRH) with 328 usable responses (93 per cent response rate). Data were analyzed using multiple regression and moderation analyses in the statistical package, Statistical Package and Systems (SPSS) version 29. Findings show that strategic positioning has a positive influence on clinical efficiency (beta (.312, p < .05) and operational efficiency (beta (.289, p < .05). Contemporary leadership has a significant moderating effect, increasing the influence on clinical efficiency (beta interaction = -0.098, p < .05, delta R2 = 0.008) and on operational efficiency (beta interaction = -0.085, p < .05, delta R2 = 0.007). These results highlight the critical role of leadership development in boosting efficacy of strategic initiatives to offer actionable information for policymakers and managers working in resource-limited settings and contribute to universal health coverage goals in Kenya.