Table Of ContentTHE POLITICS OF STRUCTURAL ADJUSTMENT PROGRAMS IN KENYA
THE CASE OF COST-SHARING IN EDUCATION AND HEALTH CARE
By
PETER WANYANDE
A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL
OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT
OF THE REQUIREMENTS FOR THE DEGREE
OF DOCTOR OF PHILOSOPHY
UNIVERSITY OF FLORIDA
1993
Copyright 1993
by
Peter Wanyande
To my parents and to JoKasideg, for their support.
ACKNOWLEDGMENTS
This dissertation benefitted from the contributions of
a number of individuals and organizations. First, I wish to
express my gratitude to Professor Goran Hyden, my committee
chair, for his constant encouragement and excellent advice.
Through his patience, understanding, and commitment, he was
a great inspiration to me.
I also am very thankful to the other members of my
committee. Professors David Hedge, Wayne Francis, Arun
Agrawal, and Uma Lele. Their comments were of immeasurable
help.
I am equally grateful to all the professors at the
University of Florida with whom I had the opportunity to
interact in graduate seminars. I particularly wish to
mention Professor Rene Lemarchand, who also served briefly
as a member of my committee prior to his accepting a
position with the USAID in Abidjan, Cote de Ivoire.
I want to express special gratitude to the Smithsonian
Institute in Washington, D.C., for providing a scholarship
for my doctoral studies at the University of Florida. My
special thanks go to Professor Ivan Karp, former Curator of
African Anthropology at the Smithsonian Institute, who was
instrumental in negotiating the scholarship on my behalf and
IV
who administered the grant during my four years at the
University of Florida. Needless to say, I would not have
enrolled at the University of Florida without this financial
assistance.
The field work for this study was funded by the Ford
Foundation's University of Florida Governance Project in
East Africa, and I am very grateful for their support. I am
egually thankful to the Center for African Studies at the
University of Florida for a grant to conduct the preliminary
research in Kenya.
The actual interviews for this study were carried out
with the assistance of Mary Warinda, Vincent Kasololo, Abel
Nyambu, Tobias Owambo, John Oduge, and Francis Wainaina. To
these very able and dedicated research assistants, I owe
many thanks. The statistical data analysis was completed
with the help of Ken Meese, a fellow student in the
Department of Political Science at the University of
Florida. Anne Odongo was very helpful in the preparation of
the tables included in this dissertation. Anne, together
with Sam Thomas, did the technical editing required by the
Graduate School. I am most grateful to them for this
assistance. I also wish to thank Mark Walkup for reading
drafts of this dissertation and for his useful editorial
comments, and Nancy Weintraub for her editorial assistance
during the final stages of the manuscript preparation.
V
Finally, I owe much gratitude to my wife Serrah, my
daughter Katherine, and my son James for their support,
patience, and love. They stayed behind in Kenya during the
four years I was at the University of Florida. Their
sacrifice provided great encouragement to me, making all the
difference in my life as a student.
vi
TABLE OF CONTENTS
page
ACKNOWLEDGEMENTS iv
LIST OF TABLES ix
ABSTRACT X
CHAPTERS
1 STRUCTURAL ADJUSTMENT PROGRAMS AND GOVERNANCE:
AN OVERVIEW 1
The Concept of Structural Adjustment Programs 4
Literature Review 13
World Bank Literature on the African Crisis 14
Social Dimensions of Structural Adjustment Programs. 31
Framework of Analysis 36
The Concept of Political Elasticity 43
Justification of the Study 49
Hypotheses 52
Methodology 59
2 THE POLITICAL ECONOMY OF EDUCATION AND HEALTH CARE
IN KENYA 69
Factors Influencing the Provision of Social Services 70
Major Features of Kenya's Political Economy 73
Education and Health Care in the Colonial Period.... 89
The Colonial State and the Provision of Education
and Health Care 94
Education and Health Care in the Post-Colonial
Period 103
3 THE INTRODUCTION OF COST-SHARING 117
The Crisis in Kenya's Education and Health Care 118
The Introduction of Cost-Sharing 132
Objectives of Cost-Sharing 137
The Politics of Adopting Cost-Sharing 143
TIhsesuePsoliCtoimcpslicofatiCnogst-thSehaArdionpgtiaonnd oPfoliCtoiscta-lSharing.... 147
Elasticity 159
vii
4 THE IMPLEMENTATION OF COST-SHARING 162
The Policy Process in Developing Countries 162
The Policy Process in Kenya 163
Political Elasticity and the Implementation of
Cost-Sharing 184
Other Problems in the Implementation of
Cost-Sharing 196
TFhienanIcmipallemeCnotnasttiroainntosf Canodst-thSeharIimnpglenitnatHieoanlth Care... 202
of the Policy 208
Regime Structure and the Implementation
of the Policy 209
Education and Health Care as Public Goods 216
Cost-Sharing and Political Elasticity 221
5 COST-SHARING: WHO BEARS THE CROSS? 224
Cost-Sharing and Access to Health Care 225
Nonstate Sources of Health Care 233
Cost-Sharing and Efficiency in Health Care
Provision 237
Cost-Sharing and the Use of Different Levels
of Health Care Facilities 239
Cost-Sharing in Education 244
Cost-Sharing and the Administration of Schools 251
Cost-Sharing and Government Expenditure 256
6 CONCLUSION: POLITICAL ELASTICITY AND PUBLIC POLICY
IN KENYA 263
Conclusions of the Study 265
The Policy Process 282
Enhancing Political Elasticity 292
APPENDIX 294
REFERENCES 300
BIOGRAPHICAL SKETCH 314
viii
2-
3- LIST OF TABLES
Table page
1: Government Grants-in-Aid to Mission Schools by
Race in 1926 (in sterling) 99
3-1: Growth in Primary Education 1963-1991 124
43--2: Number of Health Care Facilities Between
1963-1991 125
3-3: Distribution of Health Care Facilities by
Province 126
3-4: Government Expenditure on Main Sectors 1984/85-
1991/92 127
5: Government Expenditure on Education, Health, and
Defense in Tanzania, 1987/88-1988/89 128
1: Number and Percentage of Respondents Who Talked
to Government Officials About Cost-Sharing in
Education and Those Who Did Not 178
4-2: Number and Percentage of Respondents Who Talked
to Government Officials About Cost-Sharing in
Health Care and Those Who Did Not 178
4-3: Respondents' Views About the Role of Government
and Parents Under Cost-Sharing 192
4-4: Respondents Who Said the Policy Was Adequately
Explained and Those Who Said It Was Not 194
4-5: Reasons for Not Accepting Cost-Sharing in
Education 195
4-6: Distribution of Respondents With and Without
Problems Regarding Cost-Sharing in Education 197
4-7: Classrooms and Workshops Completed by Each
District in 1992 198
4-8: Distribution of Respondents by Source of
Information About Cost-Sharing 209
ix
4-9: Distribution of Respondents on Whether Cost-
Sharing in Health Care Was Adequately
Explained 210
4-10: Respondents' Views About Whether or Not Cost-
Sharing Was Introduced Suddenly 212
4-
4-11: Respondents Who Accept and Those Who Do Not
5- Accept Cost-Sharing in Education 215
4-12: Respondents Who Accept and Those Who Do Not
Accept Cost-Sharing in Health Care 215
13: Respondents Who Want Cost-Sharing Abolished in
Education and Health Care 216
1: Respondents Utilizing Government Hospitals
Before Cost-Sharing 229
5-2: Percentage Drop in Utilization of Government
Health Care Facilities by District After
Cost-Sharing 231
5-3: Primary School Enrollment Between 1973 and 1991.. 246
5-4: Share of Government Recurrent Expenditure on
Education (Kshs.'OOO) 257
5-5: Budgeted and Actual Total Government Expenditure
on Primary Education for Fiscal Years 1979/1980
to 1990/1991 259
X
