The Micro-Dynamics of Health and Education Provision in the Slums of Nairobi.

Abstract

Over the past thirty years, the provision of social welfare changed dramatically in much of the developing world. Economic and political reforms limited the role of the state and promoted private sector involvement in service delivery. Explosive growth in the number of non-governmental organizations and community-based organizations followed, as non-state actors attempted to fill gaps in social service provision left by state retrenchment. This dissertation explores how the increase in non-state provision and the ceding of what is traditionally viewed as the responsibility of the state to a diverse group of actors has affected poor households’ access to health and education services.

Using data from an original survey of 1,054 households in Kibera and Korogocho, two informal settlements in Nairobi, Kenya, the study deviates from conventional theoretical and empirical approaches to research on service provision in developing countries. I adopt a multi-dimensional conceptualization of access that expands on standard indicators and includes perceptions of accessibility and quality and satisfaction with services. Furthermore, I explore the relational and contextual nature of service provision through a multi-level analysis that includes micro- and meso-level sociopolitical factors and meso-level organizational factors.

This approach yields several findings relevant to research and policy. First, perceptions matter; health and education outcomes depend on both service quality and households’ service-seeking behavior, and behavior is shaped by perceptions. This work argues for the consideration of social demand factors in the development of policies and interventions. Second, in contrast to narratives in public and scholarly discourses, I find broad support for public health services; in the fragmented service environment in the settlements, the state plays an important role in ensuring access to care for the most impoverished households. Access to state services also depends less on households’ social positionality. These findings suggest that efforts to improve equity and access should focus on strengthening state capacity and improving public provision rather than supporting a fragmented system of non-state providers. Finally, the community-level sociopolitical and organizational context shapes households’ perceptions and experiences. A multi-level approach is needed to more effectively improve health and education outcomes in low-income urban communities.