Fertility and development: The legacy of structural adjustment policies in Kenya
Author: Alda Isabel Scebbi
Originally Published at Peace and Conflict Monitor on: 10/01/2012
The SAPs were meant to develop the economy of Kenya, to improve social and healthcare programs, and to decrease fertility rates, which in the 1980s-1990s were among the highest in the world. SAPs tried to decrease fertility rates by distributing free contraceptives and free healthcare services. However, when these policy changes were introduced, they were neither regionally nor economically appropriate, and once the services were no longer free, they still required constant checkups and maintenance, which many women could not afford. Such shortsightedness led to a decrease in women’s reproductive health, which in turn led to an increase in poverty (Alila and Atieno 5).
The World Health Organization considers maternal health to be a basic human right and seeks its recognition and protection through the Millennium Development Goals. Several other United Nations organizations also emphasize the importance of women’s right to reproductive and sexual health, maintaining that reproductive health is not just based upon the quality and accessibility of healthcare, but also on socioeconomic development levels and women’s position in society (Cottingham, Kismodi, et al. 1).
History and Ideology Behind SAPs
SAPs were applied in developing countries in the 1980s-1990s by the World Bank and International Monetary Fund (IMF) as a condition for the granting of loans or the restructuring of existing debt. The policy changes consisted of increasing exports to encourage foreign investment and privatizing public companies and services, among other market-oriented adjustments. There was also a health component as SAPs sought to lower fertility rates in developing countries through population control policies such as family planning.
The means of implementing these policies were entrenched in both neo-liberal and neo-Malthusian ideological constructs.
Neo-liberalism emphasizes the role of non-state institutions in social and economic development, and is thus closely tied to the conservative ideology of the minimalist state. Privatization and deregulation are encouraged in order to minimize the role of the state in national economics. This neo- liberal environment reduced regulation over private companies and was thus conducive to corporate corruption, as private companies set out to maximize their profits by avoiding environmental and labor regulations (Hildyard).
Another ideology behind SAPs, Neo-Malthusianism, is based on the belief that the world population will drastically increase, leading to famines and diseases. In order to avoid such “natural” population control mechanisms, Neo-Malthusians support strict reproductive policies, such as China’s one child policy, putting women (once again) at the frontlines of the battle against population growth.
Fundamentally, SAPs are connected population control with development. This connection is invalid, however, considering that it takes more than lowering fertility rates to develop a country. In Kenya, population growth was increasing rapidly but was not on the exaggerated brink of widespread famine.
Ester Boserup is a scholar who contradicted Malthus. Her model is called the Boserup theory and it is based upon necessity being the mother of invention. In essence, when a population increases, the demand for food increases, and that demand is an incentive to invent agrarian technology to produce more food efficiently. Boserup paid attention to land and labor ratios along with gendered work and different types of agricultural societies. As such, Boserup addressed the division of labor within African agriculture, demonstrating through empirical data that women do nearly all the tasks in food production (Boserup 16). Since women compose the bulk of the workforce in agricultural societies, women are often the innovators of producing food efficiently. Therefore, women’s health should be of highest importance to insure food security.
While the Neo-Malthusians were concerned with the idea of a rapidly growing world population, other factors were not taken into consideration: for instance, equitable food distribution, improvements in living standards, and the expansion of rights. The expansion of rights reframes the issue of development from an emphasis on a surplus of people on Earth to a lack of basic rights: “Too many people have too little access to resources” (Hartmann 39), and too many women have too little autonomy over their own reproduction. Rapid population growth is not rooted in underdevelopment, but the slow pace of social reform (Hartmann 39).
Article 25 of The United Nations’ Universal Declaration of Human Rights states that everyone has the right to a standard of living adequate for the health and well-being, which includes food, clothing, housing and medical care and necessary social services, and the right to security in the event of unemployment, sickness, disability, widowhood, old age or other lack of livelihood in circumstances beyond one’s control. Motherhood and childhood are entitled to special care and assistance. The increase in access to these basic human rights were addressed in the SAPs documentation, however, when put into practice SAPs did not follow through.
Contradictory Application of SAPs in Kenya
SAPs in Kenya were contradictory since they initially provided free/affordable healthcare services, but eventually allowed the interests of private companies to override the interest of health and social services. For example, IUDs and birth control were initially prescribed to Kenyan women at no cost, but once the deficit increased, subsidized health programs were cut. This left women’s health vulnerable to contraceptive infections, such as infection from IUDs. By failing to realize that Kenyan women could not afford basic healthcare nor routine checkups, SAPs were not regionally appropriate programs.
In the specific case of Kenya, social and economic conditions were not very conducive to significant fertility decline. At the time, many families were relying on child labor in agriculture work. This is related to privatization and the encouragement of cash crop agriculture, which led to the best land being commandeered by corporations and a relatively few rich farmers (Hartmann 84). This marginalized the smallholders and further increased reliance on child/family labor. This privatization of land and export-oriented agriculture is deeply connected to SAPs because it was in SAPs’ doctrine to encourage privatization of companies and land and to encourage exports of cash crops.
Another contradiction, therefore, is that SAPs encouraged privatizing agriculture and exporting cash crops, which also encouraged higher fertility rates among poor rural families, at the same time as they were trying to reduce fertility rates through family planning.
The Kenyan state, agreeing with the conventional development theory of the time, had long blamed Kenya’s economic problems on rapid population growth, while ignoring the issue of unequal distribution of resources. This goes at least as far back as Kenya’s invitation of the Population Council to investigate the population problem in 1965. Their advice was to declare the pressing need for population control policy, to encourage the IUD, and to hire more foreign advisors.
These recommendations were perceived as a white plot of genocide (Hartmann 85), a view which eventually led to cutting the family planning program. The fact that many rural clinics were understaffed and under-funded meant that they could barely give adequate basic healthcare, much less give adequate family planning services. Furthermore, urban clinics received the majority of the resources. The average client came back to the clinic less than four times and then dropped out of the program completely (Hartmann 86).
From 1982 to 1989, foreign population assistance fronted $8 million to Kenya to speed up the population control process. Since they realized their initial policies recommendations were perceived incorrectly, they decided to take a different approach: the World Bank pressured Kenya’s Ministry of Health to allow mass promotion of the pill and Depo-Provera without adequate healthcare backup, and also to allow sterilization services (Hartmann 88).
Although relaxing the guidelines for contraceptives did decrease fertility rates, which was a goal of the SAPs, Kenyan women were treated as the guinea pigs for new contraceptives. Furthermore, sterilization accounted for 5.6 percent of contraceptive prevalence in 1983, whereas condom use accounted for less than 1 percent – in a country that is hard-hit by AIDS (Hartmann 89). Kenya is still feeling the aftermath of the family planning programs installed by SAPs, and it continues to be in need of a safe and comprehensive reproductive healthcare system for men and women.
Interpretive gaps – miscommunications and misinterpretation regarding the implementation of a program – also led to the poor application of SAPs in the country. For example, discourses on overpopulation at international conferences may be translated differently in clinics, where, in Kenya for example, they caused an increase in strict population control policies (Richey 2). Also, the program policies are often misconstrued by the manner they are passed down from person to person. For instance, as Booth points out: “Those who have studied nurses as social, economic, and political agents argue […] that nurses occupy a critical position brokering relationships between policymakers, medical scientists, financers of healthcare, public perceptions of women and diseases, and patients” (6). The argument follows that the negative assumptions held by nurses – that working-class women in Nairobi are unable to insist that their husbands use condoms, for example – are why clinics have had comparatively little influence on improving women’s reproductive health. The apathy of nurses in clinics towards the prospects of empowering working-class women in Kenya seems to have led to their further disempowerment.
Socioeconomic Status, Education, and Reproductive/Maternal Health in Kenya
In Kenya, the healthcare services that the government provides are necessities for the poor population. SAPs brought along the introduction of user charges and the deregulation of prices of pharmaceutical drugs. This placed many healthcare services out of reach for the poor population (Manundu). Women are often the “poorest of the poor” due to gender inequality through lack of landownership and access to social services. Although women make up the majority of the agrarian workforce, they only own 1% of land (Chiwara and Ndiaye 2). Still to this day, landownership in Kenya is the most significant productive asset (Wandia, Obondoh, et al. 1). Since agriculture is the largest sector in Kenya’s economy, rural areas were often the focus when it came to policy reform.
As shown below, the Human Poverty Index (HPI) is a good indicator of how SAPs impacted certain regions in Kenya:
The Human Poverty Index (HPI) rose to 31.8% in 2001 from a value of 26.1% in 1997. In Kenya, human development has declined steadily since the mid 1980s. The decline was more dramatic after 1990, with the country falling from rank 93 to 123 from 1990 to 1999 in the Human Development Index (HDI), with values 0.531 to 0.514, respectively. There are wide regional disparities: Nairobi has the highest HDI (0.783), followed by Central Province (0.595), while North Eastern Province registers the lowest HDI at 0.426. Table 1 shows the regional indicators of human development in the country ( UNDP 2001).
Socioeconomic status also played a big role in education, where male children were given preferential access to education by their families over female children, even as educational facilities increased in Kenya under SAPs (Rono 92).
In regards to reproductive health, the statistics show that contraceptive use increased from 1989 to 1998, rising from 18 percent to 32 percent. However, after the
1990s, the use of contraceptives decreased due to lack of funding. Also, government funding shifted from family planning to raising awareness of HIV/AIDS.
According to the World Health Organization, Kenya’s maternal mortality ratio (MMR) was high among developing countries even in 1995, with 1,300 per 100,000 live births. Kenya having a higher MMR some of the least developed countries is yet another indication that SAPs were not effective in the healthcare sector, especially for women’s reproductive health (WHO).
Still Hope: A New Constitution
On August 27, 2010, a new constitution was promulgated in Kenya by majority vote. It states a new political-economic framework for Kenya. For instance, Kenya will be a democratic developmental State that separates the public and private domains. This helps Kenyans break free for the neo-liberal policies since the State will no longer become involved in the conflict of public good with profit motive, as they did under SAPs. The State often put foreign agendas over local interests but now the recent Constitution has a main principle of making citizens primary policy-making actors and is expected to steer Kenya away from the hegemonic interests that developed under the SAPs (Oyugi, Thigo, et al. 1).
Even though SAPs are out of Kenya, there are still remnants. Not enough has changed since SAPs were implemented and the likelihood of Kenyan women gaining complete reproductive autonomy in the near future is low. This is because complete reproductive autonomy for women exists nowhere; it is a utopian concept, just like the minimalist state idea, which drove the SAPs.
Unfortunately, Kenya is still far from women gaining complete reproductive autonomy because of a fundamental lack of reproductive healthcare. SAPs made the situation worse for women by encouraging the use of high-maintenance contraceptives and then cutting the program. SAPs cut the programs for several different reasons: lack of public support due to the program being perceived incorrectly, lack of funding for some programs, and shifting of subsidies away from social programs and health programs towards private companies.
SAPs did not take into account that Kenya is mainly agrarian society, there are many small land-owners, and that women contribute to the majority of the food production. Perhaps going with Boserup theory, which does take such factors into account, would have been more regionally appropriate. Moreover, women make up the majority of both the workforce and the poor population in Kenya. With these two facts in mind, SAPs could have addressed women’s health more thoroughly, perhaps through women’s income inequality.
Bio: Alda Isabel Scebbi is an MA candiate in the department of International Law and Human Rights at the University for Peace.