Expectations vs Reality

Street-level bureaucrats are the frontline workers or policy implementers in

government agencies in areas ranging from the health service, safety and security,

education, and services. A key contention of street-level bureaucracy theory is that the

decisions and actions of street-level bureaucrats, actually ‘become’, or represent, the

policies of the government agencies they work for. In particular, we look at the role street

level bureaucrats played in the implementation of family planning in Kenya and motivation

behind this.

In 1967, Kenya adopted the Neo-Malthusian population policy and implemented a

family planning program. The program advocated the use of contraception methods to limit

population growth. To achieve this, Kenyan government needed to remove the barriers that

keep men and women from obtaining contraceptive methods; whether they be attitudinal,

physical, medical, or social, and increasing access to family planning methods. National

guidelines states that women of any parity may use these methods, women of any age may

use an injectable, and women younger than 40 may use the pill. The Kenyan policy depends

on community-based distributors to assist in the implementation of the program in their

assigned areas. However, here lies a problem in policy implementation- there is a

discrepancy between the policy and the actual program implemented.

At the street level of the state public policies get their final form and substance from

the street level bureaucracies. Community based distributors wield their considerable

discretion in the day-to-day implementation of public programs. The shape in which they

bend the policy lies heavily on their own personal motives. CBDs used their role as

providers of contraceptive methods as bartering tools in exchange for good will and

prestige in the community. They also use their ties with other health workers with higher

positions to gain preferential treatment when referring patients or gaining help. This has

considerably increased the respect and status of the CBDs in their communities, giving

them a doctor-like status in the eyes of their neighbors. Despite what seems as subliminal

self-advertising of the CBDs, a certain degree of respect is needed to be credible advocates

of any program. An advocate campaigning for acceptance of family planning and the use
of contraceptive methods must be someone the community looks up to otherwise they are

less likely to believe in contention of the campaign. In being doctors for example, people

say that the prestige and respect are beneficial side effects of the title but these are necessary

tools to any practitioner who wishes to influence patients into adopting better and healthier

health practices. And CBDs are most likely to protect their reputation by avoiding causing

harm to their constituents.

In South Nyanza however, CBDs altered the guidelines of the family planning

program to avoid being blamed for fertility problems in the long run and protect the name

they have made for themselves. Kenyan culture put great importance in women providing

her husband with the desired progeny to continue the family name and support their parents

in old age. To avoid being associated to being the cause of a women’s potential infertility,

CBDs limited the access of contraceptive methods to those who are unmarried and women

with low parity. By changing certain aspects of the guidelines, the policy envisioned by the

state is different from the program experienced by the community. And in this case, the

very people tasked to remove barriers to the access of women are the very ones who restrict

it. Part of what drives the program is increasing the desire of families to have lesser number

of children with the use of contraceptives. It is necessary therefore, to create a demand for

contraception and meet that demand. The desire of women of low parity and younger

women indicate that there has been a shift into desiring to control fertility and limit the

number of children. This is a positive response to the campaign of the national government

however, if CBDs bend the guidelines to restrict access based on age and parity, these

positive attitudes will not stick. Starting family planning at a younger age and with less

number of children could have also contribute in further decreasing the fertility rate and

population growth in the country. Hindering access to family planning will not however

aid in achieving the objectives of the program.

CBDs are considered professionals and knowledgeable people in the field of

contraception, and hence their actions will reflect on the credibility and safety of the

program. Their refusal to give out contraceptive methods to avoid fertility problems is a

silent acquiescence to the belief that these methods can indeed cause infertility. Central to
this behavior of the CBDs are their own core beliefs towards contraceptive methods. If the

supposed advocate of the methods also believe that they cause harm, then we do not

achieve to influence positive attitudes towards the use of contraception methods. The belief

of the providers play an integral part in how they implement the program and what shape

they bend it into. In this case, it caused reluctance in the part of the CBD to give pills to

young women without children.

In the end, the expectations of national government when making these policies

does not necessarily translate the way they envisioned it to be in reality. Policy cannot

always mandate what matters to outcomes at the local level, incentives and beliefs are

central to local responses, and effective implementation requires consideration on the

interaction of the community and providers. Understanding the CBDs motivations,

constraints, and concerns will create realistic assessments of how the policy will translate

in the grassroots setting.