Skip to main content

Non-state actors and universal services in Tanzania and Lesotho: state-building by Alliance*

  • Michelle D'arcy (a1)

In recent years over half of all African states have re-introduced some form of universal basic service provision, though many more have done so in education when compared with health. Most existing explanations of these developments have emphasised the importance of demand side factors associated with democratisation. This paper argues that while democratisation has been important in generating pressure for reform, alliances with actors outside the state – such as donors and non-state service providers – have been the critical enabling factor allowing weak states to overcome their capacity constraints and respond. Two illustrative case studies are used to show how variation in alliance opportunities has led to differences in outcomes both between social sectors and across countries. An inter-sector comparison of health and education policy in Tanzania shows how a difference in donor policy preferences between sectors – donors having converged behind the principle of universal primary education but not universal healthcare – has led to variation in alliance opportunities and hence policy outcomes. A ‘least likely’ case of healthcare reform in Lesotho shows how an alliance with a non-state provider has made difficult reforms possible.

Corresponding author
Hide All

I would like to thank Niamh Hardiman, Bo Rothstein, Paul Walsh and Vincent Durac, as well as the anonymous reviewers and editors of The Journal of Modern African Studies, for their comments and feedback on earlier drafts of this paper.

Hide All
Adepoju A., ed. 1993. The Impact of Structural Adjustment on the Population of Africa. London: James Currey.
Akin J. S., Birdsall N. & De Ferranti D. M.. 1987. Financing Health Services in Developing Countries: An Agenda for Reform. Washington, DC: World Bank.
Amico P., Aran C. & Avila C.. 2010. ‘HIV spending as a share of total health expenditure: an analysis of regional variation in a multi-country study’. PLoS One 5, 9e12997. doi:10.1371/journal.pone.0012997
Benson J. S. 2001. ‘The impact of privatization on access in Tanzania’, Social Science and Medicine 52, 12: 1903–15.
Bourguignon F., de Melo J. & Suwa A.. 1991. ‘Distributional effects of adjustment policies: simulations for archetype economies in Africa and Latin America’, World Bank Economic Review 5, 2: 339–66.
Brooks S. M. 2009. Social Protection and the Market in Latin America. Cambridge: Cambridge University Press.
Burki O. 2001. The Sector Wide Approach in Tanzania; observations from a bilateral. End of Assignment Report for the Swiss Agency for Development and Co-operation, ms.
Carbone G. 2011. ‘Democratic demands and social policies: the politics of health reform in Ghana’, Journal of Modern African Studies 49, 3: 381408.
Clapham C. 1996. Africa and the International System: The politics of state survival. Cambridge: Cambridge University Press.
Concord Times. 2010. ‘Free Health Care Boost – U.S. $7 Million Drugs for Sierra Leone’, Concord Times, Freetown, 29.03.2010.
Deininger K. & Mpuga P.. 2004. ‘Economic and welfare effects of the abolition of health user fees: evidence from Uganda’, World Bank Policy Research Working Paper 3276.
Demographic and Health Survey (DHS). 1991. Tanzania: Demographic and Health Survey 1991. Calverton, MD: DHS.
Demographic and Health Survey (DHS). 1996. Tanzania: Demographic and Health Survey 1996. Calverton, MD: DHS.
Demographic and Health Survey (DHS). 2004. Lesotho: Demographic and Health Survey 2004. Calverton, MD: DHS.
Department for International Development (DfID). 2009. UK Pledges £12 million to Help to Deliver Free Healthcare in Liberia. DfID press release, 4.11.2009.
Ferguson J. (1990). The Anti-Politics Machine: ‘development’, de-politicization and bureaucratic power in Lesotho. Cambridge: Cambridge University Press.
Flora P. & Alber J.. 1981. ‘Modernization, democratization, and the development of welfare states in Western Europe’ in Flora P. & Heidenheimer A. J., eds. The Development of Welfare States in Europe and America. New Brunswick, NJ: Transaction Books, 3780.
Galabawa J. C. J. 2001. ‘Developments and Issues surrounding universal primary education in Tanzania’, paper delivered at the Biennial meeting of the Association for the Development of Education in Africa, Arusha, Tanzania, October.
Globe & Mail 2001. ‘Tanzania to revive free primary schooling’, Globe & Mail, Toronto 02.04.2001.
Harding R. & Stasavage D.. 2011. ‘What democracy does (and doesn't) do for basic services: school fees, school quality, and African elections.’ Unpublished manuscript.
Hulme D. 2007. The Making of the Millennium Development Goals: human development meets results-based management in an imperfect world. Brooks World Poverty Institute Working Paper 16. Manchester: Brooks World Poverty Institute.
Hyden G. 1983. No Shortcuts to Progress: African development management in perspective. London: Heinemann.
Kaiser P. J. 1996. Structural adjustment and the fragile nation: the demise of social unity in Tanzania. The Journal of Modern African Studies 34:227–37.
Kamens D. H. 1986. ‘The importance of historical sequencing: party legitimacy in the United States and Europe’, Comparative Social Research 9: 331–45.
Kattan R. B. & Burnett N.. 2004. User Fees in Primary Education. Washington, DC: World Bank.
Kaufman R. R. & Segura-Ubiergo A.. 2001. ‘Globalization, domestic politics, and social spending in Latin America’, World Politics 53, 4: 553–87.
Kensall T. 2002. ‘Shop windows and smoke-filled rooms: governance and the re-politicisation of Tanzania’, Journal of Modern African Studies 40, 4: 597619.
Kingdom of Lesotho (KoL). 2004. Poverty Reduction Strategy 2004/5–2006/7. Maseru: Kingdom of Lesotho.
Kingdom of Lesotho (KoL). 2007a. Annual Joint Review Report – 2007/08. Maseru: Ministry of Health and Social Welfare.
Kingdom of Lesotho (KoL). 2007b. The Memorandum of Understanding between the Government of Lesotho and the Christian Health Association of Lesotho. Maseru: Ministry of Health and Social Welfare.
Knippenberg R., Nafo F. T., Osseni R., Camara Y. B., El Abassi A. & Soucat A.. 2003. Increasing Clients' Power to Scale Up Health Services for the Poor: the Bamako Initiative and West Africa. Background paper to the World Development Report 2003. Washington, DC: World Bank.
Lall S. 1995. ‘Structural adjustment and African industry’, World Development 23, 12: 2019–31.
Lindberg S. I. & Morrison M. K. C.. 2008. ‘Are African voters really ethnic or clientelistic? Survey evidence from Ghana’, Political Science Quarterly 123, 1: 95122.
Little E. & Logan C.. 2008. ‘The quality of democracy and governance in Africa: New results from Afrobarometer Round 4’, Afrobarometer Working Paper, 108.
Maarifa ni Ufunguo. 2001. Cost Sharing: a case study of education in Kilimanjaro. Arusha: Maarifa ni Ufunguo.
MacLean L. 2002. ‘Constructing a social safety net in Africa: an institutional analysis of colonial rule and state social policies in Ghana and Cote D'Ivoire’, Studies in Comparative International Development 37, 3: 6490.
Martin H. G. 2003. A Comparative Analysis of the Financing of HIV/AIDS Programmes in Botswana, Lesotho, Mozambique, South Africa, Swaziland & Zimbabwe. Cape Town: HSRC Publishers.
McPake B., Asiimwe D., Mwesigye F., Ofumbi M., Ortenblad L., Streefland P. & Turinde A. (1999). ‘Informal economic activities of public health workers in Uganda: implications for quality and accessibility of care’, Social Science and Medicine 49, 7: 849–65.
Mesa-Lago C. 1997. ‘Social welfare reform in the context of economic-political liberalization in the Latin American cases’, World Development 25, 4: 497517.
Mosley P. and Weeks J.. 1993. ‘Has recovery begun? Africa's adjustment in the 1980s revisited’, World Development 21, 10: 1583–606.
Nabyonga J., Desmet M., Karamagi H., Kadama P. Y., Omaswa F. G., & Walker O.. 2005. ‘Abolition of cost sharing is pro-poor: evidence from Uganda’, Health Policy Plan 20: 100–8.
Oketch M. & Rolleston C.. 2007. ‘Policies on free primary and secondary education in East Africa: retrospect and prospect’, Review of Research in Education 31: 131–58.
Olson M. 1993. ‘Dictatorship, democracy, and development’, American Political Science Review 87, 3: 567–76.
Research on Poverty Alleviation (REPOA). 2003. Policy and Services Satisfaction Survey: final report. Dar es Salaam: REPOA.
Right to Education Project. 2008. Country database. <>, accessed 28.9.2011.
Rudra N. & Haggard S.. 2005. ‘Globalization, democracy, and effective welfare spending in the developing world’, Comparative Political Studies 38: 1015–49.
Save the Children. 2004. The Unbearable Cost of Illness: poverty, ill-health and access to healthcare – evidence from Lindi Rural District, Tanzania. London: Save the Children.
Shiffman J., Berlan D. & Hafner T.. 2009. ‘Has aid for AIDS raised all health funding boats?Journal of Acquired Immune Deficiency Syndromes 52: 45–8.
Simwanza Sitta M. 2007. ‘Towards universal primary education: the experience of Tanzania’, UN Chronicle, 44: 4.
Skocpol T. 1992. Protecting Mothers and Soldiers: the political origins of social policy in the United States. Cambridge, MA: Belknap Press.
Stasavage D. 2005a. ‘Democracy and education spending in Africa’, American Journal of Political Science 49, 2: 343–58.
Stasavage D. 2005b. ‘The role of democracy in Uganda's move to universal primary education’, Journal of Modern African Studies, 43, 1: 5373.
Thomas I. 1983. Population and health facilities in Tanzania, 1978, Vol. I. Norwich: Overseas Development Group, University of East Anglia.
United Nations (UN). 2000. Millennium Development Goals Declaration. New York, NY: UN.
UNAIDS. 2008. Lesotho UNGASS Country Report. Geneva: UNAIDS.
United Nations Educational, Scientific and Cultural Organization (UNESCO). 1990. Jomtien Declaration. Paris: UNESCO.
United Nations Educational, Scientific and Cultural Organization (UNESCO). 2000. Dakar Declaration. Paris: UNESCO.
United Nations Educational, Scientific and Cultural Organization (UNESCO). 2008. A Compilation of Background Information about Educational Legislation, Governance, Management and Financing Structures and Processes. Background paper prepared for the Education for All Global Monitoring Report 2009. Paris: UNESCO.
United Republic of Tanzania (URT). 1995. Education and Training Policy. Dar es Salaam: Ministry of Education and Culture.
United Republic of Tanzania (URT). 1999. Basic Educational Statistics – Regional Data. Dar es Salaam: Ministry of Education and Culture.
United Republic of Tanzania (URT). 2000. Basic Educational Statistics – Regional Data. Dar es Salaam: Ministry of Education and Culture.
United Republic of Tanzania (URT). 2001. Education and Training Sector Development Programme. Dar es Salaam: Ministry of Education and Culture.
United Republic of Tanzania (URT). 2003. National Health Policy. Dar es Salaam: Ministry of Health.
Van de Walle N. 2001. African Economies and the Politics of Permanent Crisis, 1979–1999. Cambridge: Cambridge University Press.
Wallace T., Bornstein L. & Chapman J.. 2006. The Aid Chain: Coercion and Commitment in Development NGOs. Rugby: Intermediate Technology Publications.
Wintrobe R. 2007. ‘Dictatorship: analytic approaches’, in Boix C. & Stokes S., eds. Oxford Handbook of Comparative Politics. Oxford: Oxford University Press, 363–96.
World Bank. 1999. Tanzania: social sector review. Washington, DC: World Bank.
World Bank. 2004. World Development Report: making services work for the poor. Washington, DC: World Bank.
World Bank. 2011. African Development Indicators Database. Washington, DC: World Bank.
World Health Organization (WHO). 1978. Alma Atta Declaration. Geneva: WHO.
World Health Organization (WHO). 2004. Summary Country Profile for HIV/AIDS Treatment Scale-Up, Lesotho. Geneva: WHO.
World Health Organization (WHO). 2005. Summary Country Profile for HIV/AIDS Treatment Scale-Up, Lesotho. Geneva: WHO.
World Health Organization (WHO). 2008. Towards universal access: scaling up priority HIV/AIDS interventions in the health sector. Geneva: WHO.
Yates R. 2009. ‘Universal health care and the removal of user fees’, Lancet, 373: 2078–81.
CHAL representative 2009, Maseru, 8.12.2009.
Civil Society Representative 2009, Dar es Salaam, 9.11.2009.
Donor Representative 2009a, Dar es Salaam, 5.11.2009.
Donor Representative 2009b, Dar es Salaam, 12.11.2009.
Donor Representative 2009c, Dar es Salaam, 16.12.2009.
Dyer, Kate, Former Executive Director of Maarifa ui Ufunguo, Dar es Salaam, 10.11.2009.
Ramatlapeng, M'e Mphu, Minister of Health, Government of Lesotho, Maseru, 9.12.2009.
Recommend this journal

Email your librarian or administrator to recommend adding this journal to your organisation's collection.

The Journal of Modern African Studies
  • ISSN: 0022-278X
  • EISSN: 1469-7777
  • URL: /core/journals/journal-of-modern-african-studies
Please enter your name
Please enter a valid email address
Who would you like to send this to? *


Full text views

Total number of HTML views: 5
Total number of PDF views: 74 *
Loading metrics...

Abstract views

Total abstract views: 204 *
Loading metrics...

* Views captured on Cambridge Core between September 2016 - 26th February 2018. This data will be updated every 24 hours.