The fact that the global pandemic, Covid-19, has exposed the deplorable state of health systems in Africa is not surprising at all. Will these systems examine their worth when the emergency has passed? Perhaps in view of the ongoing struggles to contain the virus, this question may not be a priority at this point. But it is an important one nevertheless. With all due recognition of the efforts that African scientists, physicians and other healthcare workers are putting into the fight against Covid-19 and into caring for the victims of the disease, all under hard working conditions, the obvious question has been whether or not they have a health system that gives them the tools, the weapons and the robust backing that an army at war needs to have. The answer is “no”. What they got is political and bureaucratic bluster. The exceptions to this reality are few and far between.
What Africa’s healthcare workers get are politicised emergency response announcements, lip service to the disease control measures, physical isolation orders that have proven draconian as to be counter-productive, and politicians who speak about the need for patriotism in this combat but then go about their own lives in violation of the very measures they want the rest of their populations to abide by. What the healthcare workers need most and are not getting are honest political decisions. They also need money, along with transparent systems for the public to know how these huge sums are disbursed. Right now, emergency funds have been announced left and right, but there have been no accountability measures to go with these funds.
All across the continent, national budgets show such paltry allocations to healthcare, often justified on the basis of resource dearth. This has meant that much of the financing and staffing of health systems has fallen on the shoulders of donor countries, the United Nations and International non-governmental Organisations; or on private clinics for the few who can afford.
In South Sudan, for example, more than 80 per cent of the country’s health services are covered by these foreign entities. The result is that these services are insufficient, uncoordinated and are not thought out well enough to respond to the country’s healthcare priorities. Instead, the foreign health interventions largely address the problems the NGOs and their donor countries deem as priority. Because the country’s healthcare system is run by foreign organisations, it does not include the development of the country’s healthcare cadres to any meaningful length and standards, beyond the rudimentary “nursing” or “midwifery” skills that are offered on the job. Biomedical research remains singularly in the hands of medical colleges that are housed in woefully underfunded universities, producing far fewer and ill-prepared medical officers than the country requires.
In Kenya, Uganda and Tanzania, the trend is towards privatisation of the health systems. The big public hospitals, from Kenyatta National to Mulago to Muhimbili, these countries’ major referral hospitals and the training grounds for the best healthcare cadres, are left gasping for breath, as they struggle to retain the best physicians, pay their staff decent wages, obtain and maintain medical equipment and other supplies, provide quality care that is affordable for the vast low income populations that need their services.
Sadly, there have been no signs that governments of these countries would ever prioritise the health sector, to inject new investments into it or increase its budget by directing some cash away from, say, defence to revamp public hospitals, public health surveillance, sponsor research and stand ready to combat any health emergencies.
The challenge facing healthcare systems in East Africa does not stop at the decay of facilities but extends most importantly to staff morale as they struggle unsupported, unequipped and unclear about the processes of procurement and distribution of medical supplies. This has forced some of the best biomedical minds to seek work in private practices, where wages and working conditions are far better, but where they end up only catering for the small segment of population who can pay. Such private outfits, uncoordinated by any national body, cannot respond meaningfully to a public health emergency. This came to a head when the novel coronavirus showed up in Africa in late February.
This goes beyond the usual claim that attributes this poor investment into healthcare to the weak economies and lack of resources. It is primarily caused by corruption, where even the minimum funding allocated to health is diverted or wasted through mismanagement, much of which is hardly ever accounted for, as oversight institutions, parliaments and ethics commissions are toothless due to their subjugation by and submission to the presidency.
Lack of investment in health can also be attributed to a political leadership that lacks the will to act decisively, with the politicians of most African countries becoming the butts of all jokes, that they do not care about the well-being of their populations, that they abandon the national healthcare systems in preference for seeking their own individual and family medical care in foreign countries at the expense of the public.
In South Sudan, health budget stands at four per cent of the national expenditure in good years, a level of investment that has left physicians in public hospitals unpaid for months on end, forcing them to either flee the public system or reduce themselves to consultants for the NGOs and the United Nations. Meanwhile, 400 members of South Sudan’s parliament were offered cash of $40,000 (Sh4 million) each as car loans in 2019 and $25,000 (Sh2.5 million) as health insurance in 2020. They were also given additional monies outside their salaries, all as a way to buy their loyalty to the executive office. The entire illegitimate expenditure on the lawmakers amounted to a total of $28.1 million (Sh2.81 billion), a sum that could have equipped all the three major teaching hospitals, provide them with constant supply of water and electricity, hire their consultants, provide medications and then have more left to replicate those upgrades in seven other state referral hospitals throughout the country.
Similar echoes can be heard about big medical research institutes in East Africa, which have been drowning in under-funding, chronic maladministration, graft and nepotism. These conditions have rendered them unable to be at the forefront of the fight against outbreaks. Covid-19 pandemic has called their bluff.
The strategy adopted by most of the world’s governments is to “protect the health system” by “flattening the curve” and reserving resources for coronavirus cases. Africans seem to follow suit. But this approach not only has negligible benefits for Africa because there is really no health system to protect, the designers of physical isolation measures have also forgotten that it is near-impossible to achieve the level of isolation necessary to slow down or prevent infections when dealing with populations that are desperately poor, who just can’t stay home without their usual hand-to-mouth livelihood activities. At least not for much longer than this. On the contrary, spending the meagre resources on beating people into isolation diverts these resources from tackling the leading killers of Africans, malaria, complications in childbirth, Hepatitis B, child malnutrition, food insecurity and push back on violence as a public health scourge. How was it that the continent’s research centres could not see this and recommend a more suitable course of action is testament to the quality of health system they undergird?
The author is a professor of anthropology at Maxwell School of Citizenship and Public Affairs, Syracuse University.