THE LAST WORD: Rethinking healthcare in Africa

Immediately after independence, all governments in Africa and elsewhere moved very fast to elaborate these public goods and services, attempting to provide them to everyone. Then they confronted the hard reality i.e. that their newly acquired states lacked the basic human skills and finances to do what they had promised. In attempting to do too much too fast, the state got overdeveloped in function, yet it was underdeveloped in capacity – both human and financial. Its reach, therefore, went far beyond its grasp.

I believe that in attempting to bite much more they could swallow, the post independence state eviscerated even the limited institutional capacities the colonial state had tried to develop. Contrary to the popular view that Africa failed because it had selfish leaders who cared only about feathering their own nests, I have come to the conclusion that our continent faltered because our leaders were excessively and idealistically public spirited. They tried to do too much for so many people in too short a time.

I have been studying the development of bureaucracy in the Western world and in other nations of Asia. I have learnt that the fastest way to undermine the development of an effective bureaucracy is to develop it rapidly without due consideration of available skills and funds. Rapidly developing bureaucracies (except in such rare circumstances as post-genocide Rwanda) tend to degenerate into cesspools of incompetence, corruption and neo-patrimonial plunder. The lesson, therefore, is that good and effective bureaucracies are a scarce resource that nations need to use sparingly.

The post-independence governments in Africa also focused on the expensive yet less effective aspects of healthcare i.e. clinical medicine. They built hospitals across their territories and tried to treat every sick person. But the same governments lacked personnel and did not have enough funds to pay for the medical equipment and drugs. As a result, poorly paid and also poorly facilitated medical staff did not have the tools to do their work. They began stealing the little money and drugs, and selling the latter on the black market. Others left these countries for greener pastures abroad.

We now know that the most effective healthcare in poor countries is not in clinical medicine but public health. For example, the leading causes of death in poor countries are communicable diseases affecting children that are best handled through preventive measures, not medical treatment. Such measures include improved sanitation, access to clean water, improved nutrition, better hygiene and vector control like eradicating mosquitoes. The governments can also invest in such aspects of health as immunisation and vaccination.

The focus on clinical medicine is a function of both the mindset and also the self-interest of elites. It is a mindset in that when we talk of healthcare, people think of hospitals and doctors, not sanitation and clean water. It is self-interest because the most articulate sections of the elite in Africa actually have access to clean water, good sanitation, better nutrition etc.; therefore their problem is clinical treatment. Thus public policy on healthcare tends to privilege the interests of these elites rather than the ordinary person. This is why there was a hue and cry in the media when the cancer machine at Mulago Hospital collapsed but there is never anything like that when immunisation programs fail.

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