Category: Development

Africa can and should have universal healthcare.

WE ALSO COMMIT OURSELVES to take all necessary measures to ensure that the needed resources are made available from all sources and that they are efficiently and effectively delivered. In addition, WE PLEDGE to set a target of allocating at least 15% of our annual budget to the improvement of the health sector – Abuja Declaration 2001

In April 2001, the heads of state of African Union countries met and pledged to set a target of allocating at least 15% of their annual budget to improve the health sector. Yet almost decade later, not only have just a handful of African nations allocated the pledged amount of money to their healthcare systems, but Africa still has the worst health outcomes in the world (figure 1). The poor and vulnerable still have limited access to healthcare, the insurance and coverage schemes that do exist usually miss out those in the informal sector who make up a sizable portion of the African workforce. Despite some marked improvements since 2001 too many Africans are still falling victim to diseases that could be prevented, too many Africans are being made bankrupt paying medical bills for friends and family and far too many Africans are going without the care they need lowering their quality of life.

Figure 1 source: Angus S. Deaton and Robert Tortora, People in Sub-Saharan Africa Rate Their Health And Health Care Among The Lowest In The World 2015, Health Affairs

 

If we are to think of development as being people centred, then the health of the people is crucial. Quality of life (not to mention length of life) improves significantly when everyone has access to quality healthcare at an affordable cost (which is the WHO’s definition of universal healthcare[1]). If Africa is serious about development we must get serious about healthcare, and the best way to do that is through pursuing universal healthcare. Many will say this isn’t possible, it is too expensive, or African countries simply do not have the resources, however both Botswana and Rwanda show that not only can universal healthcare be done in Africa, but there is more than one way to do it. Thus, the question African policy makers should be pursuing is what do we have to do create quality, affordable healthcare with access for all.

Lessons from Botswana and Rwanda

Rwanda and Botswana have slightly different ways of implementing universal healthcare. Botswana operates a fully public system where the governments owns over 95% of healthcare facilities. The system is built around the delivery of primary healthcare which is available through an extensive network consisting of;

  • 844 mobile stops and 338 health posts which deliver primary preventative care to all it is citizens;
  • 272 clinics (101 of which have beds) which provide outpatient and general inpatient care;
  • and finally, there are the district hospitals and the two referral hospitals which provide long term and complex care and procedures.[2]

Almost all services are free except people between the ages of 5 and 65 pay 5 pula (‘USD’ or ‘$’ 0.50) for general check-ups.

Rwanda pursues universal health through a mandatory health insurance system called Mutuelles de Sante. The scheme is community based, residents of a particular area pay about ‘USD’ or ‘$’ 6 into a community insurance pool, richer citizens are charged higher premiums and for those who can pay a 10% service fee is paid for each visit to a health centre or hospital. Like Botswana Rwanda’s system is decentralised and built around providing primary care through;

  • 34 health post which do outreach activities such as immunisations, antenatal care and family planning;
  • 18 dispensaries and 442 health centres which provide preventative and primary care, out and inpatient services and maternity care;
  • 48 district hospitals which provide inpatient and outpatient care and 4 referral hospitals which provide specialised complex care.[3]

In both countries over 90% of the population have access to affordable healthcare whose quality has seen significant improvement over the last decade.

Botswana and Rwanda hold valuable lessons for policy makers on the continent. The first and most important being that universal healthcare is possible. Secondly multiple funding models are available and there is no reason that you cannot mix match payment, insurance and tax revenue to pay for it. Third, to be effective, primary and preventative health must be at the centre of the system. Primary healthcare focuses on people and their communities, by providing preventative and early continuous care and education, treatment of illnesses before they become life threatening and the early identification of serious health issues that require specialist treatment. Fourth you need appropriate infrastructure, specifically clinics, dispensaries and health posts/centres that are situated in communities around the country and are just as important as big hospitals. If you only invest in big hospitals they will end up being crowded with patients who could have been more effectively treated in facilities in their own communities. Investing in community health centres and facilities ensures that everyone has access to healthcare close to home and that large hospitals can take care of those who need the most help. Finally, we need to invest in people, and this strikes me as part of the solution to an existing problem. Africa has far too many young men and women who are educated but unemployed, to me this presents an untapped pool of administrators, doctors, nurses, pharmacists and clinical technicians who would be needed staff a universal health care system.

Health as development

Universal healthcare in Africa is achievable but only if our governments begin to think of healthcare as just as important to development as roads, power, jobs and education. Fundamentally healthier people are happier people. Universal healthcare will significantly improve the quality of life for hundreds of millions of people, it would take away the spectre of going broke because you, or a relative got sick and it could provide millions of meaningful jobs for young men and women who would jump at the prospect.

In 1948 Great Britain was broke and had just come out of two devastating world wars in the space of three decades, yet it was in that year that they launched the National Health Service which was and still is based on 3 principles; ‘That it meet the needs of everyone, that it be free at the point of delivery, and that it be based on clinical need, not ability to pay.’[4] Today, the NHS is the institution that the British are most proud of. Today, like Britain in 1948, Africa is not rich and faces a myriad of challenges, but we can and should dream big, that all Africans should all have access to quality affordable universal healthcare. If development in Africa is to mean anything surely it must mean that Africans can live full and healthy lives, it is time to bring the Abuja declaration to life.

 

 

 

[1] http://www.who.int/health_financing/universal_coverage_definition/en/

[2] http://www.gov.bw/en/Ministries–Authorities/Ministries/MinistryofHealth-MOH/About-MOH/About-MOH/

[3] http://www.hrhconsortium.moh.gov.rw/about-rwanda/health-system/

[4] https://www.nhs.uk/nhsengland/thenhs/about/pages/nhscoreprinciples.aspx

What is Development?

Freedom should not be understood to mean leadership positions or even appointments to top positions. It must be understood as the transformation of the lives ordinary people in the hostels and the ghettos; in the squatter camps; on the farms and in the mine compounds. 

It means constant consultation between leaders and members of their organisations; it demands of us to be in constant touch with the people, to understand their needs, hopes and fears; and to work together with them to improve their conditions. – Nelson Mandela

This is the question at the centre of the African story, at least when it comes to policy, yet we do not seem to have that discussion, leaving it open to be defined by those in power rather than those whose lives its supposed to change. In academia the question as to what development is much debated but it has failed to leave the confines of the ivory tower and development aid industry. Today development is too much like beauty, it’s in the eye of the beholder, every time the government builds a footbridge or a railway it claims development, economists and business leaders look at economic growth figures and call that development, the UN looks at the Human Development Index and Sustainable Development Goals and calls that development. What about the people, those for whom this development is being done, it seems to me that if the vision of development being pursued was one that came from the people, then governments and international development agencies may have more success pursuing it.  A policy shift to people centred development, that actually takes what people want and need into account would in my view make the whole notion of development much more relevant and impactful.

Roads, railways and power.

Most of the continent is busily pursuing the infrastructure gap, which can be summarised as the need for infrastructure (roads, railways, power, water and sewage systems, housing etc.). In Africa the African Development Bank has estimated that Africa needs 95 billion US dollars a year to close its own infrastructure gap[1]. Governments have latched onto this and across the continent there is a massive building program being pursued. Physical infrastructure is perfect politically, its tangible and can (if done properly) make an impact on people’s lives, without the complicated political, administrative and moral issues that come with improving education or fighting corruption. Business and banks love it because they can make significant profits funding roads, railways and power stations while saying they are contributing to ‘development’. Infrastructure is important, there is no doubt about it, a road connecting a rural community to an urban market can radically increase opportunities, electricity has and can change the lives of the poor the world over, but is it development? I don’t think so, I see infrastructure as an enabler, a building block towards development, but not development itself.

GDP growth and jobs

You cannot have a conversation about development without someone bringing up GDP growth numbers. Despite academic attempts to dethrone economic growth as the primary indicator of development it is the standard statistic that people cite. But what does GDP growth actually tell us? GDP is the value of all the goods and services produced in an economy in any given period (usually quarterly or annually). So, when it grows, it means that the country is producing more things and as a whole earning more. However, it doesn’t tell you important details such as who is earning more – are the rich getting richer or is the additional income being spread to the middle and lower income groups. It doesn’t measure standard of living, or the quality of social goods such as healthcare and education. It is just an aggregate, a useful one but without context and additional data it doesn’t tell you whether peoples lives are actually improving. When people point at GDP growth and call it development, take it with a pinch of salt.

Ask the people?

What is missing from the development debate for me is the people, most of whom are still stuck without meaningful employment or prospects of progress, far too many living in poverty. What does development mean to them. I think at its core, development would be the ability to live a life with dignity. A life where our children have a decent education that gives them a chance at a future where families can rely on the health care system and have adequate housing. A job to support you and your families. A police force and courts that are fair and protect society and a government that respects our rights. Thus, to me development is about growing the economy in such a way that provides jobs and income for the majority, building the infrastructure that enables this, investing in social services that improves quality of life and the rule of law and respect for human rights. Development isn’t just about jobs, or growth, or new roads and power stations, to me it’s about uplifting the lives of Africans, and our development policy, whether economic, education, infrastructure or law and order has to have that as its goal. But that’s just me, ideally, we should start by asking the people. Governments around the continent would benefit from broad consultation process to see what their citizens consider development and make their policy on that basis.

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[1]https://www.afdb.org/fileadmin/uploads/afdb/Documents/Publications/Africa%20Econo%20brief%202_Africa%20Econo%20brief%202%20(2).pdf