Tag: healthcare

Charity is not policy.

Our donors, who art abroad, hallowed be thy purse. Thy aid come in dollars and pounds. Thy will be done in our countries, as promoted by Bono. Give us this day, our yearly funding. And lead us not into self-reliance. But deliver us from ourselves. For thine are dollars, the pounds and the euros, forever and ever. Amen – Elnathan John – Becoming Nigerian: A guide

On the 24th of February Ghana became the first country to receive a shipment of Covid-19 vaccines through the multilateral Covax facility. Throughout the pandemic (and one could argue throughout the post-colonial period) Africa has been the worlds charity case. Asking for and receiving billions of dollars of donations of PPE, sanitation supplies, and now vaccines. While all of this is lovely it is highly problematic. Relying on the generosity of the developed world to help us respond to crises or define our development agenda is tantamount to giving up our agency over those same issues, and it allows our political leaders to outsource responsibility for development or crisis response.

While the lack of vaccines, testing capacity, PPE is blamed on hoarding by the rich world, which is true, it should also be blamed our own inability to manufacture vaccines, testing materials or PPE. This is down to the bad leadership which outsourced development policy to those, with money and good intentions with pet issues, those who think that intellectual property is more important than responding to a global pandemic.

As millions around the world get vaccinated and Africa, reliant on the charity of others gets left behind to become the Covid continent. Hopefully, it brings us to the realization that charity is not policy. Over the last year, I have devoted much (virtual) ink to looking at how Africa could re-imagine capitalism for itself, forge a post-pandemic vision of development, stimulate our economies and measures we could take to respond to the crisis. All of that is useless, if we do not take responsibility for our own development and recognize that charity is not policy.

The problem with charity as policy

The problems associated with development aid and assistance charity in Africa are well documented. The creation of bloated self-serving bureaucracies that have little or no impact while allowing ex-pats to live charmed lives on the continent. Trillions of dollars spent with little to show for it. The self-serving nature of most spending which is spent on consultants and companies from the originating country. The use of aid to push various geopolitical agendas and to buy the support of African governments. However, this is not the most corrosive aspect of aid and charity on the continent that comes in two forms.

First, it robs us of our agency. Our development agenda is decided in London, Berlin, Washington, Beijing, and Geneva, in board rooms at various foundations and charitable organizations. It rarely has anything to do with what the “targeted” African communities actually want or need. Should massive infrastructure projects be the focus of our development spending, maybe, or maybe not, but that agenda was driven by the multilateral development organizations. The various development fads of microlending, SME/entrepreneur/youth/gender empowerment, digital identity etc. have all primarily come out of western research and institutions. If African development is not driven by the stated wants needs and aspirations of its people, then it does not serve them but the agenda of others. Charity serves the agenda of those doing the giving, not the receiving.

Second, aid and charity enable governments to outsource their responsibilities. Why should the Nigerian government bother to provide real services to the people of the oil-rich Delta region when the Oil companies will spend billions in building schools, clinics, and roads as part of their CSR. Why bother devoting real resources and policy to healthcare, health research and public health finance if the Gates Foundation, US-AID, The Wellcome Trust, and other donors are all pumping money into it. When you outsource responsibilities, you lose control of them as others decide what the focus of the money will be. Thus, our health systems have severely undeveloped but critical elements (like blood services, non-communicable disease prevention, mental health treatment, pharmaceutical research development etc.) because donors have other issues (and more often specific diseases or issues) that they care about.

The impact of this is all too clear to see. Development when funded by aid and Charity is done to us rather than by us. And, when problems that are not a priority for donors, like a global pandemic, come to the fore we find ourselves without the capacity to properly deal with them.

Conclusion – taking back our agency

After its independence in 1947, India made a very deliberate choice, facing serious health challenges among its large population, one of the critical things that India needed to vaccinate millions of people against TB, Smallpox, Polio, and other infectious diseases. However, at the time, much like Africa today, India was reliant on the importation of often expensive pharmaceuticals and biomedicals. The Indian government very deliberately set about investing in indigenous pharmaceutical companies, enabling them to build up R&D capabilities and most importantly the capability to produce pharmaceuticals in India. By the 1990s when India’s economy was being opened up these companies combined rapid growth in their own large domestic markets with global partnerships and continued investment and supportive policy from the government to become global players. The greatest example of this is the Serum Institute of India (SII), set up in 1966 to produce immunobiological’s, it was a beneficiary of the Indian government’s policy and today is the largest vaccine producer in the world. The majority of the Covid vaccines delivered to Africa are made by the SII.

Doing away with charity as policy means taking a lesson from India’s book. Making, deliberate choices to invest in areas that will wean us off dependence. It may take us 20 years to build up the infrastructure to produce our own vaccines, but it will mean that the health of our people will no longer be reliant on whatever others have to spare to deploy programs like COVAX or GAVI.

This thinking isn’t just limited to the health sector but will require us to make very deliberate choices and investments in the design and deployment of our education systems, climate policy, food security, transport, and science and technology. Not just for jingoistic, populist reasons that sound good on the campaign trail, but to free critical aspects of our development from whims of charity and geopolitics and put them in the hands of Africans. If we do not, when the next crisis rolls around, Africa will once again find itself left behind, begging bowl held out dependent on the charity of others.

Making it through the crisis: Africa’s crisis response policy

A few weeks ago I wrote a piece on what Africa can do to kickstart its economy and drive long term growth after the coronavirus crisis has ended. What’s becoming clear is that the crisis will be longer and deeper than many had first thought. This poses the question, what policies do we need to put in place so that when it ends, we are in a position to kickstart a recovery.

African governments do not have the financial firepower or operational capability that developed countries have deployed. But I do not believe that means we are hobbled. As policy responses around the world are showing, what was previously thought impossible, too expensive or too complex is doable. The same applies to Africa. To make it through the crisis we must abandon the art of the possible and attempt the impossible. This crisis presents critical obligations to African policymakers, that we must be bold and creative to save lives, livelihoods and possibly the state itself. This crisis also presents policymakers with an opportunity, to redefine what policy in Africa can do, particularly when health, wealth and well-being of its people are at its centre.

The Nature of the crisis

This crisis is unlike anything Africa has seen before. Its effects are multiple, simultaneous and intense.

First, this crisis will last longer than many of us thought. Until there is a widely available vaccine or cure, we will continue to see outbreaks, travel restrictions, social distancing, quarantines etc. In various parts of the world and Africa as governments try to avoid a second wave. Considering the staggered way in which the virus has spread across the world, it’s estimated that the most severe restrictions will continue for the next 3-6 months and various restrictions could remain in place for up to 18 months until medical solutions are widely available.

Economically the World Bank predicts the continent could lose between $37 billion and $79 billion in output and face a recession of –5.1% (negative 5.1%). Furthermore, agricultural production (the most important sector in terms of output and employment on the continent) could contract by between 2.6% and 7%. This is an economic disaster for the continent. The formal sector will be defined by falls in productivity, revenues and severe job losses. In the informal sector which accounts for 89% of employment on the continent, its traders, farmers, vendors, MSME’s, tradespeople who rely on daily incomes are facing disaster if those incomes are disrupted endangering their ability to afford food and shelter not just for them but also the people who rely on them.

This crisis will also stretch our healthcare systems, in many cases past their breaking points. Endangering, the lives of those with Covid-19 and the lives of those who need medical attention for things other than Covid-19 (expectant mothers, HIV-AIDS patients, cancer patients, malaria patients etc.).

Internationally, help (financial or technical) from the traditional donor/development aid community will not be as forthcoming, as it has been during previous crises, as they try to deal with the crises within their borders. Thus, Africa cannot rely on the international community as we have become accustomed to doing.

With all these effects, in responding to this crisis we have to have a core goal. That we have to keep our people fed, healthy and secure livelihoods as far as is possible. Which means designing and implementing a mechanism to enable people to keep themselves fed and secure. Providing lifelines to the informal and formal sectors, so that people have livelihoods to sustain themselves in the long run. Restructuring how our governments communicate with the public to ensure that the measures taken are as effective as possible and provide a foundation for re-forging our societies.

Keeping people fed and secure

This is probably the biggest headache facing African policymakers in their response to the crisis, and many will default to what they know, distributing foodstuffs. However, what we need in a situation like the current crisis where millions of people who were ok now fall into vulnerability, is a solution that is big, simple and fast. One solution that encapsulates all three is cash transfers. Give vulnerable populations money and trust them to know how best to use it. As I have previously written, cash transfers are effective, and people are rarely irresponsible with them. With innovations like mobile money which has permeated across much of the continent, it is possible to get money where it needs to go and to do it quickly. And, it avoids the mess of corruption and delays associated with government procurement. Finally, it puts money where the economy needs it. In the hands of consumers who buy their food and other essentials from the informal economy, keeping those value chains alive.

How do we pay for this? Simple, print money. The UK is doing this. Those afraid of inflation should note that the money would be replacing depleted economic activity, thus limiting the inflationary impact.

Reinforcing health systems

First, African countries need to devote more resources to public health. For decades we have let public health fall into a state of disrepair and underfunding. Over the short term, this needs to be remedied by immediately ramping up funding, and resourcing over the short term to fund the immediate Covid-19 response. As well as thinking through how to implement public health measures in an African context. Rather than lockdowns, how can we make markets which are critical nodes of the food system sanitary and credibly social distant? How do we make informal settlements where people share multiple spaces as safe as possible?

But it also represents an opportunity to start long term investment in community health. If we want to keep hospitals free to treat Covid-19 we need to deliver care to people in their communities. This means public health communication and education, provision of basic care at a grassroots level and investing in preventative infrastructure (sanitation, water, clean cooking etc). That could over the long-term form the basis of a viable universal healthcare system.

Paying for this will require shifting resources for normal noncritical spending (non-salary and critical operations) to the health systems, delaying or freezing development projects and tapping into capital markets (borrowing) where possible.

A lifeline to the economy

Through no fault of their own, businesses across the continent are suffering as demand falls, export markets go into lockdown, their supply chains are disrupted, and their consumers stay at home. To save jobs, livelihoods and in some cases whole industries. Many governments have already put in place tax holidays and encouraged banks to renegotiate loans with businesses. However, in a recession predicted to be deep, more is needed, and this could consist of several measures such as:

  • The utilisation of domestic private sector capacity by the government as part of the crisis response. Using streamlined public procurement to buy goods and services (e.g. Masks, logistics and transport, beds etc.) that are needed by the government to respond to the crisis. This will help keep some local businesses alive and build local capacity.
  • An SME loan program divided into two tranches. The first tranche would be given now, to keep SME’s alive and the second tranche would be given when the WHO declares the crisis over to enable SME’s to quickly restart their operations. This can be done by the banking sector backed by a guarantee given by the central bank in case of defaults. The guarantee would have 2 conditions: low-interest rates and a 6-12-month grace period before the loan payments start to give SME, breathing room. This would have the effect of giving SME’s working capital and keeping the credit system alive.
  • Safe business programs. Many businesses require social interaction such as open markets, salons & barbershops, restaurants bars and clubs, etc. We should be developing guidelines and rules for safe interactions in these businesses that integrate sanitary measures and social distancing (where possible) to enable these businesses to reopen as early as possible without endangering public health.
  • Utility bill and commercial rent holidays to ease pressure on businesses with reduced cash flows. Utility providers and commercial landlords can be provided with tax credits to offset the reduced revenue. I

Communicating with the public

I have written previously on the need for effective and persistent communications strategies to be built into policy design. This is critically important during a crisis, where not only do the public need to know what is happening, they need to buy into it, trust what their governments are saying and understand that it is being done for the public good. For that to happen governments have to change how they communicate with their publics from talking at them to engaging with them, this means:

  • Be honest. Now is not the time for bluster or false assertions. If governments lie and people die as a result, trust will be fundamentally broken, and people will be unwilling to listen again. Thus, governments must lay out the truth to their people, what this crisis will do to every one’s health, livelihoods and general welfare and why they are implementing exceptional measures.
  • Explain your thinking. Governments will be implementing measures that will affect people’s lives in a multitude of ways. As the heavy hand of government, intervenes in people’s lives in unprecedented ways, the government must explain why, what drove the thinking, and what they are hoping to achieve
  • Accept and respond to criticism. No policy response will be perfect. Being able to acknowledge where something has not gone as planned or was not implemented properly and communicating real action taken to fix it, will build trust and support.
  • Communicate often. This is a constantly evolving crisis; people need to be updated regularly. In times like these, there is no such thing as talking too little.
  • Engage across channels. To reach everyone, you must go where they are, which means going beyond traditional media onto social media, and breaking language barriers. If information is inaccessible, then it may as well not exist.

Communicating, honestly, effectively, and openly will help reshape the relationship that has been characterised by a lack of trust between opaque African governments and populaces that have long been indifferent to whatever pronouncements and declarations those governments make. Rebuilding trust can be the basis for rebuilding the sense of community and society that too many African countries have lost, reinforced by genuine efforts to assist people.

A pan-African response

Though the international community may be pre-occupied, it does not mean the pan-African community cannot respond. Though we may not have the money or the resources that the developed world can deploy, we can cooperate to ease the pain of the crisis. Critical areas of cooperation would be:

  • Sharing data and information on how the pandemic is evolving in each country. providing public health officials and policymakers valuable data on the epidemiology of the virus within similar demographics that can help every country fine-tune their response.
  • Sharing policy responses. What measures have implemented in other African states, how effective have they been, can they be adopted elsewhere.
  • Sharing resources. If the crisis has eased in one country but is ramping up in another, they could provide resources (equipment, personnel, money) to help in that fight.
  • Buy Africa first. Stimulating the African private sector by encouraging African governments to buy what they cannot find at home (e.g. if there is a food shortage) in other African countries before looking abroad.
  • Engage the world as one. While African states do not agree on everything, this crisis will bring us together on various things. One of the most important of those things is Debt. Africa needs debt relief to give it the fiscal space to pay for the virus response and a post-crisis stimulus. Rather than have each African country go to its bilateral and development partners on its own to beg for debt relief or a payment pause. The message will be much more powerful if the continent speaks and negotiates with one voice, increasing its bargaining power and the momentum behind the issue.

Unprecedented crisis – an unprecedented response

This crisis is unlike anything Africa has ever seen before. Even the Ebola crisis of 2014 did not threaten the whole continent and had significant international assistance. It is hampering our health systems, economies and socio-cultural way of doing things on a scale we have never had to deal with.

This is by no means a comprehensive look at the policies that can or should be implemented. The policy interventions I have presented are a few among many that a lot of talented and clever people are thinking of across the continent. What I have tried to lay out in this piece is that this dual health and economic crisis is a threat to us all. And responding to this crisis requires a multi-pronged approach that is big and bold. That will need African governments to get out of their comfort zones and implement measures such as cash transfers which they have termed too expensive or too hard,  shift money from cherished infrastructure and other projects to the health system, invest in the private sector especially SME’s in new ways and talk to the public in a more genuine way.

If we do not respond in a big and bold manner, many African nations will emerge from this crisis hobbled, suffering extended socio-economic aftereffects and much more likely to suffer civil and political unrest. If we can respond with boldness then we could lay the foundations for a genuine recovery after the crisis, a public health system that isn’t an oxymoron, a reset of the relationship between private enterprise the and public good and a  much more positive relationship between the government and its peoples. I’m hopeful that maybe, this time, African leaders and policymakers will recognise this crisis for the threat it is and start thinking big and acting boldly.

After the crisis: driving Africa’s post-Coronavirus recovery

Right now, and understandably so, African governments are focused on dealing with the immediate health crisis presented by Covid-19. Preventing the spread of the disease among African populations and treating those who are already sick, are the priority of government right now. However, eventually, this crisis will pass, public health authorities will eventually manage to control the spread of the disease and effective treatment measures (or vaccines) will be developed. When the crisis is over its negative economic impact will become clear, and African governments will need effective strategies that to foster economic recovery in the short term and a medium to long term strategy to fix the fragilities in African economies exposed by the crisis.

The economic impact of the crisis

For Africa, this crisis will have many effects on the economy.

  • For oil and commodity-exporting countries, the fall in prices will drastically cut their tax revenue as well as related incomes within the economy.
  • Disruptions to trade will hit manufacturers and projects on the continent as they cannot get enough of the components or raw materials they need. Similarly, retailers who import goods to sell may run out of stock. Combined this will drive inflation and possibly force manufacturers or projects to shut down.
  • Disruptions to trade will also hurt those economies such as Kenya, Ethiopia, SA, and Ghana who export agricultural goods and produce, where the majority of the population is involved in agriculture, falling prices and exports will hurt incomes of both businesses and households.
  • The tourist industry, which is a top income earner in several African economies will be severely hurt by the travel restrictions and quarantines on the primary tourist markets in the USA and Europe. Across the continent’s tourist destinations, hotels, conferencing destinations, resorts, parks etc, will be bleeding money and jobs. While the continent’s airlines will be suffering massive losses as passenger numbers plummet.
  • A global economic downturn will shift investor sentiment, international investors will be warier of investing in Africa and we are already seeing the impact as stock markets across the continent register large falls as international investors withdraw their funding.
  • In China (which is now Africa’s largest trading partner and investor) the government will be more focused on economic recovery at home. Meaning that some of the expected Chinese investment on the continent will likely be delayed.

Short term response – kickstarting the economy

For all African economies, the combination of a global economic slowdown and the economic impacts described earlier will decrease both private sector activity and public sector revenues and spending. In an environment where most African governments were already struggling with large debts and deficits, what can we do kickstart the economy once the crisis is over.

Forget spending focus on tax

The first impulse of much African government will be to spend, to use the government’s ability to spend large amounts of money to create demand within the economy. Frankly, this won’t work in Africa at least over the short term. This is because African governments are incredibly inefficient (and often corrupt) so it not only takes a while for governments to spend money it also means that the not all the money intended for a specific purpose necessarily reaches it. Secondly, the money has to be found, which for many governments on the continent is a problem.

A short-term policy response intended to kickstart the economy must be something that is quick and has an immediate impact on the bottom lines of businesses and people’s pockets and the best tool for that at the moment is taxes and credit. For businesses, the key is helping them preserve cash flow so they can make it through the worst and drive a recovery.

  • There are a lot of taxes and fees that are levied on the short term (monthly, weekly, or daily) income of businesses (especially SME’s) such as turnover taxes, or licenses. Governments should consider waiving these for short term (3 to 6 months), that will enable businesses to preserve cash flow.
  • Statutory payments to public social safety net schemes e.g. health insurance, social security etc. which are usually paid by businesses on behalf of employees could be waived for the short term which would make it cheaper for businesses to retain people in employment.
  • Work with banks and the wider financial sector to come up with solutions (e.g. invoice discounting backed by government bonds) that would ensure that all pending government bills are paid quickly. This would put money in the pockets of companies that business with the government quickly, which will help ensure there is cash flowing through the system.

For individuals and households, the highest impact thing government can do to put money in pockets and help demand recover is again taxes, specifically VAT, which is often levied on (almost) everything. If VAT can be waived, for the short term, on critical items that people commonly buy (food items, data and mobile phone credit, soap, water, electricity) it will give people some extra money which they can spend on other things, and help drive the recovery of aggregate demand within the economy.

Long term response – long term growth and resilience

The crisis has exposed some key fragilities in African economies. But, as the Americans like to say, never let a good crisis go to waste, in other words in crisis there is an opportunity. Africa can use the opportunity of this crisis to build in greater resilience and the foundations of long term growth into its economy.

Trade

Africa can take advantage of the fragility that has been exposed in global supply chains. Companies both in Africa and globally will be looking to diversify their supply chains so that in future they are not as widely disrupted by a crisis in a particular part of the world (namely China).

With its significant labour pool, government focus on industrialization and improving infrastructure Africa offers a potentially attractive location for diversified supply chains.

For African companies specifically, governments would do well to focus on those goods and products whose production and distribution has been disrupted and encourage their production in Africa. Taking advantage of the soon to be active Africa Continental Free Trade Area, African based supply chains could prove to be more resilient for African producers and consumers than those based abroad. Investing these would not only foster resilience but create jobs and income as well.

FDI

As happened after the global financial crisis Central Banks in the developed world have responded by cutting interest rates, as a result, yields on government bonds are close to zero or in negative yield territory. This will likely be the case for some time after the crisis has passed as Central Bank’s try to fuel a quick recovery. As a result, investors from these markets will be looking for higher yields from their capital, which they cannot get at home. This will give them a greater appetite for risk with the payoff being higher returns, Africa will present multiple opportunities for these investors to try and take advantage of with their greater risk appetites. If we identified the right project’s and opportunities (such as privatisations or stock market flotations) that would benefit from these flows, and package them right we can direct this money to places where it will have a long term positive impact.

Domestic investment

International capital markets will be distorted for some time after this crisis, by central bank and government stimulus policies. It will thus be important to put in place policies that encourage domestic investors (e.g. pension funds, mutual funds, etc) to engage with and invest in African businesses and commodities.

Structural reform

Crises offer governments the opportunity to address issues that would otherwise be politically impossible to address. For instance, a public health crisis emphasises the need for Universal Health Care, an expensive proposition which government are not usually brave enough to attempt. However, a health crisis offers the opportunity for a fundamental reshaping of the health sector. The same goes for government finances, its hard to take away MP’s perks, the cars of senior civil servants, cancel the vanity project of politicians. However, a public health and economic crisis can serve as a valid reason to cut the fat that will not elicit too many questions or a fightback.

Conclusion

Just as we cannot afford to be lax in how they respond to the crisis, African governments cannot be lax in how they deal with its economic consequences. Otherwise, an economic crisis will follow swiftly on the heels of the public health on. If we do not have a strategy to deal with it we may end up with an economic crisis that disrupts more lives than the Coronavirus.

As I have suggested in this article there are tools that the government can use over the short term to put more money in the hands of businesses and individuals. This can help spark a recovery. Over the medium, to long term, there are a number of policies that government can pursue to equip Africa economies with the tools they need to weather future crises as well as lay the foundations for a more robust African economy.

Crises suck, we have to ensure they don’t last longer than is necessary.

Good communication is good policy

In 2017, in his Jamhuri day (Kenya’s independence day) speech, President Kenyatta of Kenya announced his Big Four Agenda. To enhance the manufacturing sector, to build 500,000 affordable homes, to ensure all Kenyans are food secure and to build and deploy a universal health coverage (UHC) system to ensure all Kenyans have access to affordable health care. Since then technical committees have sat and designed the requisite policies, regulations and actions needed to make this a reality. However, in a recent conversation, I had with someone working on the UHC policy, I was struck when told that without better political support, and funding; UHC in Kenya would remain consigned to the realm of flowery speeches. A policy that could save millions of Kenyans misery and bankruptcy will die a slow death for lack of money and support.

Africa does not lack for good policy. Around the continent, there are reams of policy that could genuinely change people’s lives sitting on shelves in the offices of government departments, think-tanks, civil society groups and universities, all of them gathering dust. In the world of policy, good policy is often stopped by two things political reality and financial constraints. Ambitious policy rarely ever survives the gauntlet that those two constraints pose. In a previous post, I talked about reforms that would enable governments to better implement good and ambitious policy. In this post, I want to take a step back and examine how we can get good policy to the stage of implementation in the first place with proper funding commitment and political support built using effective and persistent communication

 

Embedding core policy support

Policy has to be sold. To the public, to those who will implement it, to experts, to civil society, to the media and even to digital influencers. This selling is done via communication with all those stakeholders. Crucially, this communication has to start before policy gets to the implementation phase. Public opinion has (as Samantha Power once put it) a circular problem. Circular, because public opinion is rarely roused on its own, it is usually provoked by public leadership (e.g. political or other community leaders making something an issue), and public leadership is usually itself provoked by public opinion (e.g. public outrage at a particular issue provoking a political response). Thus, when done properly, communicating policy is a journey. A journey that first builds a base of support for the ideas and goals behind the policy and how it is relevant and beneficial among key stakeholders. A presidential speech or two and some articles in the newspapers are not enough, you need to engage people who will form the core base of support in forums, spaces, and channels where they are comfortable and attentive.

Getting public support

Once you have that critical base of support you then need to sell your policies to the two most important groups of stakeholders; the public and people within government who have to implement it.

Effective broad public communication is not merely a matter of adverts or getting a popular musician or sportsman to tout a particular policy. It is a multi-channel and messenger affair. Rather than telling the public that some policy is good for them, you need to engage people, from the mass media right down to community forums and door to door campaigns. That way you build an understanding of the policy, its goals and benefits at an individual, community and mass level. By successfully selling a policy to the public, you can bypass the political viability problem. When people quote political viability as a problem, they are usually referring to the lack of political support for a particular policy. However, by building public support through smart and inclusive communications, you can create political viability through public pressure. And with political viability and support, you have the ability to get proper funding.

The people within the government are usually forgotten in policy advocacy campaigns, but it is crucial that you get the support of the people who will be implementing the policy. Do they understand it, do they understand the impact it will have on the lives of their fellow citizens, do they see what role they are playing in bringing those positive outcomes to life. If the people implementing the policy don’t buy into its chances of success diminish significantly. The people in government who are implementing the policy need to understand and back the policy because they, they are also the people who have to defend and sell those policies to the public and political policymakers and if they aren’t invested, then the investment of others likely won’t follow.

Communicating Policy Implementation and beyond

Getting support for a policy is not enough though. Communication does not stop at implementation. Rather communication is an essential element of implementation. Stakeholders and the wider public need to know and understand what is happening with a policy that they lent their support to, to get it off the ground. They need to understand what progress is being made, the successes, and achievements of the policy. Beyond keeping people up to date, this allows you to make mistakes, to withstand the inevitable missteps that happen in all complex programs. However, because you have been open and upfront with your stakeholders and the public about those mistakes and clearly communicated solutions for these problems, you will be in a much better position to recover from any issues with an understanding public willing to cut you some slack.

Communicating policy in Africa

African governments can be singularly terrible at communicating policy. Policy generally comes as a surprise, presented as a fait accompli something from on high that is good for development and thus good for you and you better not question it. Which ends up with people being suspicious about those policies, and the people who are charged with implementation see it as just another order they need to carry out (or look like they are carrying out as opposed to being invested in the policy and its success.

Policy does not sell itself, even if it is fantastic. It needs to be communicated to all the people that will be impacted by it. It’s an often-overlooked part of the policy process, especially in Africa. Around the continent, it’s not just Kenya attempting to implement some form of universal health coverage. South Africa is exploring plans, Lagos state is set to make it mandatory, Tanzania has a political commitment to do so. As Africa explores and tries to implement ambitious policies such as these, policymakers and governments need to understand that part of good policy is good communications. That through effective communication they can build broad effective support for their policies and in doing so create the political will that will give them the political and financial ability to actually implement them properly.

Warehousing African development

Amazon has built a trillion dollar business around them, farmers around the world rely on them, modern healthcare would be crippled without them, the manufacturing industry needs them to smooth out production and demand cycles and global trade needs them to work. They aren’t glamorous like railways and airports, nor are they as fulfilling for donors who prefer to build schools or fund feeding programs, but warehousing is critical to modern societies and economies and they will be crucial for the development of African economies.

Warehouses won’t make living conditions or livelihoods better by themselves, but they are a crucial enabler for things that will. What’s needed from African governments isn’t money or infrastructure, but rather the right set of policies that will enable businesses and individuals to build, and use warehouse facilities as they see fit, to the benefit of their businesses, communities, and the wider economy.

More than storage

Most people do not spend much time thinking about warehouses let alone their transformative power. To most of us, warehouses are just storage, inert spaces where goods and commodities are kept either in transit or until they are needed. I thought the same until I learned the role that certified warehouses (warehouses certified by the government or other trusted actor) and storage play in making the world that we live in. Which got me thinking about the role that certified warehouses could play in Africa’s development on several fronts.

Agriculture

The Food and Agriculture Organisation of the UN estimates that sub-Saharan Africa loses about 20 % of its cereals, 40%-50% of its tubers, fruits and vegetables, 27% of its oilseeds, meat, and milk, and 33% of its fish, to post-harvest losses. This is millions of dollars of lost income for African farmers and it is enough food to feed at least 48 million people, equivalent to the population of Angola, Zimbabwe, Swaziland, Namibia, and Malawi all together.[1] A significant contributor to this phenomenon is the lack of adequate and suitable storage for agricultural goods. This forces African farmers to sell whatever produce they can at whatever rates they can get (the much hated farmgate price) or simply to let their produce go to waste if they can’t find a buyer.

Available (within reasonable distance), affordable (reasonably priced) and suitable (the facilities can store perishables goods appropriately), could cut post-harvest losses dramatically, simply by giving farmers somewhere to store their produce. Thus at the most basic level, proper storage ensures adequate food supply and food security. In addition, it could significantly improve farmer incomes as they will be able to store produce and search for the best prices rather than be forced to take whatever is given to them.

However, certified storage can do a lot more than simply bolster food supplies, farm incomes and cut losses. Certified storage can open the door to farmers gaining access to credit, having produce in a certified warehouse is an asset that farmers can use collateral for credit. Smallholder farmers produce almost 70% of food consumed on the continent, an improvement in their productivity would impact on poverty and living standards throughout Africa (something I cover in more detail here).  Providing smallholder farmers with access to credit is essential to unlocking long-term, sustainable gains in African agriculture. Without credit, farmers cannot afford inputs such as quality seed and fertilizer, they cannot purchase or rent tools that increase efficiency and reduce labour costs, they cannot afford training and support services. Certified storage can be the key to unlocking agricultural credit, as financial institutions will have collateral which they can sell if the farmer defaults, and farmers will not be rendered destitute as their primary asset, their land, will not be taken away as collateral. Furthermore, it could allow farmers access to financial instruments that farmers in the west have long had access to such as hedging (locking in a price for the next harvest) and providing themselves with some security.

The third thing certified warehouses can do for African agriculture is enable commodity exchanges, depositing agricultural produce in certified warehouses will allow that produce to be listed on commodity exchanges and traded, enabling farmers to sell their produce to buyers anywhere in their country, region, or even continent, and allowing consumers (through large purchases like millers and supermarkets) a larger selection of producers to buy from and thus a better chance of getting better prices.

Trade

Trade (both domestic and international) relies on finance, specifically trade finance. Formally its where banks and financial institutions provide credit, hedges, guarantees, and increasingly complex structured products to companies and people buying and selling goods across borders. On the informal scale, it’s the trader who borrows a bit of money (usually on a mobile lending platform) which he uses to buy produce or some other goods, which they then take to market and sell at a profit, paying back the loan with interest and keeping their profit margin. Fundamentally, both formal and informal, trade finance relies on trust. A key issue that hampers trade finance and thus trade across the continent is the lack of trust within the African trade ecosystem.

For instance, financial institutions (both big banks and mobile lenders) do not trust warehousing facilities and are thus unwilling to lend with those goods as security. Thus, financial institutions add a significant risk premium (high interest) to their financing which traders are unable to pay, or the few facilities that are trusted can charge exorbitant rates thus raising the cost of trade. Certified warehouses which issue verified receipts of the goods deposited in their warehouse could fill this gap and get rid of this hurdle to trade on the African continent because in the rest of the world this is precisely what certified warehouses do. Like in agriculture, having a place where you can store your goods verified by a trusted actor will kickstart trade by enabling their crucial lubricant, credit.

Healthcare

Markets and economics aren’t the only benefactors of proper warehouses. Pharmaceuticals are volatile things, they are carefully engineered chemical substances which need to be kept at stable temperatures and conditions. They need what’s called a cold chain, which is a series of refrigerated production, storage, and distribution facilities and capabilities. Refrigerated storage is a key link in that chain, as it would allow government and health systems to store medicines, smoothing out distribution chains, making public health campaigns (like vaccination drives) easier and allow health authorities to plan for contingencies, for instance, stocking vital medicines for a possible Ebola breakout. Storage isn’t just about commerce it’s a key enabler for health systems as well.

Warehousing policy

If storage is a key enabler in a number of developmentally key areas the question becomes what’s needed. The first thing that comes to my mind is to stay away from the solution that so many governments on the continent have tried, government-owned and operated storage facilities. Particularly in Africa they have become magnets for corruption and are often neglected to the point that it’s not worth storing anything in them.

The bare minimum that is needed from government is a legally enforceable framework that does two key things. First, it must put in place a trusted regulator who is able to certify warehouses. To be trusted it cannot simply be another government entity it must incorporate stakeholders from the private sector like the stock exchange, trusted multilateral institutions like the AfDB or TDB, independent bodies like central banks and industry associations to ensure that when it does issue a certificate everyone from farmers to banks will trust them. This regulator must have legally enforceable repercussions for those who violate standards and regulations set by the regulatory authority. Trust is not just about having someone in charge whom you have confidence in, it’s the certainty that when the rules are violated, for instance, someone’s goods are stored improperly, that those responsible are in fact held responsible, in this instance all affected parties are compensated.

Second, is that governments must get out of the way and encourage innovation, particularly in agriculture. Where to this day, far too many African governments maintain outdated systems of produce boards whom farmers are compelled to sell to, and control prices and maintain substandard storage facilities.

Third, is to ensure that small farmers are accounted for in any warehousing policy, e.g having a requirement that warehouses devote a certain percentage of their storage space to small farmers, or cater for small farmers at a discounted price (e.g tax-free storage for small farmers)

In an ideal world, African government would go beyond putting in place a trusted regulator and getting out of the way of farmers, they would actively encourage the building the storage facilities. This could take a number of forms that again do not require significant taxpayer investment such as:

  • Making land available to warehouse developers in agricultural areas to ensure that farmers have access to storage facilities.
  • Allow goods in transit held in certified warehouses to be held tax free, to help the free movement of goods, development of commodities markets and encourage trade.
  • Set standards for databases and goods tracking so that all stakeholders will be able to track goods through the certified storage system, thus bringing more trust into the system.
  • Make available guarantees or funding to groups of smallholder farmers enabling them to build their own suitable storage facilities and engage in the market without fear of being taken advantage of.
  • Give tax incentives to developers willing to invest in cold-chain suitable storage facilities that could benefit the health system.
  • Take a holistic view of warehousing aligning it with other development efforts, such as ensuring that rural roads lead to warehouse sites, that electricity, mobile networks, and data cables reach warehouse sites

Conclusion

It may seem odd to focus on something as mundane as warehouses and storage. Unlike other development policies like universal healthcare, infrastructure or police it is not grand and flashy. However, not all of development policy is grand and flashy, often times to make the big things like agricultural reform, universal healthcare or intra-African trade possible, it requires investment in the mundane things, like a policy and regulatory framework for certified warehouses. Proper and certified storage is an enabler for a number of key developmental goals, my hope is that policymakers are aware of this, that if they want the new railways and roads, they are rushing to build across the continent to work and spur a new era of growth and trade they will require humble storage facilities, certifiably trusted and available to all.

[1] http://www.fao.org/africa/news/detail-news/en/c/445333/

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