Monthly Archives: April 2013

Is Universal Health a Public Burden in Africa?

The WHO has a long convoluted definition of health as is typical of most organizations of its stature and mandate. To the average person, African or not, health is subjectively defined in simpler terms; a state of wellness and ability to cope with the daily demands of life. The similarities end here. What counts for normalcy in Western Europe and North America is literally worlds apart from the same in Asia or Africa. While the per capita annual spend on health in the US is about $8000 and $3000 in Western Europe, every African individual spends only about $85 towards their health annually! This comparison, at face value, is damning. Indeed health care in the West is highly specialized and commensurately expensive; in great contrast to the African context where healthcare largely involves basic primary care. The expenditure gap is therefore a result of the size of the health ‘shopping cart’. This cart is significantly small for most of Africa with just a handful of goods while our American/European counterparts have a large cart bursting with goodies. Looked at differently, the African public sector is unable to push the ideal health cart and has chosen to keep only as few goods in it as it can push. This beggars the question; is health a public burden in Africa?


In his book ‘Why Africa Is Poor; And What Africans Can Do About It’, prolific author, researcher and international expert Dr Greg Mills goes at great lengths to demonstrate the central role the health of any nation has on its ability to grow from poverty to prosperity. Health is the very foundation of productivity and growth. A population afflicted by disease and illness spends less time in the production of the goods and services it needs. Complementary to good health is education; the skills to produce, and leadership; the organization of priorities. All developed economies have had to make deliberate provisions for the health and skills of their people to be where they are today. Other factors are subsets of these three pillars. Is it thus plausible to argue that leadership is wanting in Africa for it not to have prioritized the health of her people? The statistics all point to a sector in wanton neglect and crying for attention; life expectancy at birth of 56 years (against 80 in developed countries) and unacceptably high all-cause mortality and disease rates. Viewed against investment in health and other social services, these grim figures are proportionate to the dismal investments in these sectors. However, Africa is a vast territory of 54 nations; each unique in its own right and internally very diverse. A sweeping statement like this may not fly but remains valid for the most part. Analyzing individual countries paints a more accurate if grimmer picture than these continental averages.

Take Kenya for instance, a country with a per capita GDP (PPP) of  just under $ 2000 spending a meager 4% of her GDP on healthcare. Two thirds the citizens live on less than $ 2 a day and predominantly rely on the state-run health system for their health needs. The health system is mainly funded by central government taxes (direct and indirect) in addition to co-payment into a largely voluntary national insurance scheme that covers nearly two million of the 40 million citizens. Those not covered, an overwhelming majority, are expected to share costs with the state in the form of user fees at points of care. These direct fees amount to 60% of all the national health spend. There is no explicit provision for the care of the worst-off in the society; the elderly and the extreme poor. Where provisions exist, like for children under five, free treatment is often negated by a lack of an assortment of supplies including drugs which patients routinely have to buy out of pocket. In addition to the direct costs of healthcare, majority of the population bear disproportionately high indirect costs in accessing health. Transport costs are highest in the rural areas where physical access is lowest and poverty highest. The opportunity cost of time in seeking care also tends to be higher for the worst-off of the society; they make no income when sick and have to pay to get back on their feet. As though not already overburdened, the poor further face a silent hidden cost: counterfeits and illegal practitioners. Illegal practitioners take advantage of the unmet health needs of those disenfranchised by the formal system. It is here where counterfeits are passed off for genuine drugs and overall quality of care much lower than anywhere else but at a fraction of the direct monetary cost. This situation is not unique to Kenya: across Africa, millions of poor peasants have to make the choice between their health and food or work. While it is obvious that productivity is lost with every episode of illness, most African governments have failed to embrace this rather simple fact that a good health status is the basic unit of productivity; even ahead of education/vocation.

A sad irony is that while majority wallow in poor health, a small middle class in Kenya (like in other African countries) has access to fairly comprehensive employer-financed health covers tenable at some of the best health facilities around the country. These people do not lose much income (if at all) for their sick-time and do not have to pay for their health costs at the point of care. This sad state of affairs ensures that only a small subset of the nation enjoys good health and subsequent productivity and therefore carries the resultant burden of the sick and less productive. This further widens inequalities and keeps entire nations stuck in poverty, disease and underdevelopment; a reality so prevalent across Africa and within nations.

On the contrary, Germany spends 12% of its GDP on healthcare with direct private fees amounting to only 25% of the total health spend. The health basket in Germany is certainly larger but it is important to note that the bulk of the financing for health is prepaid. Public funds shoulder nearly one quarter of the health budget with the rest covered by prepaid compulsory universal health insurance into which employees and employers contribute. Further, the government makes payments for those out of employment or otherwise unable to make an income. This single feature creates a system in which ability to pay is not a determinant of access to health services. Efficiency and collaboration between private and public players in financing, service delivery and research into healthcare is high and the overall result is a system that meets the health needs of all citizens including the less fortunate. Needless to add, the dividends of a healthy nation are self-evident; greater productivity, longer lives and greater quality of life.

However, a good national health service is not by itself a guarantee to improved national health status. The health service is only one of a retinue of factors that determine the health status of individuals. Commodities like food security, water and sanitation, education, clean energy and social cohesion achieve greater health benefits and savings than the health service itself. It takes leadership to define programs that integrate these individual components into a system that delivers health to the nation. This demands an awful amount of political capital and ownership for any meaningful success. Africa must begin making homegrown decisions for her people. The introduction of user fees in hospitals and state divestiture from several key public sectors (including water, electricity and transport) can be remembered by all to have been a top down condition by the Bretton Woods institutions in the infamous Structural Adjustments Program era of the 80’s. Today, fragmentation of healthcare in most African countries amongst disparate donors with as many interests has made sure that only modest gains have been made in the improvement of healthcare. The presence of these programs if for nothing else is testimony to the fact that our health systems are not functional as presently constituted. A conscious effort must be made to ensure the attainment of universal population coverage as the first step in achieving universal health care. To ensure a meaningful health package, the financing of health – as a necessity – needs to be prepaid rather than at the point of service. Mechanisms must also be placed to ensure the most disadvantaged of society are not disenfranchised from the health system by way of fees. And more importantly, there must be efficiency at every level; collection and pooling of funds, purchasing of health goods and services, management of the health workforce and research. This calls for closer mutual public-private partnership and for emphasis; leadership. Only then shall we begin to have a healthy enough population that can engage in production and economic and social development. Fortunately, these developments are already taking place in countries like Ghana, Rwanda and Burkina Faso with steady and remarkable results. It must remain alive to us that universal health is a public burden; not to be shunned, but one to be borne by everyone in a way that especially seeks out the most disadvantaged in the society.