By Vincent Okungu- KEMRI-Wellcome Trust & University of Cape Town
Political governance in Africa has seen some of its worst episodes. In 1974, Francisco Macias Nguema, the then President of Equitorial Guinea, exiled a third of his country’s population, banned newspapers, and closed all schools and libraries. He then executed the governor of the Central Bank and transferred all the money and the national pharmacy to his village. Jean-Bedel Bokassa of CentralAfricaRepublic spent a third of his country’s national revenue on his ‘coronation’ as emperor of the ‘Central Africa Empire’. In that period, health indicators in Africa were at their worst; general discontent persisted, socioeconomic and cultural tensions simmered and often resulted in endless civil wars and murderous ethnic conflicts.
While Africa has largely moved on from the delusions of grandeur and debauchery that characterised her past, it is worth noting that some of the wealthiest African countries in terms of mineral resource endowment are some of the most chaotic, unequal and poorest in the region: D. R. Congo, Equitorial Guinea, Nigeria, Guinea and CentralAfricaRepublic, among others. Most of these countries currently experience soaring social tensions and suffer inequitable health systems with high out-of-pocket expenditures.
Redistributive policies are less likely to succeed in divided nations as well as those with weak abilities to unionise or those with high levels of social inequality and class tensions. In Africa, divisions are mostly along the lines of ethnicity, religion and income. Universal social policies to which all citizens contribute and benefit from are likely to create solidarity among beneficiaries and strong support from the citizenry. However, this is contextual and will depend, to a significant extent, on trust in governance systems and solidarity among a diversity of different communities. Stuckler et al (2010) argued that socioeconomic and cultural tensions make it difficult to cultivate a feeling of social solidarity among different groups yet social solidarity is critical in pooling funds for universal health coverage.
Needless to say, universal health coverage per se is not enough; it has to be equitable. One of the criticisms leveled against MDGs is that they have no considerations for inequities in access to health services and health outcomes amongst different socioeconomic groups. The socially disadvantaged among us, according to UNICEF (2010) also have the worst health MDG indicators. This group also suffers relatively higher mortalities and heavier disease burden. Ideally, these inequities mirror wider societal problems in governance and group cohesion.
Inequities in health systems need to be addressed in the post MDG debates with a view to improve population health as a whole not just the health of a segment of the population. To achieve this, the post-MDG debate would best start from the basics: governance and social cohesion, noting that overall good governance is a cost-saving endeavour and a basis for national unity and equitable health systems.