P. ANYANG' NYONG'O
Any publication on the status of health in Africa that one comes across is likely to portray a gloomy picture. Of the 13-15 million cases of HIV-infected adults alive in 1994, over 8 million were to be found in Sub-Saharan Africa. Almost all African countries do not meet WHO's health-for-all targets, whether one is talking of standardized death rates, maternal mortality rates, life expectancy or child survival beyond the age of five. Once there was some hope that there would be health for all by the year 2000 in Africa. This goal post can no longer be reached. And anybody trying to push it forward has a great problem counting sufficient decades ahead within which Africa can catch up with the more developed world. Why is this the case?
Health and Poverty
The reason is that health is closely related to wealth. Poverty, it has now been proven, breeds ill health. Poverty, ignorance and disease: the three always go together in the third world. Every year in the developing world 12.2 million children under 5 years die, most of them from causes which could be prevented for just a few US cents per child. But they cannot be prevented because the parents are too poor, the economy still backward and the governments too corrupt to efficiently use the available resources for an effective public health programme. The rest of the world, it must be noted, has become increasingly indifferent to Africa.
The average life expectancy in the developed world is well over 70 years; in Africa it hovers around 45 years. The number of children under 5 years who died in 1993 in the whole world were more than 50 million, a figure equal to the entire population of Norway and Sweden combined. Of such deaths in the developing world, the great majority could have been avoided if those countries enjoyed the same health and social conditions as the world's most developed nations; but they don't. And the gap between the rich and poor nations continues to widen, with African countries being relegated further and further down among the least developed of the world's nations.
Quality of Population
About 600 million people live in Africa today. Within the next 40 years we shall have 1.6 billion Africans. Every year, the population in Africa increases at about 2.7%, this is likely to decline to 2.0% in the year 2040. With HIV/AIDS as a contributing factor, the death rate is one of the highest in the world: 15 persons out of 1000 die every year; this could go down to 5 by 2040 if there is improvement in health care.
In developed countries, individuals are generally catered for in terms of health and sanitation facilities. While in Denmark, 100% of the population have access to clean or safe water, sanitation and health facilities, in Cameroon only 20% have access to health facilities, 41% to clean/safe water and 40% to sanitation facilities. Denmark has one of the lowest infant mortality rates, 5 per thousand; Cameroon's infant mortality rate stands at 56 per thousand-one of the lowest in Africa.
The Political Economy of Poverty and Poor Health
At independence, Africa had the ambition to develop and to create the wealth that would be used to conquer both poverty and diseases. But the past three decades, while starting with great promises in the sixties, ended with tremendous disappointments in the eighties. The vast resources of Zaire are now buried under the debris of a grossly mismanaged state and a regime whose corruption has no parallel in modern history. Southern Sudan, reputably the bread basket of Africa, deserves that name only in her potential and not in how her people live. Engulfed in fratricidal and civil wars since the fifties, life in Southern Sudan is nasty, brutish and short. Only Somalia is equally bad; and the league of such war-torn societies has recently been joined by Liberia and Sierra Leone.
The complete destruction of normal life, amid abject poverty and rampant diseases, typifies these war-torn societies. Thus the creation of peace as a condition for securing life for people becomes the most urgent task. But this cannot be done without people who are willing to live together, governments which are legitimate and can work and systems of economic activities in tune with the needs of human beings. The life lived below the poverty line by the majority of African people typifies most of the other states, normally seen as more stable politically. Thus the most prosperous nation, South Africa, also has one of the highest rates of current slum growth, accompanied by an increase in urban violence that could make her major cities virtually uninhabitable if nothing is done to curb the alarming levels of unemployment and poverty.
Two Types of Poverty
There are two types of poverty that one confronts in Africa, namely relative poverty and absolute poverty. Relative poverty depends on the general standards of living in a society. For example, the poverty that hits a retired civil servant who suddenly finds himself without a job, a proper pension and the means to sustain his family at the standard of living they have been used to, is different from the poverty of the absolutely unemployed. This civil servant suddenly finds himself relatively poor. There is also the relative poverty of the unemployed school leaver or university graduate who depends on relatives for basic needs. This poverty comes as a result of the gap between a potential standard of living (which schooling and university education is expected to bring) and actual living (which unemployment brings in slow-growing underdeveloped economies such as those found in Africa). In societies with social welfare such as the capitalist ones of the western world, relative poverty among the unemployed is reduced or cushioned by unemployment benefits or social welfare programs. In societies like Kenya, relative poverty can very easily approach absolute poverty among certain categories, such as the university graduate referred to above.
Absolute poverty is related to access to and availability of the basic needs of life such as food, shelter (or housing), clothing and moral/intellectual needs. The first three are usually referred to as "material needs" and the latter as "post material needs." It is, of course, true that one who is absolutely deprived of material needs will have no chance to develop some mental capacity, nor to go beyond the immediate environment of mental or moral imagination. Hence the satisfaction of basic material needs is at the very foundation of enhancing primary moral and intellectual needs that make one an active creature of society or, for that matter, a citizen.
Data on the absolutely poor in Africa, while not usually accurate in official statistics, are generally high. Two million school leavers enter the job market in Kenya every year; virtually none of them finds anything productive to do. At least half of these are not assured their basic needs in any regular way. Those who take national statistics have not included relative poverty in their data collection as this category would include those unemployed who are taken care of by their relatives and friends regarding basic needs.
Among the urban and rural poor, issues of absolute poverty stand written in large letters. And yet from these urban and rural poor are to be found reservoirs of casual and seasonal cheap labor often used in construction sites and agricultural farms. While they are not totally excluded from any gainful activity, they provide the army of small time thieves, house breakers, street children, and so on. Obviously this is a heavy negative weight at the bottom of a slow growing economy. Therefore, the question is: how can poverty be reduced in developing countries?
Improving Standards of Living
Africa's hopes for a better future depend in large part on improving the health of its people. This means better access to those facilities that establish the foundation for good health from infancy, facilities like safe water and sanitation which are the basis for proper primary health care. This also means better access to good and high quality health services, particularly family planning, and the improvement in the health status of women—the main bearers of reproductive health functions and responsibilities
The reality of reproductive health in Africa is far from the ideal, and that is why there continues to be such a high infant mortality rate, ranging from 56 per thousand in Cameroon and Kenya, to about 140 per thousand in Malawi, Guinea Bissau and Gambia. It is quite clear that these figures are highly concentrated among poor families within these countries. Among the poor, women start child bearing in their teens, and have an average of six children. Just 18% use contraception, and the level of unmet need for family planning¾i.e. over one-quarter of married women or more than 222 million—is higher than in any other region.
Early and frequent child bearing means that 1 in 15 women in Africa dies in pregnancy or child birth. Meanwhile, AIDS has struck hard in eastern, central, and southern Africa, where roughly 1 in 10 adults—both men and women—are infected with HIV. The HIV infection kills much faster among the poor than the rich; with health costs as high as they are to-day, it is to be expected that the well to do will find it much easier to meet the treatment and dietary requirements for prolonging life following HIV infection.
To reduce the possibilities of girl marriages, better and safer opportunities and facilities for the education of girls will be needed. African countries must expand access to education for girls and economic opportunities for women. This will require substantial financial contributions for good public education from governments, households and donor agencies.
Human Resources Development
Contrary to the current neo-liberal orthodoxy that the state should withdraw from its social welfare commitments, it is quite clear that now, more than ever before, a responsible state is needed to invest in Africa's human resources development. The primary beneficiaries of this investment must be women and children.
Better educated families are much more likely to make good decisions about family planning; this has been found as an invariant fact in all societies. Better planned families will, in turn, lead to increased abilities of families to invest in quality education for the children. This will further complement the government's efforts in investing in public education, hence the general increase in standards of education.
With better education, attention to primary health care needs will also increase, reducing the incidence of preventable diseases and hence of medical care bills as well.
This is the result to which initial substantial public investment in health and education will lead. It cannot, therefore, be over-emphasized that the root towards poverty eradication lies in human resources development. In addition, an educated populace ends up to be a source of more productive labor than an ignorant populace.
Agriculture and Land Use Policies
The deterioration of land quality, in combination with poor agricultural practices and policies, has left Africa less able than ever to feed herself. Food output per person has dropped by 16% since the early sixties. This is one of the main reasons why close to 40% of Africans are chronically undernourished and nearly one in three children go hungry every day. This malnutrition is a major factor underlying continuing high rates of child mortality, high rates of primary school drop outs (especially among girls), and poor performance in school in general of children from poor rural communities.
Agricultural and land policies need to respond to rapid investment requirements for capital and technology in agricultural production. Reliance on subsistence peasant agriculture will take Africa nowhere. States that are reluctant to establish tax on land, so as to stimulate the productive use of arable land—rather than the speculation of landed bureaucratic bourgeoisie—will not take Africa anywhere. Such conservative public policies are the cause, rather than the cure, of poverty in Africa.
Poverty Reduction: The Kenyan Case
Bahemuka and Mbatia, in a study on Sustainable Human Development in Kenya state that: “In Kenya, despite impressive growth rates recorded in the 1970's and early 1980's, the proportion of the population living under the distress of poverty has increased. The major instrument of poverty reduction should be the creation of gainful employment and investment opportunities. Economic growth and poverty reduction should positively reinforce each other with education and training enhancing the quality and productivity of labor, poor people's most important asset. Within the framework of addressing the social dimensions of development, the development partnership should work towards alleviating the negative consequences of adjustment programs whose fall-out include poverty creation and perpetuation.”
Further, they continue to argue:
"Poverty drives people to depletion of natural resources in the fight for basic survival. Poverty encompasses not only mobility to attain the minimum income level but also systemic deprivation of basic services related to human welfare. The situation is aggravated by limited and/or lack of participation and limited access to available options and opportunities.”
Although public policy during the current plan period in Kenya is cognizant of the need to reduce poverty within the context of sustainable human development as implied in the relationship between economic growth and poverty reduction, there continues to be a chasm between stated policy and policy implementation. Thus argue Bahemuka and Mbatia:
"... it should be remembered that in the past, economic growth failed to reduce poverty, and resource allocation systems have not on their own favored the vulnerable groups, short of consciously targeted programs. Also, the good policy intentions have not been complemented with supportive institutions and mechanisms for effective participation, mobilization of resources such as land and credit, management and provision of the kinds of services necessary for long term empowerment and sustainability of their betterment efforts. As a departure from the past, the problem of planning without implementation and sometimes that of implementation without planning should be avoided."1
The above observations, though specific to Kenya, could apply with equal weight in many other African and developing countries, if not in all.
Poverty Reduction Projects
Large capital development projects that burden the economy with heavy loan repayments but add little to domestic wealth creation, income generation, foreign exchange earning and employment creation can hardly be classified as poverty reduction projects. Were the governments in Africa and other developing countries to focus attention on rural infrastructure (particularly roads) and urban renewal as major public projects, many people would be put to work; they would earn stable wages over a period of time and there would be backward linkages in the economy. Thus I have always advocated the mobilization of domestic savings, such as pension funds, for urban renewal projects that would wipe out slum dwellings in the third world, and subsequently to enforce codes for construction, use of space and availability of infrastructure to reduce the presence of inhuman living quarters in urban areas.
Use of Domestic Savings
Where investments should be done using public sector resources, this should occur without interfering with private incomes destined for consumption or private investment. In this regard, the extraction of resources from the poor through forced contributions to public projects has grossly distorted public sector investments in the third world and has led to the tying down of resources on unproductive ventures. For example, villagers who are compelled to deplete their savings in building a class room which cannot be completed in ten years are obviously compelled to use their savings unproductively. If the money had been used to subscribe to a village cooperative which then lends its members money for vegetable growing, this would enhance a horticultural economy not existing before. It would thereby improve the nutritional standards of villagers and be a preventive measure against certain diseases. Such an economy would obviously be more income generating than the stagnant classroom which government administrators are frequently eager to identify as indicators of progress while the pupils in those classes are grossly malnourished.
Many governments in developing countries are not ready to confront problems of poverty and poor health systematically from the grassroots. Public works meant to benefit the poor are very often directed towards projects with minimal impact on poverty reduction, especially through creating large scale employment opportunities. But this is to be expected in situations where corruption and mismanagement grossly deplete public resources while channeling them into private hands. Something is obviously wrong in countries where the rich are mainly those who occupy public offices. It is the entrepreneur, the real business person, who should be wealthy in a capitalist society and not the civil servant.
Good governance provides the necessary context or enabling environment for sustainable human development. But having said that, the point still remains that “good governance” may fast be becoming a cliché, quite often invoked more for ritual than for serious discourse.
It seems to us that the crisis between the governors and the governed in many developing countries can be summarized as follows:
1. From the authors' unpublished paper: “Poverty and health in Kenya.” 1995, in a study on Sustainable human development in Kenya. 1995
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