Why attempts to provide too much too fast are the cause of corruption and institutionalised incompetence
Last week I moderated a World Health Organisation panel on providing universal healthcare in Africa. These ambitions assume that poor countries have the ability to deliver the set goals and what is missing is honest government and political will. The debate took place in Rwanda where a poor country has achieved universal medical insurance. I have come to believe that using Rwanda as a reference point is misleading because the conditions that have made it successful are rare to find and difficult to recreate. This article’s central message is that we need to unlearn assumptions that inform our policy prescriptions for poor countries.
The concept of universal publicly funded healthcare is slightly more than 100 years old. It developed in the Western world in the early 20th Century and gained full expression after the Second World War. This development was occasioned by the transformation of the West from agricultural to industrial and from rural to urban societies. This transformation produced a large and educated middle class, a professional class, organised labour and civil society and most critically massive growth in state revenues.
In other words, the state in Western Europe and her offshoots in North America, New Zeeland and Australia began providing healthcare to all citizens when they could afford it. That is to say when they had developed the financial and human (institutions backed by skilled people) capacity to do the job. Indeed, the veritable National Health Services (NHS) of the United Kingdom was created in 1946. In the United States, Medicare and Medicaid began in 1965.
This was an entirely new governance model. Henceforth, the legitimacy of the government depended to a large degree on the ability of the state to provide a wide range of public goods and services to all citizens equitably. While European governments did this at home, they did not do it in their colonies. There, they relied largely on traditional systems (indirect rule) to secure the consent of the governed. This was done by using public resources to co-opt powerful traditional, religious, and other influential leaders of public opinion in local communities i.e. patronage. Where there was resistance to colonial rule, they used repression.
Within the colonial territories, the Europeans governed their expatriate staff and its “native” allies by actually providing a modest basket of these public goods and services – education, piped water, healthcare, electricity, paved roads etc. However, the majority of the population was not catered for. The services were also, for the most part, (especially health and education) not provided by the state but by private agents and/or by nongovernment organisations; especially churches and other charitable bodies.
But the African elite who went to school read about or even saw what the colonial government was doing at home. So the leaders who fought for Africa’s independence argued that the colonial state denied natives these services because of racism. That was only partly true. Even without its racism, the colonial state could not have funded the large basked of public goods and services to all its subjects in the colonies because it could not afford it. So our founding fathers promised to deliver this wide range of public goods and services to all citizens in imitation of the colonial state at home.
Immediately after independence, all governments in Africa and elsewhere moved very fast to elaborate these public goods and services, attempting to provide them to everyone. Then they confronted the hard reality i.e. that their newly acquired states lacked the basic human skills and finances to do what they had promised. In attempting to do too much too fast, the state got overdeveloped in function, yet it was underdeveloped in capacity – both human and financial. Its reach, therefore, went far beyond its grasp.
I believe that in attempting to bite much more they could swallow, the post independence state eviscerated even the limited institutional capacities the colonial state had tried to develop. Contrary to the popular view that Africa failed because it had selfish leaders who cared only about feathering their own nests, I have come to the conclusion that our continent faltered because our leaders were excessively and idealistically public spirited. They tried to do too much for so many people in too short a time.
I have been studying the development of bureaucracy in the Western world and in other nations of Asia. I have learnt that the fastest way to undermine the development of an effective bureaucracy is to develop it rapidly without due consideration of available skills and funds. Rapidly developing bureaucracies (except in such rare circumstances as post-genocide Rwanda) tend to degenerate into cesspools of incompetence, corruption and neo-patrimonial plunder. The lesson, therefore, is that good and effective bureaucracies are a scarce resource that nations need to use sparingly.
The post-independence governments in Africa also focused on the expensive yet less effective aspects of healthcare i.e. clinical medicine. They built hospitals across their territories and tried to treat every sick person. But the same governments lacked personnel and did not have enough funds to pay for the medical equipment and drugs. As a result, poorly paid and also poorly facilitated medical staff did not have the tools to do their work. They began stealing the little money and drugs, and selling the latter on the black market. Others left these countries for greener pastures abroad.
We now know that the most effective healthcare in poor countries is not in clinical medicine but public health. For example, the leading causes of death in poor countries are communicable diseases affecting children that are best handled through preventive measures, not medical treatment. Such measures include improved sanitation, access to clean water, improved nutrition, better hygiene and vector control like eradicating mosquitoes. The governments can also invest in such aspects of health as immunisation and vaccination.
The focus on clinical medicine is a function of both the mindset and also the self-interest of elites. It is a mindset in that when we talk of healthcare, people think of hospitals and doctors, not sanitation and clean water. It is self-interest because the most articulate sections of the elite in Africa actually have access to clean water, good sanitation, better nutrition etc.; therefore their problem is clinical treatment. Thus public policy on healthcare tends to privilege the interests of these elites rather than the ordinary person. This is why there was a hue and cry in the media when the cancer machine at Mulago Hospital collapsed but there is never anything like that when immunisation programs fail.