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.
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