Ending the failing approach to healthcare

After decades of neglect, the provision of effective healthcare is becoming one of the biggest concerns in Africa. Both foreign donors and African governments are keen to make this their priority, and consequently the money taps have been opened. Foreign aid in the form of hard currency is flowing in unprecedented quantities into the ministries of health of many African countries. Despite this generosity, however, things are not really improving on the ground: medical staff are demoralised, access to essential medicines remains low, and corruption remains a serious problem.

The Development Assistance for Health (DAH) has increased from US$ 2.5 billion in 1990 to over US$ 13 billion in 2005. Overall, approximately ten percent of Africa’s health care expenditure is now financed directly by donor aid. Nevertheless, the majority of African countries are way off-track with their progress towards the health-related millennium Development Goals.

Access to essential medicines remains low in the poorest parts in the world. According to the World Health Organisation, over 50 per cent of Africans lack access to essential medicines. Around the world, over 10 million children in developing countries die unnecessarily from diseases that are easily preventable and cheap to treat, such as diarrhoea, measles and malaria. Furthermore, up to 80 per cent of Africans have to pay for treatment straight from their own pockets. In short, public health systems are failing to deliver.

A major factor behind this failure of foreign aid to improve healthcare is the fact that nearly all of it first passes through health ministries before it can reach patients. According to studies undertaken by the World Health Organization and the Center for Global Development in Washington DC, bureaucrats have little idea of what actually happens to the money after it is handed over to the government.

As a result of these lax controls, a great deal of this money is subverted by health officials for private gain, particularly in countries that have a problem with corruption. This can occur in the ministry itself, or further down the line in the hospital. A study by Maureen Lewis of the World Bank shows how corruption in the health care sector of developing countries is so bad that it is severely undermining the effectiveness of donor funding.

The leakage of drugs from the supply chain is a particular problem, mainly because publicly funded drugs can fetch a high price if stolen and resold on the black market. Recent surveys in Nigeria show that 28 public health centres had received no drugs from the federal government in two years.
Meanwhile, a 2001 study by the World Bank showed that fewer than half of government health facilities in Lagos and Kogi states had received drugs from the federal government.

Last year, NAFDAC boss Dora Akunyili disclosed that it is commonplace for donated drugs such as Vitamin A capsules, Mectizan and Coartem tablets and oral rehydration salt to be pilfered and re-sold on the open market. In the same vein, it was reported that Global Fund was considering suspending two of Nigeria's five-year grants totaling $80 million because of concerns over grant management, transparency of fund allocation and grant implementation and the ability of the Nigerian government to achieve the goals of the grants. The Global Fund has already terminated grants to Uganda and Chad.

And this is not counting the dozens of other forms of corruption that plague the health system in Nigeria, including mismanagement of funds at the ministry and hospital level; absenteeism; staff extracting payments from patients for services that are supposed to be free; and the abuse of procurement contracts for hospital supplies.

According to the NGO Human Rights Watch “the government’s failure to tackle local-level corruption violates Nigeria's obligation to provide basic health and education services to its citizens.”

Add to this the chronic mismanagement that has left health workers owed months’ pay and hospitals with obsolete equipment, and it is seems hardly surprising that donor funding is not making much of a difference to patients’ health.

Healthcare delivery in Africa is never going to improve, however, while it remains under the control of public sector. Government ministries have very few incentives to deliver care to patients other than the goodwill of their staff. As any manager of a private company will tell you, relying on this alone is not going to keep your customers.. Unless there is a significant change in the way we manage the health sector, there will be few improvements – no matter how much money donors spend.

Bearing in mind the historic failure of African public health systems to provide citizens with the care they deserve, we should shift towards a situation in which governments no longer provide and manage all healthcare. The private sector should be given a far bigger role as well.

The advantages of this are three-fold. In the first place it would reduce corruption. Corruption certainly also exists in the private sector, but any private enterprise that has not shown integrity risks being excluded from future programmes and contracts. Secondly, since private businesses care deeply about their reputation, there would be pressure to deliver whatever it sets out to accomplish. After all, without reputation, there are no customers, and therefore no business. Thirdly, putting private sector bodies into competition with each other would force them to improve their productivity and improve patient care. Costs would fall and standards would rise. The opposite happens in the public sector, where there are few incentives to improve ways of working, and operations are disrupted the moment there is a change of government or ministers.

According to the International Finance Corporation, 60 per cent of the $16.7bn spent on health in Africa in 2005 was privately financed, with half of that money being spent in the private sector. It is time to harness this huge amount of capacity so it can work for patients in an efficient and equitable way.

It has been demonstrated by various health departments in Africa that most of the funds granted for disease prevention or control are largely misused. Grant-makers must let the private sector be the foundation upon which efficient and durable healthcare delivery will be built. To do otherwise would be to condemn millions more patients to an early death.

Ayodele is the Executive Director of Initiative for Public Policy Analysis, a Lagos based think-tank.