ANDREW M. MWENDA| 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.