Back in the 1990s, the Nobel-prize winning economist Amartya Sen
famously wrote that “no famine has ever taken place in a functioning
democracy”, coining an argument has shaped thinking across countless
sectors – and none more so than healthcare. If governments face open
criticism and are under pressure to win elections, we assume, they are
incentivised to improve the health of their populations. Dictators are
not.
“Democracy is correlated with improved health and healthcare access…
Democracies have lower infant mortality rates than non-democracies, and
the same holds true for life expectancy and maternal mortality,” Karen
Grépin, assistant professor of global health policy at New York
University, wrote in a
2013 paper. “Dictatorship, on the other hand, depresses public health provision.”
She argues that democracies entrench longer-term reforms than their
dictatorial counterparts – often involving universal healthcare or
health insurance schemes. “The effects of democracy are more than a
short-term initiative, such as an immunisation programme, which don’t
always have lasting effects,” she said in a telephone interview.
“Democracy can bring larger-scale reforms that create new things or
radically transform institutions.”
But does that theory hold water in Africa?
Ghana, one of the continent’s deepest democracies, is doing well. According to Gallup
data,
75 percent of its population consider its elections to be honest,
compared to a median of 41 percent over 19 sub-Saharan countries.
Correspondingly, it was also one of the first countries in Africa to
enact universal health coverage laws.
In 2003, roughly a decade after entering a multi-party democratic
system, the west African country hiked VAT by 2.5 percent to fund a
national health insurance programme. Voters who had been overstretched
by the previous ‘cash-and-carry’ system happily swallowed the tax
increases, and the scheme was so popular that when the government
unexpectedly changed in 2008, it survived the transition.
The country still has a way to go to attain universal coverage.
According to the National Health Insurance Authority, by the end of 2010
34 percent of the Ghanaian population actively subscribed to the
scheme. But the institutions are now in place, laying the foundations
for the future.
Similar schemes are being rolled out in other democracies like South
Africa. But this isn’t a simple equation. There are plenty more
multi-party systems which have failed to enact meaningful reform – think
of the pitiful performance in
Kenya, where the government changed earlier this year – while some more autocratic regimes are performing well.
“Several of the countries that are seen as the big success stories in
public health are not very democratic,” argued Peter Berman, a health
economist at the Harvard School of Public Health.
Take Rwanda. Led by Paul-Kagame’s decidedly authoritarian Rwandan
Patriotic Front, the country is considered “not free” by Freedom House.
In the run up to 2010 presidential elections Human Rights Watch alleged
political repression and intimidation of opposition party members
against the leadership. Yet the government has a strong developmental
track record. “Rwanda started out with somebody who is autocratic, but
who genuinely wants to see these indicators change,” Grépin said.
Over the last decade, Rwanda has registered some of the world’s
steepest healthcare improvements. After the 1994 genocide – when
national health facilities were destroyed and disease was running
rampant – life expectancy stood at
30 years. Today, citizens live to an average of almost double that. Deaths from HIV, tuberculosis and malaria have each
dropped by roughly 80 percent over the last 10 years, while
maternal and
child mortality rates have fallen by around 60 percent.
Part of its success stems from the fact that its healthcare services
reach rural citizens. The leadership hands responsibility to local
government and authorities and holds them accountable for their
efficiency; and almost 50,000 community health workers have been trained
to deploy services to marginal populations.
Like Ghana, Rwanda runs a universal health insurance scheme, though
it has fared better in its roll out. Upwards of 90 percent of the
population is covered by the community-based Mutuelles de Santé
programme, which has more than halved average annual out-of-pocket
health spending. “By decreasing the impact of catastrophic expenditure
for health care we increase the access,” explained Agnes Binagwaho,
minister of health, from her Kigali office.
The benefits of that programme are clear to see at the bustling
Kimironko Health Centre, which is a 20-minute drive from central Kigali
and deals with most of the suburb’s non-life threatening medical
complaints. As dozens of men, women and children queue to hand over
their health cards, a young nurse named Francine Nyiramugisha explains
that “Ever since the Mutuelles de Santé was introduced, there has been a
huge difference. You pay 3,000 RwF ($4.50) per year and then you get
treatment.”
In the reception, thirty-year-old Margaret Yamuragiye, a slender
sociology student who has been diagnosed with malaria, waits patiently
for her prescription. “Before I got my Mutuelles card I would fear that I
could not go to the clinic because it would be too expensive. Today if I
have simple cough or flu, I come to the doctor, I don’t wait to see if
it gets worse,” she said.
Nearby in Ethiopia, another autocratic regime registered by Freedom
House as “not free” is also clocking significant health improvements.
Like Rwanda, leaders in Addis Ababa have little time for political
opposition, but are registering impressive developmental gains. “They’re
not very democratic but they have the power and authority to allocate
resources towards population health needs,” Harvard’s Berman said.
There’s no universal coverage scheme in Ethiopia, but government has
opted to focus on deploying basic healthcare services across
hard-to-reach rural areas. Starting from a pitifully low base, it has
spent a decade training a network of around 40,000 extension workers to
bring care to rural communities. Over ten years, the nation registered a
more than 25 percent decline in HIV prevalence, according to a
2012 progress report.
Under-five mortality has declined to 101 deaths per 1,000 live births
in 2009/10, from 167 in 2001/2. Infant mortality halved in the same
period.
Those examples should be evidence enough that the relationship
between democracy and improved healthcare isn’t a simple one. “There are
autocratic governments that care about the people and there are
autocratic governments who don’t. There are democracies where
politicians respond to a broad public demand, and then there are
democracies where the politicians respond to narrower interest groups,”
Berman said.
“There is no simple equation between democracy and caring about public health.”
SOURCE:www.africanarguments.org
