Religion and Health Care in East Africa

Lessons from Uganda, Mozambique and Ethiopia

Lloyd, Robert, Haussman, Melissa, Robert B Lloyd, Melissa Haussman, Patrick James

• Publisher: Policy Press
• Year: 2019
• Edition: 1
• eBook ISBN:
  9781447337898
• Topic: Medicine
• Subtopic: Health Care Delivery

What social factors contribute to the tragic state of health care in Africa?

Focusing on East African societies, this book is the first to investigate what role religion plays in health care in African cultures. Taking into account the geopolitical and economic environments of the region, the authors examine the roles played by individual and group beliefs, government policies, and pressure from the Millennium Development Goals in affecting health outcomes.

Informed by existing related studies, and on-the-ground interviews with individuals and organizations in Uganda, Mozambique and Ethiopia, this interdisciplinary book will form an invaluable resource for scholars seeking to better understand the links between society, multi-level state instruments, and health care in East Africa.

1

Religion, health care, and Africa

Overview

Few studies focus on the influence of religion or a religious world view with regard to health care in Africa. An impressive policy review on health care in Africa by Cooke (2009), for example, acknowledges the importance of religion but does not go beyond that point in exploring the connection. A recent and valuable study of health-care policy in Africa acknowledged the importance of spirituality, but its agenda on state and society only touched upon religious institutions (Gros 2016: 179). The intersection point of religion, health care, and Africa emerges as a principal item for the research agenda on well-being.

Among other aspects of this book, the primary argument is that religious beliefs (including, by extension, the beliefs of those who do not necessarily profess religious beliefs) are central to an integrated world view. This world view shapes Africans’ understanding of the world and how best to respond to its complexity. Health care is an essential aspect of an individual’s physical, emotional, and psychological well-being. The study examines the relationship of the physical and spiritual domains by examining how religious belief affects the provision and consumption of public health.

States sometimes cannot fulfill their social contract to citizens. Thus, dysfunctional states create an opening for religion to impact significantly on both the provision and consumption of health care in Africa. Government corruption and incompetence vary throughout the continent, but it is fair to say that no regime in Africa is free from the side effects, which include seeking public services from the private sector. This is one underlying explanation for why traditional healers, along with Faith-Inspired Institutions that provide modern medicine, turn out to be so important in the pages of this book. The other foundational reason is the importance to Africans, in seeking health care and other services, of meeting needs in a way that is in line with their religious faith. Many Africans pursue health in a holistic way—spiritual and physical needs are regarded as connected to each other.

Among Africans, the role of religion is significant across the board. The impact of religion on politics and policy in Africa is well established (Meier and Steinforth 2014). Faith-based medicine is long-standing. Some time ago, Mbiti (1969: 166, 170–171) identified traditional medicine with herbalism and, although allowing for exceptions, cast it in a generally positive light. Traditional medicine “refers to health practices, approaches, knowledge and beliefs incorporating plant, animal and mineral-based medicines, spiritual therapies, manual techniques and exercises, applied singularly or in a combination to treat, diagnose and prevent illnesses or maintain well-being” (Birhan et al 2011: 2). “In African villages,” Mbiti (1969: 169) observed, “disease and misfortune are religious experiences” and it “requires a religious approach to deal with them.” Yet, even otherwise comprehensive studies of health care in Africa tend to leave faith healing out of the research agenda (Gros 2016: 258).

Knowledge about African-based humanitarian organizations, another important part of the story regarding religion and health, is also limited. This is true despite a sustained history of involvement from missionary hospitals (Olivier and Wodon 2012c: 1; Gros 2016: 154). These entities, with Dr Albert Schweitzer as the most well-remembered figure among those active long ago, played an essential role in African health care from the turn of the 20th century onward (Gros 2016: 9). The history of Christian evangelism to Africa, and, by extension, spiritual and physical healing, extends back to the early Church. The New Testament Book of Acts of the Apostles (Chapter 8, verses 26–39) records how Philip, an early Christian leader, met a high-level Ethiopian government official visiting Jerusalem to worship God. Through this encounter and their subsequent discussion of Jesus and the Old Testament Book of Isaiah, the Ethiopian becomes a Christian. He is baptized and subsequently returns home. Ethiopia and much of North Africa had become Christian within a few centuries of the birth of the Church at Pentecost. By the early 15th century, Portuguese Catholic missions had become established along a few coastal areas of sub-Saharan Africa.

In particular, the degree of influence of Faith-Based Organizations (also known as Faith-Inspired Institutions in the literature) on Africa in general is far from fully understood (Tolchinsky 2013).¹ According to Schmid et al (2008: 10 emphasis added; see also Budge-Reid et al 2012: 104), there is “little data on the faith-based contribution to health and to date no comprehensive database of religious health facilities for SSA [sub-Saharan Africa] exists nor of their funders and good practice exemplars; even less is known about non-facility-based services.” Recent works from the World Bank (Olivier and Wodon 2012g, 2012h, 2012i) focus on the role of faith-inspired health-care providers in Africa along multiple dimensions: (1) public–private partnerships; (2) in comparison with other sources; and (3) with respect to mapping, cost, and reach. Results from these studies, to be reviewed in detail at a later point, encourage further research on religion and health care in Africa from both academic and policy standpoints.

Health care, moreover, is rising on the agenda of the public in Africa as well. This is a natural by-product of economic stagnation and even decline for the continent; Africans can see, quite easily, the seriousness of ongoing health challenges in a setting of limited and, in some instances, even diminishing resources. According to a recent Pew Research Center survey carried out in nine African states (Wike and Simmons 2015: 2), Africans put health care, followed by education, as the highest development priority. The survey of over 9,000 respondents in nine states from March through May 2015 also happens to include two of the three states featured in the present study: Ethiopia and Uganda. In Uganda and Ethiopia, respectively, 44% and 38% of respondents identify health care as the top priority for their country—the highest of any issue. This is to be expected because, as forthcoming pages will reveal, health care is both essential and challenging to obtain.

Some limitations should be noted before the study moves along much further. The most obvious is that a sample of three states from a population of over 50 quite properly induces a sense of caution about generalizing on the basis of results from research. The three states are also located in East Africa and contain Christian majorities and a Muslim minority. With regard to interviews conducted, ethical considerations limit the sample to those with roles in the health-care sector. Providers are represented more than patients, though, of course, every person is also a seeker of health care.

For the present volume, two interrelated research questions set the agenda. The first query is: how does religion contribute to the social determinants of health care in each country?² The social determinants of health (SDOH) are defined as the “circumstances in which people grow, live, work and age, and the systems put in place to deal with illness” (World Health Organization, 2014: 88). Three dimensions are considered: (1) the nature of the providers—religious (eg Muslim, Christian, and also separated out by denomination and whether evangelical, along with traditional) or secular (ie national or local government), along with the location of provision; (2) health-seeking behaviors by various populations; and (3) the influence of religion on the public. These dimensions combine to cover the process through which religion is connected to health care. The other basic research question focuses on how religion is linked with desired outcomes: how does religion impact the countries as to moving forward (through providers, institutions, and public beliefs/behaviors) on the Millennium Development Goals (MDGs)³ of the United Nations (UN)? Similarly, what will the effects be, post-2015, as the MDGs are subsumed into the Sustainable Development Goals (SDGs)? All African governments made a public commitment to the two preceding sets of objectives, so these are the most relevant indicators to consider in terms of health outcomes.

The eight MDGs are obviously interconnected; it is easy to imagine how pursuit of one goal might impact upon another. Several of the goals focus on health in an explicit way: Goal 4—reduce child mortality; Goal 5a—reduce maternal mortality; Goal 5b—increase access to contraception and comprehensive reproductive services; and Goal 6—combat HIV/AIDS, malaria, and other diseases.

Some of the binary connections that feed into the preceding goals are quite easy to see as well. Potentially most important for this study, in that sense, is Goal 3: promote gender equity and empower women. This goal, for instance, obviously possesses important implications, to the degree of its fulfillment, for Goals 4 and 5 in particular. An improved position for women in society, by intuition even prior to systematic research, must help along any number of dimensions impacting upon families, such as reducing child mortality. As will become apparent from subsequent chapters, all of that is influenced by religious world view.

Another important connection with the explicitly health-oriented objectives concerns Goal 1, which seeks to eradicate extreme poverty and hunger. Health is impacted in so many ways by poverty—the inability to prevent the spread of disease and losses through infant mortality due to the lack of care come immediately to mind, along with other unfortunate connections. Still further connections emerge with Goal 2, which pursues universal primary education. Knowledge constitutes power in the domain of health, notably, in relation to practices that can head off illness. Furthermore, it is easy to see how Goal 7—ensuring environmental sustainability—is relevant to health as well. Air pollution, for instance, is a menace to good health.

Finally, Goal 8—develop a global partnership for development—is panoramic and intersects with all of the other goals. It stands as an overarching objective, the achievement of which is certain to help with the MDGs that are specific to health.⁴

One feature of this volume, intellectually speaking, will be a special focus on women’s health. MDGs 2 and 4–6 are addressed in detail by the three country chapters in order to assess changes in women’s health care since 2000. Attention is paid to: the interaction of the MDG goals and targets for sub-Saharan Africa (including the three countries emphasized in this volume); the role of religion in beliefs and the provision of health care; and outcomes for African citizens, disaggregated by gender, in our three case studies. Thus, as the World Health Organization recommends, both system- and individual-level factors are investigated.

UN member states approved the Millennium Declaration in 2000. This multilateral effort aimed at improving the economic and social well-being of the world’s poorer countries by 2015. Five of the Declaration’s eight goals related in whole or in part to health. The next year, the heads of member states of the African Union, while meeting in the Nigerian capital of Abuja, subsequently reached an agreement on increasing health spending. The Abuja Declaration on HIV/AIDS, Tuberculosis and Other Related Infectious Diseases, among a number of items, stated that national health budgets would increase to a targeted amount of 15% of the total government budget. The African leaders also called for wealthier donor countries to increase their foreign assistance to 0.7% of their gross national income. Taken together, these two measures would increase the funding available for health spending in African countries. The African leaders also called for forgiveness on debt owed to donor states and multilateral organizations, a major issue at that time, so African states could redirect funds to the social sector. By 2015, the Abuja Declaration had not reached the intended targets for health spending. Nonetheless, some measures, such as the President’s Emergency Plan for AIDS Relief (PEPFAR)—authorized by the US Congress as the U.S. Leadership Against HIV/AIDS, Tuberculosis, and Malaria Act 2003—represented a major increase in donor funding for HIV/AIDS prevention and treatment (Organization of African Unity 2001; World Health Organization 2011).

In related fashion, the Assembly of the African Union in Maputo, Mozambique, adopted the Maputo Protocol to the African Charter on Human and Peoples’ Rights on the Rights of Women in Africa in 2003. The Protocol took effect in November 2005 after 15 countries had signed on. So far, 49 of the African Union countries have signed the Protocol, while 37 of them have ratified and deposited it, becoming “States’ Parties” to the Protocol. Developed in meetings held in Africa the same year as the Beijing Conference on Women’s Rights, the Protocol requires states to take measures to end female genital mutilation (FGM) and ensure women’s autonomy in contraceptive use and reproductive decisions in general. A list of articles from the Protocol includes:

the elimination of discrimination against women; the right to dignity; the right to life, integrity and security of the person; the right to access to justice and equal protection before the law; the right to participation in political and decision-making processes; the right to peace; and the right to protection in armed conflicts. (Sigsworth and Kumalo 2016: 2)

Many of the Protocol’s guarantees are consistent with the Convention on the Elimination of all Forms of Discrimination Against Women, the Beijing Platform, and the gender-focused MDGs 2–6. Among the chapter-length cases included in this study, Mozambique and Uganda signed and ratified, while Ethiopia signed, the Protocol. Based on two separate information sources, of the 55 states in the African Union, 37 have ratified the Protocol, with 49 members merely signing it (FIDH 2013; African Union 2010).

Over and beyond the MDGs (now SDGs) and Maputo Protocol, it is possible to point to the declaration of the “African Women’s Decade” of 2010–2020 on November 8, 2010. The launch included African heads of state and government, African Union ministers, representatives of the UN, civil society, development groups, and the private sector, among others (UN NGLS 2010). As with the MDGs and Maputo Protocol, the African Women’s Decade brings global attention to the many areas of civil, social, economic, and political rights needing more work to achieve gender equality. The 10 areas of focus for the African Women’s Decade have included:

Fighting Poverty and Promoting Economic Empowerment of Women and Entrepreneurship; Agriculture and Food Security; Health, Maternal Mortality and HIV/AIDS; Education, Science and Technology; Environment and Climate Change; Peace and Security and Violence against Women; Governance and Legal Protection; Finance and Gender Budgets; Women in Decision-Making Positions; and Young Women’s Movement. (UN NGLS 2010)

Clearly, the three multi-level instruments mentioned earlier, with central foci on many aspects of gender equality, draw on prior work such as the UN Declaration of Human Rights, the Convention on the Elimination of all Forms of Discrimination Against Women, the Cairo Programme of Action on Population and Development, and the Beijing Platform on Women. Women involved in global rights-seeking organizations have been active on multiple fronts, so it is possible to see various frameworks in operation at the same time (for example Maputo, the MDGs, and the African Women’s Decade). The multiplicity of frameworks speaks to strategic decisions by women’s movement activists, plus those affiliated with the UN and African Union, to keep issues related to gender equality alive and on the “front burner” of international policymaking.

Since the early 21st century, the World Economic Forum has constructed a global “gender gap” based on parity between women and men (1.0) or lack of parity (0) from four sets of factors: political participation; health and survival; educational attainment; and economic participation and opportunity (World Economic Forum 2016). Out of the 144 countries included on the composite global index, Mozambique ranked 21st in 2016 with a score of 0.750 (out of a possible 1), Uganda placed 61st with an overall score of 0.704, and Ethiopia came in at 109th with a score of 0.662 (World Economic Forum 2016: 10–11).

Make Every Woman Count (2016), in their Mid-Term Review of the African Women’s Decade, sees uneven implementation for some of the multi-level commitments across Africa (and East Africa, for present purposes). While the Mid-Term Review notes that maternal mortality has been dropping in the East Africa region, it also observes that, “as many East African countries have weak health-care systems, more needs to be done to ensure women’s safety” (Make Every Woman Count 2016: 42). Other issues that the Mid-Term Review identified in 2016, after the “end” date of the MDGs in 2015, included that Ethiopia routinely violates provisions in the Convention on the Elimination of all Forms of Discrimination Against Women despite having ratified it. While Ethiopia included FGM in its Criminal Code in 2005, there is no stand-alone provision against it and rates remain high. Specifically regarding MDG 5a, as of 2016, Ethiopia reported only 10% of births being attended by skilled personnel. Finally, regarding MDGs 2 and 3, Uganda and Ethiopia still had high rates of teenage marriage, with 40% of women in Uganda and 27% in Ethiopia having been married by age 18 (Make Every Woman Count 2016: 41–42).

Gender is critical as an intervening variable related to prior health, health-seeking behavior, and the future of health outcomes for individuals and groups in the following ways. The changing stances over time of the governments in the three countries that we have studied, and inconsistent access to health interventions in a timely manner (particularly during pregnancy and childbirth), affect women in ways in which men are not affected.

As with religion, the interaction of gender at an individual and collective level with health practices, including those of health-providing institutions, is not linear and the same within one country, at different time periods, or across the three countries that we discuss. The SDOH framework is used to introduce a concept of social disadvantage, whereby individual and collective scores on various health indices (such as obesity, tobacco and drug use, toxins such as asbestos or coal fires inhaled in living spaces, lack of self-control over women’s fertility, etc) are all known to affect women and men, the elderly and children, and rural and urban inhabitants differently. When individuals present themselves to a health practitioner (whether religious or secular) and/or institution, their experience will be preconditioned by their life experiences, and the ability to access better health in the future rests on their experiences to date.

The reason for integrating the MDGs with SDOH in our conceptual model is that on the MDG indicator...

Table of contents

• Cover
• Title Page
• Copyright
• Contents
• List of figures, tables, and boxes
• Preface
• 1 Religion, health care, and Africa
• 2 Background knowledge, theorizing, and evidence
• 3 Uganda
• 4 Mozambique
• 5 Ethiopia
• 6 What have we learned?
• 7 Conclusion
• Appendix
• References