Making and Unmaking Public Health in Africa

Ethnographic and Historical Perspectives

Ruth J. Prince, Rebecca Marsland

• Publisher: Ohio University Press
• Year: 2013
• eBook ISBN: 9780821444665
• Topic: Historia
• Subtopic: Historia africana

Africa has emerged as a prime arena of global health interventions that focus on particular diseases and health emergencies. These are framed increasingly in terms of international concerns about security, human rights, and humanitarian crisis. This presents a stark contrast to the 1960s and '70s, when many newly independent African governments pursued the vision of public health "for all, " of comprehensive health care services directed by the state with support from foreign donors. These initiatives often failed, undermined by international politics, structural adjustment, and neoliberal policies, and by African states themselves. Yet their traces remain in contemporary expectations of and yearnings for a more robust public health.

This volume explores how medical professionals and patients, government officials, and ordinary citizens approach questions of public health as they navigate contemporary landscapes of NGOs and transnational projects, faltering state services, and expanding privatization. Its contributors analyze the relations between the public and the private providers of public health, from the state to new global biopolitical formations of political institutions, markets, human populations, and health. Tensions and ambiguities animate these complex relationships, suggesting that the question of what public health actually is in Africa cannot be taken for granted. Offering historical and ethnographic analyses, the volume develops an anthropology of public health in Africa.

Contributors: Hannah Brown, P. Wenzel Geissler, Murray Last, Rebecca Marsland, Lotte Meinert, Benson A. Mulemi, Ruth J. Prince, Noémi Tousignant, and Susan Reynolds Whyte

PART ONE

Whose Public Health?

ONE

The Peculiarly Political Problem behind Nigeria’s Primary Health Care Provision

MURRAY LAST

The term public health presupposes the existence of a central government or a local administration that puts a high priority on minimizing the incidence of “ill health” among its people by, for example, lessening the risk of epidemics through the provision of vaccinations as well as providing water, drainage, rubbish removal, and so forth—not to mention the maintenance of local, accessible clinics offering free primary health care to all. But what happens when there is not that priority for the public’s health—when, for example, education is seen as much more worthwhile an investment? How does the public then manage its own “public health”? In this chapter I wish to suggest that northern Nigeria is an example in which governmental public health has largely lapsed in some if not all local government administrations (LGAs) despite a rhetoric of concern for health. Though there are, I believe, plausible reasons for this, at its root there is the problem of the politics underlying health provision—a problem that could be put right once the political will was there. If the first question is why did this problem ever arise, the second question must be how to solve it: is it primarily a problem of governance and bureaucratic malfunction—how does one get local health delivery to work efficiently?—or is it primarily political or even, at a deeper level, cultural?

But first, we need to understand the broader context. Northern Nigeria, where I have been working for the past fifty years, has changed its governance hugely since the country as a whole gained independence from Britain in 1961. The period 1966–67 was one of intense reform: two violent coups prompted a long process of change in the structures of government and local administration from a centralized, authoritarian system concerned with security and revenue raising (through local taxation) to today’s decentralized polity of thirty-six states and 774 local government areas with a federal government at the new capital, Abuja. The other major change has been in revenue: the federal oil account at Abuja receives monthly payments from the major oil companies, and this revenue is then distributed according to a set formula to states, LGAs, and other institutions on the list. The sums thus regularly disbursed are enormous, more really than the three tiers of government are able (or willing) to use for development; much of the money is simply privatized, one way or another. But because the money has not been “earned” by anyone—nor has it come from citizens’ paying taxes out of their earnings from hard work—there is, Nigerians tell me, a certain unreality to this flow of cash. “Development” as a discourse is still on the agenda, but personal consumption is more pressing: a degree of both is possible, given the quantity of cash on the table. Politics is a highly expensive occupation: everyone expects a politician to be very generous, and so people hassle their local politician day and night, weekday or weekend, in their search for a job, a contract, a handout, or help in a crisis. For a politician to be successful he has to be a successful patron, with all the trappings of success (and therefore power) on display. At root, then, even LGA councillors, but especially the LGA chairman, have to be full-time politicians, at least for the maximum number of terms in office they are allowed (for the chairman, that is eight years). Everyone labels the system as corrupt—and certainly personal enrichment occurs on a major scale—but in many instances it is also a system of redistribution. One governor needed four million naira (about thirty thousand U.S. dollars) each weekend for handouts, and when a first lady needed a similar sum for a brief trip to her own place, a civil servant on a Friday afternoon had to drive around the capital looking for the sum required—in cash, of course. This, then, is the context in which this chapter on local health services is set: above the ordinary farmer or trader and his family out in the countryside or somewhere deep in a megacity “slum” is this elite with access to a scale of wealth that is extraordinary in the local context. What is striking is how the two milieux do not clash: they pass each other by in peace. But there is an element of resentment in the farmer on the roadside and an element of unease inside the new, air-conditioned Honda Accord speeding by; my friends in Abuja say they half expect to die in their beds—murdered, by their servants.

Almost all my field data relate to the Hausa-speaking peoples, both Muslim and non-Muslim (Maguzawa), with whom I have lived as a long-term guest in their houses. They have been part of Islamic states whose recorded histories go back at least five hundred years. Nigeria was part of the British Empire from 1903 to 1960, and the administrative system set up by the British in the emirates of northern Nigeria has become known as “indirect rule”: modeled on British practice in India, it enabled the emirs to head a “native authority” staffed by local officials, all under the eye of a small British-staffed office. Each native authority ran in its emirate its own shari’a judiciary, a police force, and a prison, as well as collecting taxes from all adults. As a reaction to this rather oppressive regime, the reforms promoting decentralization of government were initially popular.

This chapter looks at the fate of the primary health services under this new decentralized system of government. Underlying my argument is the assumption that Nigeria’s system of administration is still a work in progress. Everyone knows it needs reform, and many a commission over the years has made recommendations (often accepted by the government), but the central dilemma is implementation of such reforms. Reforms do not simply “happen” as and when government orders them: someone has not only to enforce implementation but also to ensure that those newly empowered by the reforms comply with both the letter of the law and its spirit. But the very act of decentralization has removed legitimacy from any single institution that might have ensured that the system worked as it was meant to: in short, you can break the rules and get away with it. It may cost you something, but the risk is small compared to the rewards of getting away with the “loot.” Nigeria thus offers most of its citizens enormous freedoms to do as they will—there is now no colonial-style authority enforcing its will and ensuring that its policies are carried out to the letter; no system of close surveillance controls the population.

My focus here is more on how ordinary people I have known over the years at the grassroots level of northern Nigerian society respond to the problems of health, both personal and public. There is a cultural dimension, as well as a political one, underlying people’s broad reactions to the lack of coherent health services from the state. Cultures change, of course, but “common sense” is remarkably persistent, and this is important if only because it is so often unspoken or unrecorded.

Decentralizing the Administration: Or Why Every Politician Wants a Local Government of His Own

We need initially to recognize how fashionable it has been for foreign agencies and donors to promote, even to insist upon, decentralization—politically in the name of furthering democracy, medico-managerially in the name of prioritizing primary health care.¹ Yet sometimes these calls for decentralization also echoed the internal politics of the state, especially when separatism was in the air, as it was in Nigeria during the 1960s and 1970s or in Mali in the 1990s: minority groups needed to be co-opted into the state, and this could be done, it was thought, by giving them their own local governments complete with their own budgets.² The policy assumed that local politicians could, or would soon learn to, organize and maintain whatever was primary—primary education, primary health care—and not just such basic primary services as local markets, sanitation, and the registration of births and deaths. Another assumption was that newly fashionable “one-line” budgets (block grants made out to a single top official) could still be accounted for at the local level, no matter how huge they were—thanks to oil rents—and that any financial malpractice could be checked both by the democratic process and by transparency or, failing that, that corruption could be deterred by an economic and financial crimes commission given real teeth by central government.

If these were indeed the assumptions that policy makers in the late 1970s had at the time the policy was formulated, they soon proved overly optimistic. Horror stories quickly circulated: one colleague told me how his friend, a local government chairman, used to collect the local government’s monthly allocation of cash from the bank and take it home, where he and some of his friends would sit on the floor and divide it up; my colleague was once offered a wad of naira notes. However, for items such as health and education there was formally a “joint state and local government account” in which the relevant local government funds were kept; the state’s governor had access to it (again on a “one-line budget” system), as did the LGA chairman. Local government chairmen had little option but to comply, as the state’s governor (and his party) had usually ensured that his nominees were “elected” as local government chairmen. Even more disturbing is that some state governors have often behaved no better than local government chairmen: the “joint account” only increased the amount of funds to which the governor had access, though he might have to share some of them with his House of Assembly.

Nigeria has thus devolved or delegated many functions of government, first by creating new states and then (since 1976, when the main reforms were to start) by establishing local government administrations, both to lessen tensions during and after the “Biafran” civil war and to manage more acceptably, if not better, the distribution of the burgeoning oil wealth that began to be massive in the 1970s. Over the years, local demands have since brought about a huge increase in the number of local government administrations; it pays to get one, though these are agreed to by the central government only after hard campaigning. Despite several attempts to get the system to work well, the politics of local governments, with its intense competitiveness, has only increased local conflict while failing to deliver the allocated services. The democratic “bonus” has also been strikingly absent. Though the early horror stories about the stealing by those running the LGAs are, it seems, no longer so true, the LGAs’ provision of primary health services is strikingly poor.

Local Government Authorities: Or Why Do Large Health Budgets Seem to Have So Little to Show for Them?

Unlike most developing countries, Nigeria has followed supposedly “best policy” and decentralized its primary health care along with local government. Constitutionally, responsibility for “participating” in the provision of primary health care lies with 774 local government authorities, over whom there is effectively no budgetary oversight (though some state governors do indeed control the LGA chairmen). Finance should not be a problem: it comes directly from the federal government’s ample oil revenues. The problem lies in that monies allocated to health services do not always reach those meant to utilize them. The buildings are there (if not always well maintained), but staff are sometimes not paid for months at a time (and so are often absent from work), medicines are not in the clinics, and the necessary medical equipment and sometimes bedding and even beds are nowhere to be seen. Nor, of course, are well-paid “ghost workers.” The key issue is not the giving out of huge contracts to build or repair various health facilities: the problem lies with the recurrent expenditures on salaries, drug stocks, and repair and maintenance of equipment. Building is easy, and opening a grand new clinic is a good photo opportunity: the hard part is manning and running the necessary services consistently, day by day, year-in and year-out—that requires good, honest budgetary management. If that is not possible locally, then who should take charge of the health services? There seems to be widespread reluctance to hand over still more power to the states’ governors by ceding them control over the entire public health budget. And a return to old-style central control from Abuja would be controversial and perhaps not feasible now: a careful, recent study of the running of centralized vaccination programs, especially against polio, suggests that control from the center is no longer a viable option.³ Nigeria is too large (both in population and in distances to be covered) and too complex culturally to be run really effectively by a centralized civil service. So much has already been devolved down to the states and their LGAs that the central administration is dependent on them; not even commercial operations under contract can, it seems, deliver the services required.

Clearly, some LGAs are more honestly run than others, but overall the result is that patients and their kin resort to the private sector, not only for medicines but also for hospital care. The boom in private hospitals and specialist clinics, even in small towns, is evidence of this: they may look ramshackle but are no worse than the LGA facilities—at least the staff are there. However, the governments of the thirty-six states have the responsibility for hospitals, while the federal government runs the university teaching hospitals and the National Hospital as well as crucial agencies such as the National Agency for Food and Drug Administration and Control (NAFDAC), which tries to eliminate “fake” drugs from the marketplace. So why is there not more public outrage over the failure of the politicians who run the LGAs to provide what they are constitutionally allocated to do?

Admittedly, the fact that local voters pay no taxes, now that the government is so rich in oil revenues, means that those they elect are not seen as misusing the taxpayers’ hard-earned money when the local councillors “steal” the health budget’s cash. Demands for proper primary health care do not seem to be a major issue at election time. Schools and roads, by contrast, are on the agenda, though given the amount of election rigging, the failures of the LGA scarcely affect the result. But there is another serious political problem with LGAs today: who are their “public”? The debate lies in their right to issue “certificates of indigeneity” to whomever they please—but, more important, to deny a certificate to anyone (or any group) who displeases them.⁴ Your family may have lived in a town for a hundred years—indeed, helped to develop it—but this will not necessarily guarantee you a certificate of indigeneity, and without such a certificate you and your children cannot access local schools, scholarships, local jobs, or welfare benefits (in an emergency, though, you will not be turned away from...

Table of contents

• Cover
• Title
• Copyright
• Contents
• Acknowledgments
• Introduction Situating Health and the Public in Africa
• Part I: Whose Public Health?
• Part II: Regimes and Relations of Care
• Part III: Emerging Landscapes of Public Health
• Bibliography
• Contributors
• Index