- Towards the end of last year, stalwarts of public healthcare in Africa gathered just north of Pretoria to discuss “the past and present of public health and health systems in Africa”.
- From healthcare evolving after colonial rule to implementing universal health coverage, delegates talked about what’s worked on the continent and what hasn’t — and why this was so.
- Health policies should not be debated only by politicians, the delegates agreed, but also include the voices from those who deliver services on the ground, for a “collaboration that is uniquely African”.
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Towards the end of last year, Bhekisisa received an intriguing invitation to attend a multi-day event near Roodeplaat Dam, just north of Pretoria. Called “The Public Good, Planning and Internationalism in African Health”, the conference promised “a discussion with current and retired senior health professionals on the past and present of public health and health systems in Africa”.
As far as anyone could remember, there was no precedent for such a gathering of healthcare elders. One of the event’s lead organisers — David Bannister from the University of Oslo’s faculty of medicine — agreed that it probably was a first. (The conference was sponsored by the European Union, the Wellcome Trust and the Norwegian Research Council).
“So many of the most important insights and institutional memories are carried in the experiences of these senior people and so, instead of going from person to person and country to country, we decided it could be productive to bring researchers and experienced senior health figures together [here],” he said.
At a bushveld lodge with meeting rooms named after African mammals and looking out over a lake teeming with bass and yellowfish, it was a sort of medical Cannes. You could turn a corner and find a legend like Esther Mwaikambo, Tanzania’s first female doctor, trading jokes with a former Zambian minister of health.
The mood was genial, verging on euphoric at times — but with an undertow of caution and, dare I say it, suspicion. After finding that the available internet connections were unprotected, for example, several of the attendees kept their laptops in their bags, safely air gapped.
Said one of the South African delegates: “Health planning has never been, and will never be, politically innocent or ideologically naïve.”
‘My mother died in the village’
The point was amply illustrated by the recollections of participants who grew up under colonial rule. Mwaikambo, for example, recalled a childhood marked by avoidable illness and death, including her mother dying in 1950 from retinoblastoma, a curable eye cancer.
“It started with her left eye, and because this kind of problem was associated with witchcraft, the first thing the people in our village did was to try to counter it by supernatural means. But it didn’t work. Next, they went to the traditional healers for herbs, but the problem was getting worse and so they went to the nearest government dispensary. But at the time the government services were very basic. These facilities could treat malaria and pneumonia, and they dressed wounds and gave aspirins. That was all,” she said.
When the swelling continued, Mwaikambo’s mother was taken to hospital, 350 kilometres away in Tanga, on the country’s northeast coast. Doctors removed the eye, but the swelling remained “and after a few months the whole thing started again, so they again resorted to traditional healers, who kept on helping the best way they could until my mother died in the village”.
Esteemed public health researcher Rosemary Likwa recalled how the healthcare services available in rural Zambia when she was a child were almost entirely provided by the missions, “mainly Catholics and Protestants”, and although their coverage was patchy, the impact was not inconsequential. Likwa recounted how, after she had contracted malaria in her family’s village, her grandfather made incisions in her forehead, into which he pressed potassium permanganate “as a way of treating my unbearable headaches”.
When she returned to her school at St. Joseph’s Mission in Zambia’s Western Province, “one of the sisters” correctly diagnosed cerebral malaria, and referred Likwa to the nearest hospital, where she was given quinine. “I made a full recovery,” she said.
Former World Health Organisation stalwart Rufaro Chatora, who was also treated by missionaries in Zimbabwe as a child, said “only in the 1950s and 60s in southern Rhodesia did you start to see the government building rural hospitals — small health centres, really, with 10–15 beds — and gradually taking over from the missions. In the urban centres, more hospitals were built, but you’d have one for whites and one for Blacks.”
Two million people, three doctors
Many of the countries represented at the event became independent from colonial rule in the 1960s and 1970s, and the newly elected leaders faced the predicament of having to expand healthcare services to populations that had been largely ignored by the erstwhile governments.
Evarist Njelesani, a founding member and the current vice chancellor of the Lusaka Apex Medical University, recalled that the early challenge was “to look closely at the disease burden using whatever data you could get your hands on — which wasn’t much — and to extend infrastructure and services to the rural areas”.
“The other challenge,” he said, “was [human] resources. At independence, Zambia had a population of two million people but only three doctors. Most of the doctors in the colonial period had been European, and because they didn’t know what was going to happen when these Africans took over, they all left.”
To address the shortfall, Kenneth Kaunda, the first president of Zambia, founded the University of Zambia, “to start training [medical professionals] locally, and some were sent abroad,” Njelesani recalled.
At the time, much of the continent was poised somewhere between the competing ideologies of socialism and capitalism, and some African countries initially pursued a socialist development agenda, which led to their getting support from other socialist countries until the global economic downturn of the late 70s and early 80s.
The gathered researchers were keen to hear about the elders’ experiences of living and studying in socialist states, and how their training shaped the sort of healthcare professionals they became. Yet, as Asrat Mengiste, an Ethiopian surgeon who trained in Bulgaria, noted “there is no socialistic kind of medicine; medicine is medicine, all over, globally”. He conceded, however, that his choice to go into public health was influenced by the Bulgarian system’s prioritisation of “the preventative aspect of medicine”, an emphasis that veteran Tanzanian doctor Rachel Makunde, who studied in Cuba, recognised well.
“We stayed in the community with community members and spent a lot of time doing community outreach — health education, immunisation, and so on. I will always honour Cuba for that,” she said, and her compatriot Mwaikambo, who studied in Russia, agreed: “We were very much mentored to be people’s doctors.”
Lessons from the past for the future
Graduates faced considerable stigma when they returned home to practise medicine, and it remains entrenched in many places.
“If you trained in Russia, you were made to feel different; there was that segregation,” said veteran Kenyan nurse, Millicent Okwach. Zambian doctor Canisius Banda agreed, explaining that, in Zambia, the stigma against doctors trained abroad “is rooted in the fact that the brightest students went to the University of Zambia [and] the rest were sent to Bulgaria, East Germany and Russia, where they learned medicine in the languages of those countries, and some were taught using models and dummies whereas those trained in Zambia trained with real patients. Thus, the local team had a sense of supremacy over the internationals, and this conflict is there even today.”
The South African contingent was prompted to account for any socialist strains in the country’s current health system planning, including the government’s National Health Insurance (NHI) policy, which is on the brink of being passed into law. The NHI is often derided in the media for being “socialist” or “communist”, but Confidence Moloko, a medical doctor, former special adviser to the health minister and the current coordinator of the ruling party’s national executive committee on education, health, science and technology, said the country’s model of planning “is uniquely South African”.
Turning to former South African director general in the national department of health, Yogan Pillay, Moloko asked: “Do you remember how we used to be crazy about systems? We’d spend whole days and weekends analysing the apartheid South African health system, and then reviewing the Cuban health system, the Soviet health system, the American, Canadian and British health systems, and we’d look at the pros and the cons of each and draw the positives. One of the benefits of being both the oldest revolutionary movement on the continent and the last to come to power, is that we had the opportunity to draw lessons from those that preceded us.”
Every session had its nuggets. In the discussions on neglected tropical diseases, I was surprised to hear that entomologists in Ghana working on vector-borne diseases have been in the habit of using humans as bait, which the World Health Organisation has been trying to discourage. And it was a joy to hear the history of arguments over disease nomenclature: how plasmodiasis became generally known as malaria (“a name coined in error, because the Europeans who first encountered it thought there was a causal link between the symptoms and the air”) or that the name “river blindness” was preferred to onchocerciasis, “because you couldn’t get charities to donate towards the eradication of an unpronounceable disease”.
‘How not to get to universal health coverage’
The sessions on universal health coverage and mechanisms for achieving it, such as the NHI, were particularly robust, if a little depressing.
South Africa’s delegates had a lot to say about the historical underpinnings of the country’s NHI policy, but admitted that the powerful opposition its implementation faces along with the uncertainty this has caused, “actually drives up the price of healthcare services, and leaves quality of healthcare unmonitored”.
“I am interested,” said one of the South African attendees, “to know how other countries manage this kind of transition [from policy to implementation]”, to which one of the Kenyan delegates answered: “We can perhaps tell you how not to get there.”
Having spent 20 years of her career “studying Kenya’s national health insurance fund (NHIF), trying to reform it, crying over it”, the speaker announced that after nearly 50 years, “the NHIF is closing its doors”.
According to a Kenyan doctor and public representative the NHIF had been vulnerable to abuse by unscrupulous private sector operators. “A hospital would bus an entire village to Nairobi for arthritis surgery, and some might simply be anaesthetised and sent home thinking they’ve had an operation, when they have not, and the NHIF is billed,” he said.
There was more encouraging news from Zambia, though, where the introduction of national health insurance in 2018 has upped the proportion of the population that is covered for certain health services from 5% to more than a third. “Today, the unions, who initially opposed national health insurance, have realised its importance and they’re pushing the agenda. It has even become possible for the government to increase contributions,” said former Zambian health minister, Chitalu Chilufya, adding that it had been “important to make synergies with private sector insurers”, who initially opposed NHI “but are now important contributors to the scheme”.
The gathering ended with the recognition that cross-border exchanges about healthcare matters have tended to happen at the political level, between government officials, and that it was important to promote interactions between the professionals responsible for delivering healthcare services on the ground. Or, as Moloko put it, “collaboration that is uniquely African”.
