Healthcare: A democratic dividend?

This article is cross-posted from This is Africa a service from the Financial Times

Empirical studies have linked democracy to improved social indicators, but debate rages on the causal mechanisms at play. Africa shows there is no straightforward link between multiparty electoral democracy and better healthcare outcomes.

In the 1990s, the Nobel prize-winning economist Amartya Sen made a compelling case for democratisation. ''No famine has ever taken place in the history of the world in a functioning democracy,'' he wrote. This is because governments ''have to win elections and face public criticism, and have strong incentives to undertake measures to avert famines and other catastrophes.''

His argument has shaped thinking in countless areas of public service delivery - from education to infrastructure; but none more so than healthcare. Democracies, this line of thought goes, respond more readily to the health needs of their populations than dictatorships.

“Democracy is correlated with improved health and healthcare access. Cross-national analysis shows democracies have lower infant mortality rates than non-democracies, and the same holds true for life expectancy and maternal mortality,” writes Karen Grépin, assistant professor of global health policy at New York University, in a paper entitled Democratisation and Universal Health Coverage. “Dictatorship, on the other hand, depresses public health provision, as does severe income inequality, ethnic heterogeneity, and persistent international conflict.”

Democracies tend to entrench longer-term institutional reforms than other political systems, Ms Grépin tells This is Africa. “The effects of democracy are more than a short-term initiative, such as an immunisation programme, which don’t always have lasting effects,” she argues. “Democracy can bring larger-scale reforms that create new things or radically transform institutions, such as universal healthcare or health insurance.”

And true enough, major changes are emerging in some of the continent’s most established democracies - often involving financial protection. The most obvious example comes from Ghana, which has been a poster child for democracy and political stability in an otherwise rocky region. According to Gallup data, 75 percent of the west African country’s population consider its elections to be honest versus a median of just 41 percent over 19 sub-Saharan countries. Ghana was also one of the first countries in Africa to enact universal health coverage legislation.

In 2003, roughly a decade after entering a multi-party democratic system, Ghana raised value-added taxes by 2.5 percent to fund a national health insurance programme. Policymakers noted that earmarking the increase for health expenditures made those hikes an easier sell to voters, who were overstretched by the existing fee-based ‘cash-and-carry’ system.

“It’s pretty impressive that there was enough political support to be able to pass a new value added tax, but it happened because there was backing from people who were fed up with the old system and felt that they were paying too much out-of-pocket for their medical care,” explains Gina Lagomarsino, managing director of the US-based Results for Development Institute (R4D). She notes that Ghana’s funding system has given the country “a better stream of revenues for health than a lot of countries at similar income levels.”

The new insurance scheme became so popular with voters that it survived a change in government in 2008. “They committed to the system institutionally and it became popular, so when there was a shift in power the new government couldn’t make it go away, because it had become such a popular thing,” Ms Grépin recalls. “Democracy can have this effect.”

The nation has not reached universal coverage yet. According to the National Health Insurance Authority, by the end of 2010 there were over 8 million active subscribers to the health insurance scheme - 34 percent of the Ghanaian population. Financial protection schemes do not necessarily equate to improved health, and though it has seen meaningful reductions in child and maternal mortality, the country will still struggle to meet health-related Millennium Development Goals.

Similar schemes are in play in other other democracies too. South Africa, though a country without a credible opposition party, has held regular democratic elections since the end of apartheid in 1994. The majority of its citizens still cannot afford private medical insurance, and rely on overstretched public hospitals. However, in April 2012 the government started piloting a national health insurance scheme, which will be phased in nationally over the next 14 years with the aim of generating universal coverage. "These first steps towards establishing national health insurance are truly historic," the health minister Aaron Motsoaledi said at the time.

But a positive link between democracy and improved health coverage are not watertight. There are plenty of more nascent democracies across Africa which are failing to enact meaningful reform while more autocratic regimes are performing well.

“Several of the countries that right now are seen as the big success stories in public health are not very democratic,” argues Peter Berman, a health economist at the Harvard School of Public Health.

Rwanda provides a case in point. This country, led by Paul-Kagame’s RPF party, is flagged as “not free” by Freedom House’s global index, and is named an “authoritarian regime” by the Economist Intelligence Unit’s Democracy Index. But that doesn’t negate the fact that this is a government with a strong roadmap for human and economic development. “Rwanda started out with somebody who, yes, is autocratic, but who genuinely wants to see these indicators change,” Ms Grépin says.

After the 1994 genocide - which destroyed national health facilities, saw disease run rampant, and left many rape victims with HIV/Aids - life expectancy stood at just 30 years. Today, citizens can expect to live to an average of almost double that. Over the last decade, Rwanda has registered some of the world’s steepest healthcare improvements, and is on track to meet most of the MDGs. 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 Rwanda’s success stems from the fact that its healthcare services reach rural citizens - a problem for many other African nations. The government stresses multi-sector coordination, and requires government ministries to work together on cross-cutting issues, which include both communicable and non-communicable diseases. But its governance system is also decentralised, meaning that it hands responsibility to local government and authorities and holds them accountable for their efficiency. At the bustling Kimironko Health Centre, a 20-minute drive from the city centre through Kigali's ordered city streets, a young nurse named Francine Nyiramugisha explains that performance is evaluated quarterly by the district hospital. “All of us has our indicators. When we perform very well, we all get our performance-based financing,” she says.

Across the country almost 50,000 community health workers have been trained to deploy services to marginal populations. Workers at the Kimironko Health Centre assist in that process. “We work with the community health workers who go out into the community. They do different things. Some sensitise the community on disease prevention, some treat malaria, others work on maternal-child health. They refer cases they cannot handle to the health centre,” Ms Nyiramugisha explains from a plainly-furnished private office.

Like Ghana, Rwanda runs a universal health insurance scheme, though it has fared rather 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. The system is funded by a mix of donor money and community premiums, though the government subsidises contributions for the poorest. “[When people] don’t have savings they cannot face catastrophic expenditure so people are dying that day because they don’t have the funds to pay,” says Agnes Binagwaho, minister of health, from her Kigali headquarters. “By decreasing the impact of catastrophic expenditure for health care we increase the access.”

In the squat Kimironko Health Centre, which deals with most of the suburb's non-life threatening medical complaints, dozens of men, women and children queue to hand over their health cards. “If patients are part of the Mutuelles de Santé, they pay 200 Rwandan francs ($0.30) and get all the services they need, from consultation to lab tests, and then whatever is remaining is paid by the mutuelles de santé,” Ms Nyiramugisha explains. “Ever since the mutuelles de santé was introduced, there has been a huge difference. You look at paying 3,000 RwF ($4.50) per year and then you get treatment.”

Thirty-year-old Margaret Yamuragiye, a slender sociology student who has been diagnosed with malaria, waits patiently in the reception of the clinic 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 says.

Huge challenges still remain, notably in the area of human resources. “The number of trained doctors is limited. They are not willing to go to remote communities and the best ones prefer to private after a short government stint,” explains one Kigali-based civil society worker, who requested anonymity. In an effort to meet the shortfall and ensure that doctors’ skills are up to international standards, the government has set up a ‘Human Resources for Health’ training scheme. “[For] the type of diseases we face we need to create the personnel to respond to these diseases, we need to create the capacity in teaching institutions,” the health minister explains.

Asked if she’s pleased with progress, the minister argues that there is a way to go still: “Let’s say ‘yes’, with a big room for improvement always,” she says, smiling. “We find things to improve now that we didn’t even think about five years ago, but the more you improve, you find you reach a stage where there is more to improve - and it is quite exciting.”

There are parallels to be drawn with Ethiopia, another autocratic regime which has taken a decentralised approach to healthcare reform, allowing resources to reach rural populations. Starting from a pitifully low base, Ethiopia has spent a decade creating a rural health outreach programme and has trained a network of around 40,000 extension workers to bring basic care to rural communities.

“Ethiopia has come a long way,” says Harvard’s Mr Berman. “A lot of the country is physically very difficult to get around, so they have opted for building up this lower level of the system and getting things close to people where they live, and they have have put in place a reasonably effective basic health care delivery system.”

The Horn of Africa country has registered a 50 percent decline in HIV prevalence over the last decade, according to the government. 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.

There are plenty of autocratic regimes in Africa which have failed to improve the health of their populations - from Zimbabwe and Angola to The Gambia - but the Ethiopian and Rwandan examples are evidence that the causal relationship between multi-party democracy and social development is far from simple.

“The governments in Ethiopia and Rwanda have come to power after periods of crisis or revolution, and these authoritarian leaders are very committed to social and economic development. They’re not very democratic but they have the power and authority to allocate resources towards population health needs,” Harvard’s Mr Berman argues.

So perhaps there isn’t a binary answer to the democratic question. “There are autocratic governments that care about the people and there are autocratic governments who don’t. It’s the argument about the benevolent dictator. And then there are democracies like Ghana where their politicians respond to a broad public demand, and then there are democracies where the politicians respond to narrower interest groups which have political power,” Mr Berman says. “There is no simple equation between democracy and caring about public health”

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