Time to think calmly about health

Dec 05, 2004 Life & Society, Sunday Nation

Professor Jeffrey Sachs was in town this week and, as usual, he made waves. Our health minister’s much-debated, much-maligned NSHIF Bill was listing dangerously, having been breached below the water-line by employers, employees, hospitals, insurers and actuaries. Just as it was about to capsize, the famous professor came to its rescue. He praised it in a press conference, and then saw president Kibaki at State House. Lo and behold, the bill was resurrected and will apparently return to haunt parliament after a quick respray job in dry dock.

Who exactly is this man who walks into countries and changes the course of policy? Professor Sachs is widely regarded as one of the world’s foremost economists. His theories on development and international trade are taught to students the world over. Time magazine recently named him among the world’s 100 most influential leaders. He is currently a special advisor to the United Nations on the famous poverty reduction initiatives known as the Millennium Development Goals, and that is why he was in Kenya – to review our progress (or rather, lack thereof) in meeting those goals.

It is important to understand the good professor’s point. He was not here to lend his very weighty support to the beleaguered Mrs. C. Ngilu. He was not here to dive into the whirlpool of Kenyan politics. He could not care less whether the new health scheme is supported by DP, NAK, LDP or Kanu. He made a very simple and straightforward point about health care: that you cannot think about making any reductions in poverty without making improvements in health. People who are sick and dying do not get out of poverty; nor do the orphans they leave behind.

With regard to sub-Saharan Africa, he is emphatic: we have no future whatsoever if we do not get our disease burden under control. Where HIV/AIDS runs unchecked, foreign investment does not happen. Where malaria is rampant, a tourism sector cannot prosper. Where children suffer from an alarming range of debilitating (yet preventable) diseases, they cannot achieve their true potential in school and cannot take up the leadership of the next generation. Good public health, in short, is not just a “nice to do”, nor is it just a medical issue: it is central to the idea of economic development.

It is obvious that a man like the professor will be co-opted by politicians the world over to give a boost to their political capital with the poor. Which is why we must be clear on his message. He did not tell us that our new NSHIF scheme, with all its much-discussed flaws, is the correct one for Kenya. He did not say that affordability does not matter. He did not say that we must put more burdens on the relatively small number of people in formal employment. He did not say that we need to push private health service providers out of business. No, not at all. What Professor Sachs is passionate about is universal basic health. Just because the scheme our technocrats came up with is flawed does not mean we should give up on public health provision and ignore the plight of millions of Kenyans.

That is the danger in this country: that we delight in pointing out flaws and in mocking the efforts of others, without thinking through any coherent alternative proposals of our own. We just loved the childish jibes and silly vitriol that our health and finance ministers poured on each other, did we not? A bit of excitement in an otherwise dull week, then back to terminal decline. We forget the seriousness of the matter: that without proper basic healthcare available to every Kenyan, we can kiss all our fancy economic recovery plans, our tourism marketing efforts and our investor seminars goodbye. They will all be rendered obsolete by the inexorable march of disease.

Professor Sachs’ recommendations to countries like ours go something like this. The basic need is to have a strategy for universal access to essential health services. That is essential. The “too expensive” tag is plain silly. We either learn to spend a few dollars per head today on basic and preventative health care, or we carry a hundred-fold burden in a few years’ time. Think about it. Would you forgo mosquito nets, essential medicines and vaccinations for your own family, simply because you have allocated all your budget to travel, eating out, new clothes and salaries for your servants? That would be imbecilic. Yet what is stupid at the family level often becomes alarmingly wise at the level of government.

Any strategy we have must be thought through well and transparently designed. A country’s health plan cannot possibly be thought through by a small bunch of busybodies sitting in a ministry office somewhere. Painstaking advocacy is needed to get the support of civil society, the business sector and politicians. A workable health scheme needs to be a partnership between public money and private provision. Its implementation needs to be planned rigorously. It is not to be left to politicians seeing a unique opportunity to get the poor voter behind them, nor to the vested interests of private health providers. It’s too important for that.

Who pays, then? Professor Sachs argues that whilst poor African countries certainly need to increase the budget allocations they make to health, they simply cannot pay all the bills themselves. Mrs. Ngilu’s answer was to tax the working population to pay for those who can’t. We all saw what happened with that idea. Professor Sachs would suggest that we look to the rich world to foot the bill. He would argue that health and disease are global problems, not local. He has said that the billions of dollars needed are mere “rounding errors” for the multi-trillion-dollar rich economies. It is both morally wrong and economically wrongheaded for them to stay away from the health problems of the poor world.

Professor Sachs is not a friend of the present US Administration. Indeed, he said recently that the government’s emphasis on military solutions came at the expense of sustainable development for impoverished countries. He estimated the costs of the conflict and post-conflict period to be US$ 200 billion, an amount he believes would save eight million lives annually over the next six years if spent on health care in the developing world. He once said, famously, to his fellow Americans: “For every 100 dollars, you can keep $99.90; but let the world’s poor keep the other 10 cents. That will save millions of lives every year while keeping the world much safer.”

It is indeed time our donors sang a different tune. Do they not get weary of playing cat-and-mouse conditionality games with our government? Do they not tire of the “here’s a bit of money – more next year if you’re good” dance that they do with the ministry of finance every few months? Perhaps it is time they made a clear, transparent and targeted commitment directly to the people of Kenya. Our leaders are crooks; we know it better than they do. But let our children not keep dying to prove it.