Abuja Declaration: broken promises
African nations have largely defaulted on a 2001 pledge to commit at least 15% of their annual budgets to healthcare
Africa has so far seen controversial and even dramatic policy measures in response to the coronavirus crisis. From Tanzania withholding infection and fatality data as the government pushed conspiracy theories, to Egypt’s clampdown on citizens disagreeing with the government’s handling of the pandemic, to Madagascar’s promotion of a botanical brew as an antidote without following the standard scientific approval steps, the continent has had its share of the blunders that have helped exacerbate the crisis globally. Few, however, have seemed as ironic as Nigeria’s fiscal response at the peak of the crisis.
As the virus ravaged nations, overwhelmed health systems and devastated markets, the continent’s biggest economy announced a steep health budget cut in June, citing a decline in crude oil revenues. The government sliced basic healthcare funding by nearly half, reducing it to 25.5 billion naira ($71 million). The move angered a public already enraged by the government’s earlier plan to refurbish its parliament building with 37 billion naira. Before the pandemic, Nigeria’s entire health sector received 8% of the country’s total budget this year. That figure fell to 6% after the cut.
“This shows what is wrong with our country: poor prioritisation of projects,” Sam Ohuabunwa, the president of the Pharmaceutical Society of Nigeria, told the popular Lagos-based daily, Punch, at the time. “How come the renovation of the National Assembly is taking priority over healthcare and education? It does not make sense to me.” But Nigeria’s typically measly health spending this year is not unique. Kenya proposed to spend only 4% of its total budget on health this year before the pandemic started, and South Africa allotted 11.8% of its budget to the sector.
Besides being relatively low, all three budgets – and many others – share a thing in common: they fall short of a benchmark voluntarily set by African leaders in the Abuja Declaration in 2001, to yearly allocate at least 15% percent of their countries’ budgets to health expenditure. Nearly 20 years after the Abuja Declaration, named after the Nigerian capital where it was signed, many African countries have largely failed to honour it. Their health systems are without needed resources to build and equip hospitals, train and pay health workers and implement health insurance for citizens. The World Health Organization says more than 37% of all of Africa’s health spending comes from out-of-pocket payments.
Now, the COVID-19 pandemic, more than any other crisis in recent history, has shown how grim the situation is across the region. In April, the WHO said 43 African countries had just 2,000 ventilators and 5,000 intensive care beds, while 10 countries had no ventilators at all. Making up just 16% of the global population, Africa bears 23% of the world’s disease burden, yet accounts for just 1% of the total global health expenditure in 2015, according to United Nations and WHO figures. “The COVID-19 crisis and its impact on health and other social policy sectors such as education as well as the economy, has brought to the fore the importance of strong healthcare systems to pre-empt and deal with such global threats,” Kalipso Chalkidou, professor of practice in Global Health, Imperial College London, told Africa in Fact.
The Abuja Declaration was agreed to address the persistent funding problem that had seen health per capita public spending in Africa at a meagre US$70 in the early 2000s. A decade after the declaration, 27 nations had increased the proportion of their health expenditure, according to a 2011 report by the WHO. By 2013, only three countries – Rwanda, Botswana and Zambia – had achieved the 15% mark. By 2014, while the average per capita health spending rose to US$160, more countries (19) were spending less on health as a percentage of their budgets, a follow-up report by the WHO in 2016 stated.
According to the report, countries whose health spending fell lower than the pre-2000s figures included Chad, Mozambique, Tanzania, São Tomé and Príncipe, Sierra Leone, Zambia, Rwanda, Senegal, Equatorial Guinea, Zimbabwe, Cabo Verde, Cameroon, Comoros, Benin, Mauritania, Togo, Botswana, Niger and Central Africa Republic. Remarkably, the report found that a country’s wealth did not exactly determine its allocation share to healthcare. For example, while countries with high per capita income (over $10,000) such as Algeria, Botswana, Equatorial Guinea, Gabon, Mauritius, Seychelles and South Africa did not spend as much on health, those with relatively lower per capita like Ethiopia, Gambia and Malawi, surpassed the 15% target.
“Despite increases in fiscal capacity, spending on health has been deprioritised as governments strive to meet other obligations,” the report stated. “In low income settings, the deprioritisation of health in public expenditure tends to be associated with country-level fragility and political instability, poor governance and corruption.” It also found that most countries prioritised high-end care, that is secondary and tertiary levels referral hospitals that treat mostly the middle and upper classes, and committed, on average, less than 40% of health expenditure to primary care that caters for the majority of the continent’s poorest population.
In some countries, the allotted funds were never fully spent due mainly to unpredictable allocations, mismatch between policy and budget allocations, inappropriate budget structures, and under-performing execution systems. As much as 60% of the money remained unspent in Democratic Republic of Congo, for instance. The Nigeria case shows that years after the WHO’s latest report, not much has changed across the continent. Nigeria’s highest-ever public budget share for its health was 7%. A more recent assessment of specific countries in 2019 by a non-governmental group, Africa Health Budget Network, based in Abuja, found that only Burkina Faso (11.03%), Ethiopia (8.1%), Malawi (9.83%), Mozambique (8.35%), Rwanda (8.88%) and Tanzania (9.52%) made some level of progress in trying to meet the 2001 target.
Among all the countries reviewed, only Madagascar reached the 15% goal. “In the face of the current COVID-19 pandemic, health expenditure has nosedived, with many African countries relying on regional and international loans, grants, and donations,” Aminu Garba, the coordinator of the group, told Africa in Fact. By 18 August, Africa had recorded over 1.1 million cases of the coronavirus and 26,346 deaths. Activists and health experts are hoping the COVID-19 experience will provide a new window for Africa’s policymakers to take the decisive step of committing more resources to healthcare.
Chalkidou, who is also the director of Global Health Policy and senior fellow at the Center for Global Development, said with debt at unsustainable levels, they could do so by leveraging innovative and radical ways of generating revenue to not only protect but also to boost spending on health. Also, wealthier nations, although even worse hit by the recession, should do their bit by boosting rather than cutting development aid, she said.
“Radical tax reform, including revisiting fuel subsidies and introducing excise, including tobacco and alcohol taxes, smarter spending, leveraging pooled public procurement to improve procurement of pharmaceuticals where billions are wasted every year in a fragmented and inefficient fashion, and actively exploring underused tools such as debt swaps, must be at the forefront of the policy response,” she said. Response measures should also include governments cutting unnecessary overhead and recurrent expenditures and ensuring judicious utilisation of all loans, grants and donations, Garba added.
More people in Africa live without electricity than anywhere else and there is little hope things will change soon
When it comes to access to energy, Africa’s figures are noticeably unimpressive. Nearly 75% of the world’s 789 million people who lack electricity live in Africa, according to an October 2020 International Energy Agency (IEA) report, and of the 2.6 billion people who lack access to clean cooking, 900 million are in Africa. While the rate of rural electrification in other parts of the world is above 70%, in sub-Saharan Africa it is just above 20%.
However, there has been progress. According to the IEA, the number of people on the continent without access to electricity, which stood at 610 million in 2013, fell to about 580 million in 2019. That gain, however, has been overshadowed by Africa’s ballooning population, and many remain without access to power. “In the past decades, access to electricity in Africa failed to level up with its booming population and this negates the drive for development milestones,” said Ubong Edet, director at Open Policy, a development-focused civic group in Abuja, Nigeria
Attempts by most African nations to significantly increase their citizens’ access to electricity over the years largely failed, hampered by policy missteps, poor funding, corruption and sometimes instability. The result is a dysfunctional power sector that has been unable to support economic activities that can create jobs, and education and healthcare services. Only an estimated 28% of health facilities in sub-Saharan Africa have access to reliable electricity, according to Powering Healthcare, a United Nations initiative.
The IEA says unless there is considerable improvement in investment and policies, Africa is certain to default on the global sustainable development goal of 2030 (SDG7), which seeks to ensure access to affordable, reliable, sustainable and modern energy for all. The current policy trajectories will see 530 million Africans still without electricity in the next decade, it says.
“Despite progress in several countries, current and planned efforts to provide access to modern energy services barely outpace population growth,” the agency says.
It is an irony for a continent that is the most endowed with raw energy hydro, solar, oil, gas, coal and geothermal resources. Despite having more solar resources than any other region, Africa has only five gigawatts of solar photovoltaics – less than 1% of installed global capacity, says the IEA.
The bulk of the region’s energy deficiency is in sub-Saharan Africa, with Nigeria, Ethiopia, Democratic Republic of Congo (DRC), Uganda and Tanzania accounting for the largest number of people without electricity.
Years of efforts by African governments have failed to produce sufficient energy the continent needs for several reasons. The first is the funding gap.
The IEA estimates that sub-Saharan Africa needs $35 billion a year to ensure electricity access for all by 2030, and only a few countries have been able to mobilise enough funds locally for their energy projects.
Ethiopia, for example, recently raised 8 billion birr out of an expected 12 billion birr (about $550 million) for its Grand Renaissance hydroelectric dam through domestic and diaspora bonds.
Corruption is another factor. The anti-corruption group, Socio-Economic Rights and Accountability Project, said Nigeria has spent over $30 billion in the past two decades but has only managed to generate less than 7,000 megawatts of electricity, far less than required by its more than 200 million citizens. It said successive administrations had “squandered” huge amounts without a commensurate result.
There is also a policy challenge. Since jumping on the electrification trend in the post-independence days, poor management and a lack of political will have seen many African countries end up with unrealistic (or failed) mega energy projects. In contrast, Asia has, through the same period, had accelerated its electrification and achieved the most significant decline in the number of people without electricity worldwide between 2010 and 2018.
Africa’s modest improvement has been in East Africa. Here, Kenya, Ethiopia and Tanzania account for more than half of those gaining access to electricity, according to the Brussels-based Alliance for Rural Electrification. In Kenya, the electricity access rate rose triple fold within five years to 75% in 2018 as the country complemented grid connections with solar and geothermal systems.
Even with such progress, as of July 2020, only one country in Africa – Gabon – was “on track” to achieve SDG7, according to an analysis by the Sustainable Development Goals Center for Africa and the Sustainable Development Solutions Network. Twenty-two countries were “moderately increasing”, 28 were stagnating while three countries were “decreasing”.
African countries appear better on track to attain the more drawn out African Union’s own goal that seeks to harness, by 2063, all “African energy resources to ensure modern, efficient, reliable, cost-effective, renewable and environmentally friendly energy to all African households, businesses, industries and institutions.”
“Africa will have to raise its funding and actionable plans if it will ever meet up with the rest of the world developmentally in the coming years,” said Edet of Open Policy.
Access to electricity in Africa is also hampered by affordability and reliability. The unit cost of electricity to consumers in many African countries is more than double the cost in developed nations such as the United States, according to a joint assessment by Agence française de développement and the World Bank.
Also, even in instances where power is available, households spend hours without power. In 25 of the 29 countries in Africa examined by a World Bank report, fewer than one-third of firms had reliable access to electricity. Things worked relatively better in Liberia, Namibia, and South Sudan than in Nigeria, Kenya, Mali, and Tanzania, the report said.
Solving Africa’s energy problem requires proper funding and policy adjustment. Experts say off-grid renewable projects, like solar, should be Africa’s energy future because they are less costly and do not require expensive connections to the national grid, especially since the majority of the population live in rural areas.
First, African countries will have to quadruple their rate of investment in their power sectors for the next two decades to bring reliable electricity to all Africans, the IEA said. The agency recommends an annual investment of around $120 billion yearly to bring electricity to all in Africa.
“We’re talking about 2.5% of GDP that should go into the power sector,” Laura Cozzi, the IEA’s Chief Energy Modeller, said in November 2019. “India’s done it over the past 20 years. China has done it. So, it’s something that is doable.”
Given the cost, the agency recommends using more mini-grids and says attention should be focused more on the huge potential that solar, wind, hydropower, and natural gas offer.
Despite evidence that solar and wind could provide cheaper and more environmentally friendly options to expand electricity in Africa, a number of African nations are shifting to nuclear energy.
They cite the threat of drought to hydropower and argue that nuclear power can provide a reliable support for renewables such as solar and wind.
In addition to South Africa, which has Africa’s only nuclear power plant, Ghana, Morocco, Egypt, Kenya, Nigeria, Niger, Tunisia, Algeria, Zambia, Uganda and Sudan have considered adopting nuclear energy, according to the International Atomic Energy Agency.
Norbert Edomah, an energy expert and senior lecturer at the Pan-Atlantic University, Lagos, says countries should adopt options that work best for them and should consider “contextual energy geography”.
“What works in East Africa may not work in West Africa,” he told Africa in Fact. Edomah advised policymakers to pay attention to “providing energy for productivity”.
“The question to ask is, what do people use energy for? In what way can we provide energy to improve livelihoods? Things that focus on livelihoods and improve productivity is what we should focus on,” he said.
There is an immediate constraint. The IEA fears the COVID-19 pandemic may reverse years of progress made in expanding access to electricity. It says that as governments attend to the immediate public health and economic crisis, utilities are bound to face serious financial strain. Also, increased poverty levels worldwide in 2020 may make basic electricity services unaffordable.
But Damilola Ogunbiyi, CEO and Special Representative of the UN Secretary-General for Sustainable Energy for All (SEforALL) and co-chair of UN-Energy, said the pandemic also provided an opportunity that could be harnessed.
In a statement to launch SEforAll’s Recover Better with Sustainable Energy Guide for African Countries in June 2020 Ogunbiyi said, “COVID-19 has changed the world as we know it. As countries rebuild economies impacted by the pandemic, they are faced with a unique, once in a generation opportunity to ‘recover better’ with sustainable energy.
“There has never been a better time to invest in clean, efficient renewable energy. Countries that recover better with sustainable energy will see the pay off in the form of resilient economies, new jobs, and faster energy development. By making this investment, African countries can develop a competitive advantage.”
African leadership: the golden age
The continent’s current crop of leaders is more acquiescent than their post-colonial predecessors in dealing with external attempts at unwarranted interference
Former Nigerian military leader Yakubu Gowon had a telling exchange with US President Richard Nixon in 1971. Invited for a state visit, Gowon, according to a recently declassified American diplomatic cable, said he was too busy administering his country. The army general promised Nixon he would consider a possible future visit – but never did. Gowon never visited the US during his nine-year tenure and is the only Nigerian leader not to have done so. When, shortly after his election in 2015, President Muhammadu Buhari flew out to meet President Barack Obama even before he had named a cabinet, the Nigerian media did not miss the opportunity to draw a contrast. The Lagos-based newspaper Premium Times lamented the country’s foregone “golden era” of diplomacy. It supported this position with another revelation from declassified US cables.
This time the revelations concerned how, in an effort to protect farmers, Nigeria’s President Shehu Shagari resisted President Jimmy Carter’s bid to sell American rice in Nigeria. The idea of an African leader rebuffing a superpower in defence of his compatriots excites advocates of truly independent African leadership. If nothing else, it is strikingly at variance with the more acquiescent mood of the continent’s current leaders, who these days may require a US or EU visit to validate their mandates. At a time of a renewed scramble for Africa, such diplomatic encounters have triggered questions about Africa’s continued ability to check unwarranted external influence. More importantly, they have led some to ask whether Africa’s era of people-oriented leadership ended shortly after the colonial period. Both questions arise in the context of celebrated leadership figures such as Patrice Lumumba, Kwame Nkrumah, Julius Nyerere, Amilcar Cabral, Nelson Mandela, and Thomas Sankara.
“African leadership has changed over the years,” says John Magbadelo, lead director at the Abuja-based Centre for African and Asian Studies. “African leaders [who] emerged from the independence struggles through which they wrenched power from colonial administrations were different in several respects from their military and civilian successors.” In 1969, Africa had just three leaders whose power was based on multiparty elections; by 2018 that number had grown to 43. Within the same period, the number of those who gained power in single-party systems fell from 11 to zero. The number of leaders who came to power through coups d’état also dropped from eight to zero, according to the Brookings Institution’s African Leadership Transitions Tracker. Despite apparent democratic advances, the continent remains beset by leadership problems, mirrored by conflicts, corruption and woeful performance on all key economic and life indicators.
Africa’s foreign policy has also become less assertive. Acknowledging the leadership problem, the organisers of the $5 million annual Mo Ibrahim Prize – the continent’s most prestigious award for former heads of state – said they had found no worthy recipient for six years between 2007 and 2017. Many analysts argue that Africa’s leadership problem has lingered for decades, since the pre- and earlier post-independence era, which they see as the continent’s golden age of people-oriented leadership. That period saw leaders confront colonialists, win independence and lead their fledgling nations to early political and economic progress. “The current [generation of] democratic African leaders are spineless because the situation in much of the continent has gone from bad to worse over the years,” Magbadelo told Africa in Fact. “African youths are braving the Mediterranean Sea [each year] in a futile search for greener pastures in Europe because they cannot see any hope for survival in their countries.”
So, how much has African leadership changed over the decades, and how were past leaders able to do better, while warding off unwarranted external influence? Historically, Africa’s leadership problem almost certainly predates the colonial era. In a 2016 paper, “Traditional Leadership and Corruption in Pre-Colonial Africa: How the Past Affects the Present”, Benson Igboin describes corruption during a time when African kings reigned with unlimited powers, and were regarded as God’s representatives. The lack of accountability allowed bad governance to fester, and chiefs were seldom called to account for their stewardship of their kingdoms’ resources. In recent history, the first factor that enabled a more assertive leadership was political. Mehari Maru, a scholar on African governance and former lead member of the African Union High-Level Advisory Group, traces three political phases since the independence era.
These are: the pan-African solidarity era, during which leaders mainly mobilised for the anti-colonial and anti-apartheid struggle; the confusion and division era, when the cold war between the US and USSR led to ideological struggle between supporters of the west and the east; and the period of intervention and integration. The first era, which produced heavyweights like Kwame Nkrumah (Ghana), Jomo Kenyatta (Kenya) and Julius Nyerere (Tanzania), was also the most people-oriented. Many leaders in this category asserted the foreign policies of their newly liberated countries in defence of their people. According to Maru, the next era, signposted by the cold war, saw the rise of undemocratic political groups, dictatorial governance styles and bloody political changes through military coups.
It produced dictators such as Muammar Gaddafi, Mengistu Haile Mariam, Houari Boumédienne, Said Barre and Mobutu Sese Seko, who were feared at home and also proved tough for the western world and the eastern bloc. “In a sense, the courage that the military rulers projected onto the global stage was a defence mechanism to assuage their feelings of guilt for displacing democratically elected administrations,” Magbadelo told Africa in Fact. That “courage” faded after the collapse of the Soviet Union, with the US becoming the world leader. The third leadership era was born under US pressure for political and economic reforms in Africa, which resulted in the rise of civilian leaders. Africa also ceased to be a proxy for either the West or the East, but that neutrality cost Africa its influence. There were signs of deference to the US for the role it had played in the implementation of governance reforms in Africa.
Moreover, most African countries came under structural adjustment programmes facilitated by the World Bank and the International Monetary Fund (IMF) – western-inspired institutions that shaped the global economy in the second half of the 20th century. “Africa lost its voice,” says Emmanuel Akyeampong, professor of history at Harvard University’s Centre for African Studies. “With only one game in town, African political parties no longer fought over ideology or foreign policy, but over who could better implement structural adjustment and be more loyal to the United States.” It was Africa’s initial lack of relationship with these economic institutions that was the second factor – besides politics – that enabled independence-era leaders to be more assertive and people-centred. The Bretton Woods Institutions – including what would later become the World Trade Organization – were all new organisations in the 1950s and 1960s.
This allowed African leaders, in the first two decades of independence, more autonomy in defining their paths of economic development and governance, according to Akyeampong. But everything changed after 1989, with the collapse of the Soviet Union. Today’s African leaders are not necessarily weaker than their post-independence predecessors, says Yolanda Spies, a senior research fellow of African diplomacy and foreign policy at the University of Johannesburg. The open defiance of western powers in particular shown by some past leaders was not always an indication of their diplomatic strength, because the cold war afforded many of them opportunities to double-deal with both east and west. Even so, the US cables also show that some African leaders snubbed the imperialist west because they were loyal to the opposite side of the ideological divide.
Another factor in perceptions of these former leaders, Spies argues, was the limited media scrutiny that existed in those decades. This may also have been an advantage, since very little was known about leaders’ public and private lives. “We live in an era of unprecedented media scrutiny. If we had had the kind of 24/7 scrutiny of leaders then, as we have now, we would not romanticise them as much,” Spies told Africa in Fact. Yet, while the political and economic contexts of each of the leadership eras may differ, Akyeampong argues that few leaders in modern Africa have the integrity of their predecessors. To put it another way, if a country’s corruption index reflects the integrity level of its leaders, the results today are not impressive. On average, half of the 20 countries in the world with the highest perceived levels of corruption in the past decade are in Africa, according to Transparency International. “Integrity has become a rare quality in African politics today,” Akyeampong says.
“The first generation of African leaders was patriotic: shaped in the crucible of colonial rule, they wanted better for their new nation states.” Akyeampong recalls a 2018 visit to the widow of Ahmed Sékou Touré, Guinea’s first head of state from 1958 to 1984: she was living in the only home she and her husband ever had in the capital, Conakry. It was also the house where Nkrumah, Ghana’s first head of state, had lived after he was deposed in 1966, until his death in 1972. Touré was notable for leading Guinea to vote “no” in a continent-wide 1958 referendum on whether former French colonies should join the new Francophone community that was being proposed at the time. He demanded outright independence. “The leaders of the first generation were of a different ilk,” says Akyeampong. Former US President John F Kennedy rejected the “socialist” and “communist” labels that were commonly attached to African leaders like Touré, he adds.
“He decided that they were ‘patriotic nationalists’, and what the United States needed to do was to assist them with economic development, [because] these leaders valued the prosperity of their countries over ideology.” With new powers like China challenging the US for dominance in Africa, there are still bright spots of good leadership on the continent, notes Spies. Rwanda’s Paul Kagame continues to be a reference point, as is Botswana’s former president, Ian Khama. Ethiopia’s new prime minister, Abiy Ahmed, helped to end the 20-year war with his country’s neighbour, Eritrea, shortly after taking office, and recently helped to end the standoff between Sudanese security forces and pro-democracy protesters. Meanwhile, more African countries are becoming democratic, and the number of opposition wins is growing and more incumbents are conceding defeat. “That is leadership,” Spies says.
“We saw very little of that in Africa until very recently. It sends a powerful diplomatic message – that leaders value their people, and that they value their institutions.” But more needs to be done with regard to Africa’s foreign policy, says Maru. Kagame is making some effort to assert African autonomy, but his stance is not usual among contemporary African leaders. Perhaps this is because there are considerable challenges in developing a coherent continental approach to foreign relations. In Maru’s view, what is needed is “a pan-African level leadership that could withstand unwarranted interferences from external forces, including the US, China, Russia, the UAE, Saudi Arabia, and Turkey.” But there are considerable challenges in developing a coherent continental approach to foreign relations. The African Union (AU), formed in 1999 with the goal of forging a common front in global affairs while pushing for Africa’s development, has yet to provide such a coherent approach.
First, the AU has no clear foreign policy guiding its dealings with other continents and big countries – unlike the US, China and the EU, which have policies on Africa. Its structure is also seen as too centralised and weak to support effective policy implementation internally to Africa, let alone as regards foreign policy. The regional histories of north, Francophone and Anglophone Africa bring with them different ties with different parts of the world. Also, Africa’s underwhelming economic position, despite its vast natural resources, continues to make it vulnerable in external negotiations. Then there is the complex problem of how ties – in some cases, cultural and religious – between AU member nations and foreign countries sometimes hinder efforts at achieving joint decisions. A recent example is Sudan where military rulers relying on support from Saudi Arabia, the UAE and Egypt, held onto power despite the AU’s warnings and its suspension of the north-east African country.
After the removal of long-time ruler Omar al-Bashir on 11 April this year, the AU initially demanded the restoration of civilian rule within 15 days. Sudan’s military leaders later received a 60-day extension, thanks to Egypt’s President Abdel Fattah al-Sisi, who, as the AU’s current president, rallied a few leaders to support the effort. The AU finally suspended Sudan after 3 June, when the security forces killed scores of protesters and wounded many more. Sisi reportedly tried to block the decision. Sudan has for years relied on its Arab allies for support, especially since losing most of its oil revenues to newly independent South Sudan in 2011. This year, amid the political turmoil, Saudi Arabia and the UAE sent in half a billion dollars in aid and promised another $2.5 billion, handing a critical lifeline to the country’s military rulers. Africa requires partnerships, not subservience, to succeed, says Magbadelo.
Ultimately, its development will depend on quality leadership and on Africans. “Africa’s vision to attain development does not need the concurrence of any superpower, but the determination of its leadership to implement policies that would institutionalise structures that harmonise and utilise the creativity and productivity of African people for the overall development of the continent,” he says.