OXFORD, England – While tracking the trajectory of African economies, the African Development Bank (AfDB) must be wary of overlooking the most essential constituent of Africa’s economic potential, a healthy African. It is cliché that the youthful African population promises a brighter future for the continental economy. But it must be remembered that it is the healthy youth, not malnourished or blighted by infectious diseases, who are to power the African economy. In this respect, the low emphasis on the health sector in the recently released African Economic Outlook 2020, is a cause for concern. The bank should aim to influence effective economic policies, but on the basis that a vibrant economy as measured by the gross domestic product (GDP), has not been attained at the expense of the general wellbeing of the citizens in an African economy.
The gross domestic product (GDP) measures the total value of goods produced and services provided in a country over a one-year period. It has remained a widely accepted metric since its devising by Simon Kuznets as means of tracking economic performance in the wake of the Great Depression. In this year’s edition of its flagship report, the AfDB paints a picture of a resilient continental economy which has withstood challenges of national and international origins. The AfDB’s report claims that growth in Africa’s GDP, adjusted for other factors, has risen from 3.4% in 2019, and projected to 4.1% in 2021. Where AfDB estimates, for instance, an increase from 0.5% in 2018 to 5.8% in 2019 for South Sudan, one is supposed to conclude that South Sudan’s economy weathered the vicissitudes of a self-afflicted war, harassment by Ebola Virus Disease, and a famine among its internally displaced persons. The imbroglio that is the backdrop to this growth instantly inspires wonderment, until one looks at how GDP is derived. While South Sudan has been experiencing growth “mainly as a result of increased oil production following the peace agreement in September 2018,” as the report claims, this mathematical crystal ball makes no room for the associated human cost in an embattled economic performance. As an example, this “growth” in South Sudan has come at a price of environmental degradation, and poisoning of the pastoral communities in its oilfields. The self-declaring toxic fumes – which betray frequent oil spills into environmentally and economically crucial wetlands – have appeared in other reports, but are not a factor in calculation of the country’s GDP. Similarly, the convenience afforded by GDP as a metric is achieved by disregarding such things as nonchalance in the official response to reports of stillbirths among humans and animals in South Sudan’s oilfields. It is however important for an institution intended on “sustainable economic development and social progress in its regional member countries” that it influences for health-conscious economic strategies.
South Sudan is a country where 1 in 7 children die before their 5th birthday, a third of whom are malnourished, more than half the population afflicted by poverty, and where 1 in 7 mothers die in childbirth – the world’s highest maternal mortality rate (SSHHS 2006 & 2010). The discordance between the apparent 5.8% growth in the GDP despite these trends, and the fact that over 70% of healthcare remains under international NGOs, reveal a contradiction in the story of the economic performance and potential, and the trajectory of human development in South Sudan. As the bank’s president – Akinwumi Adesina – aptly noted when launching the report, “nobody eats GDP.” Evidently, the upbeat economic performance is unlikely to reduce extreme poverty and inequality, not only because “it will be driven by oil sector rather than agriculture, where most people work.” But also because of limited translation of such gains into services which would benefit the whole citizenry. For instance, South Sudan’s supposed prioritization of infrastructure, projected to be allotted 54% of the budget, may well be complementary to the health sector (See pg.181 of the report). Yet allocating the health sector a measly 1% of the projected gains is an affront to an already low 4% target in its 2012-2016 Health Sector Development Plan (2012:13). In any case, the report’s over-reliance on GDP growth restricts it to analytical domains which risk more than trivializing the human condition: it fails to capture real risk posed by weak health systems to the continental economy.
The importance of resilient health systems is self-explanatory when considering healthy Africans as the greatest asset for African economies. This warrants a distinct appraisal of the state of health systems, in a report positing a continental economic outlook. The report expectably declares that “a growth and development accounting decomposition focuses on the relative roles of physical capital, human capital, labor force mobilization, and total factor productivity” (pg.27). While the emphasis must remain on the human capital – naturally because a robust economy is a means to fulfil the needs of that human, and it’s such human without which the physical capital serves little purpose – it is largely presumed that this human, the African in an African economy, is healthy. This permitting condition is however overlooked throughout the report. An exception was made for nutrition – and only in the reflected glory of agriculture, that doyen of African economic narrative – which is supposed to fuel the minds with which, after some considerable schooling, an economically more useful African would be harnessed. Accordingly, the GDP is to be powered by a well-fed African, educated in a tailored program, in an African economy that is insured against the El Niño which haunt East African agriculture, floods such as the 2019 which plundered Southern Africa, and droughts which have proven the bane of Ethiopian and Sudanese subsistence. In this cornucopia of things to fend off, there was only a cursory mention of Ebola which has devastated Western Africa in 2014, and which threatened the Congolese, Ugandan and South Sudanese economies well into weeks before the launch of African Economic Outlook 2020. Since decades of gains in capabilities could be wiped out by a viral epidemic which looms in any of Africa’s weaklings of global health security, the bank’s strategies for ending extreme poverty remain incomplete without a resilient continental health system. It should be remembered that Simon Kuznets’ genius in devising the metric for national income is in standardization. But, despite the convenience of GDP as a metric, it would be remiss for 21st Century economists to ignore weak health systems as potential catalysts for the modern equivalent of the Great Depression Kuznets peered into. To stem extreme poverty, an insurance against catastrophic health expenditure is not any less important than a protection against poor agricultural yield, which AfDB advises. Even where agriculture is the main sector, and therefore gains from it may countenance personal costs of healthcare, tilling remains a vocation for healthy humans.
According to the Lancet Commission for Global Surgery, catastrophic health expenditure – i.e. direct payment greater than 10% of one’s total income – will cost the global economy USD 12.3 trillion between 2015 to 2030. The majority of this cost will be faced by Africans and south Asians. In this instance, a sole breadwinner – not uncommon in any of the fragile countries listed thusly in the bank’s report – may be permanently afflicted by ill health. This in turn eclipses the economic prospects for many dependent persons. Health system strengthening is therefore not a secondary goal: it’s an essential component of Africa’s economic strategy.
As defined by the World Health Organization (WHO), a health system comprises all the activities whose main objective is the promotion, restitution, or maintenance of health. Harvard professor Joseph Newhouse demonstrated at the RAND Corporation in 1970s, that healthcare expenditure strongly tracks the national income. However, this does not mean that economic growth, as measured by GDP, is in itself a necessary or sufficient condition for improved population health. Broadly, it is not the case that a growth in the GDP must precede investment in healthcare. Effective healthcare is independently necessary and could help grow the economy. It should not be regarded a burden on an economy. Specifically, as Sebastian Vollmer and colleagues have shown in a 2014 article in the Lancet, economic growth does not result in a reduced early childhood undernutrition. A direct health investment is necessary where amelioration of this vice is sought. In the same logic that the AfDB recommends investing in nutrition, a direct investment in an Incident Management System – such as would be required in a response to an epidemic – cannot be an afterthought in a continent where diseases could easily derail the gains from decades-long local and international efforts. Similarly, safeguarding against catastrophic health expenditure, not just failed agricultural yield, must be a constituent objective in the bank’s goal for eliminating extreme poverty by 2030. With the spectre of catastrophic health expenditure, the target of extreme poverty rate below 3% would remain untenable, even with the best agricultural yields and reliable oil prices.
In its future analyses, and through its influential report, the African Development Bank must seek to distinguish and emphasize the role of a resilient health system for Africa’s sustainable development goals. Beyond commodity prices, extreme weather events, elections, and slowed activity in the major global economies, all which the bank acknowledge as the main threats to African economies, the permanent blow that could be exacted by an epidemic must be suitably recognized. In addition to the underlying assumptions about oil prices, real domestic demand, and inflation, the bank should habitually comment on its forecast about health system resilience, and encourage the necessary health sector investments in constituent states. Naturally, the bank should aim to curb contagion, not just of inflation – a common disease of the economy – but also of epidemics, an ever-present threat to the human capital in Africa. On their part, the governments of African countries should collaborate on AfDB on a strategy for resilient health systems. As evident in the ongoing Coronavirus (COVID-19) pandemic, pre-emptive preparedness and collaboration across health systems is key for an effective response. A responsive health system is in the best interest of each African government as it improves government’s legitimacy, in addition to the benefits of a healthy citizenry and a resilient economy during an epidemic.