Debt, superpower rivalries and bad health — Africa déjà vu
In the second part of this decade, outside actors are trying to recreate aspects of Africa in the 1980s. To be clear, this is not a cause for nostalgia: some of the dramatic gains we have seen in both health and sustainability are at risk. This will be bad for Africa and the world.
As policy and communications experts interested in the African continent, we must prepare for a new era of destructive superpower competition. Most of all, we must take advantage of the big difference between now and the 1980s: the increasing ability and determination of Africans to make this century their own
Flashback to Africa, 1989
At about this time 35 years ago, I was picking my way gingerly across the runway at Harare’s airport to take a Balkan Bulgarian Airlines flight to Cairo. Theoretically, someone was guiding the few passengers from the terminal and between the moving planes, but safety was not high on the list of concerns of either Balkan or the Zimbabwean authorities and we almost got run over by a taxiing Ilyushin. Back then, many uneconomic intra-African routes were operated by Balkan, the USSR’s Aeroflot, or the East German Interflug. Often, the Tupolev 154s would make unscheduled stops for unexplained reasons — on one Interflug flight, we were left to wonder where we had actually stopped because the crew refused to tell us.
The Soviet bloc airlines were part of the superpower struggle that sustained crooked despots such as Zaire’s Mobuto Sese Seko (he was received warmly by George H.W Bush at the White House), vicious ideologues such as Ethiopia’s Mengistu Haile Mariam (here’s a video of Leonid Brezhnev braving the snow to greet the Butcher of Addis Ababa at Sheremetyevo Airport) and the apartheid government in South Africa (the CIA probably told the South African authorities where Nelson Mandela could be arrested since Mandela had good ties to the Soviet Union).
None of these régimes survived long after the fall of the Berlin Wall in 1989 because their hold depended on them being seen as Cold War allies. Wars in Angola, Mozambique and parts of West Africa ended too, as the superpowers stopped arming their preferred warlords.
What did live on was debts racked up by dictators linked to one side or another. L’Express of Mauritius says that Africa’s external debt skyrocketed from US $11 billion in 1970 to US $120 billion in the early 1980s, peaking at US $340 billion in 1995, with debt service costs ballooning from US $3.5 billion in 1970 to US $26 billion in 1995. Africa’s debt crisis in the 90s was not all because of the great power game, but a lot was.
There were also decades of development assistance frittered away on Cold War allies. The Germans indirectly funded Zaire’s space programme. The French helped pay for the magnificent coronation of His Imperial Majesty, the Emperor of Central Africa. The UK has one of the lowest biodiversity levels in the world and for many years, its development assistance seemed designed to try to promote the same systems of monoculture and deforestation across much of Africa — its support for tobacco farming in Malawi, was a uniquely wicked combination of expropriation, environmental vandalism, child labour and promotion of disease.
It was neglect that killed most people, though. Cold War warriors didn’t worry much about the health of little people. From colonial times to the beginning of the HIV epidemic, so few people bothered to measure health that we have to be careful what we say about key indicators. For example, life expectancy in Kenya went from about 48 at independence to about 58 in the late 1980s, but Somalia gained only about five years. Africans really started living better, longer lives as big powers stopped competing and started collaborating with African governments on issues such as HIV, malaria and mother and child health.
The 1980s revisited?
It’s not 1989. For one thing, the small players back then were the Chinese (usually working to limit Soviet influence at all costs) and the Indians (trying valiantly to promote a third, non-aligned way with African allies). Now, China and India are the ones loaning vast amounts, building grandiose but questionable infrastructure projects and competing for the favours of African governments. The US still matters, but the British, the French, and the Russians are not the dominant powers they were. Arab countries, along with the Chinese, are buying up African farmland in a way that must make European colonialists envious if they’re looking up from the fiery depths — “You can walk hundreds of kilometres without stepping on Sudanese-owned land,” a Sudanese herder told Bloomberg in 2019, but hardly any of that land was cultivated.
The struggle is still not really about economics, but about geopolitics and resources. “In 1960, Africa accounted for three percent of the global economy. Sixty years later, that share remains unchanged [albeit that the global economy is much larger], even though Africa’s global population has almost doubled: from 283 million (9% of the world’s population) to 1.34 billion (17%) in 2020. By 2047, Africa’s population will likely account for almost a quarter of the world’s (2.4 billion out of 9.7 billion), and its contribution to the global economy will have almost tripled to eight percent”, the African Centre for Economic Transformation in Accra reported last year. It put the blame principally on women not being able to limit the size of their families: were they able to make these choices, Africa could reap a demographic dividend much sooner.
Some worrying 1980s trends are re-emerging too. Warlords across the Sahel have found sponsors. There are no genocidal maniacs like Mengistu, but the Chinese are happy to work hand-in-hand with some very repressive regimes. There are no kleptocrats on the scale of Mobutu, but I saw at first-hand recent British efforts to manage away the fallout from a few billion stolen through a Russian and a Swiss bank in London — security issues and access to natural gas were at stake. No current African leader is as deluded as Emperor Bokassa or Uganda’s Idi Amin, but enlightened Western leaders have a pretty high tolerance level for governments that organise hunting parties looking for lesbians or that have links to death squads killing political opponents in foreign capitals. (I’m complicit — I am not naming names because I’m on enough visa blacklists already).
Even if there are echoes of the 1980s, the structure of Africa has changed. Democracy is under threat, often from Russian-backed kleptocrats, but most African countries have relatively free elections, and several are models of press and civil society freedom. A democratic South Africa is a member of the G20. The African Union, in its 2024 Conference of Heads of State and Government, suspended another six countries for unconstitutional governance, and it may be that the AU is now strong enough to uphold the democratic norm, despite China’s pointed indifference and the periodic hypocrisy of Americans, Europeans and Indians. However, the AU does not have the financial or administrative tools that are available to the European Union as the EU seeks to curb autocrats in its midst.
Africa’s health gains are too big to be lost easily. Between 2000 and 2017, maternal mortality declined faster in Africa than in the world as a whole — by 40 percent. Much of the decline, though, was driven by targeted and relatively disinterested development assistance: an increase of one percent in health expenditure per capita reduced maternal mortality by 0.35%. Deaths of children under five almost halved in roughly the same period, although it is a scandal that a wealthy country such as Angola is still among the world’s top 10 for deaths of young children. Much of the decline in child mortality was driven by new vaccines against diarrhoeal and respiratory infections and Gavi, which made them available.
Today’s AU is making a coherent and compelling case for Europe and America to fund Africa’s green energy transition. Why, after all, should Africa pay for a carbon crisis that it did not create? The money is only trickling in though. There are beacon states such as Botswana and Gabon, but deforestation, desertification and toxic mining are proceeding apace elsewhere, often with enthusiastic Russian or Chinese assistance. Even South Africa may, some allege, be slowing green energy initiatives for fear of upsetting well-connected coal producers.
Health may suffer
The AU is taking health seriously, and the Africa Centres for Disease Control and Prevention offer thoughtful, expert leadership, but national health spending needs to rise faster to replace ODA. A BMJ paper in 2019 reported, “health spending remains too low in many countries. Expenditure per head [per year] roughly doubled in real terms between 2000 and 2016, from $130 to $270 in upper middle-income countries and from $30 to $58 in lower-middle-income countries…In low-income countries, average government spending per head increased from $7 in 2000 to just $9 in 2016.” You don’t need to be a health economist to know that $9 per person, or even $58, is woefully inadequate. An AU task force, headed by the controversial President Kagame of Rwanda, has yet to change this much, even after COVID.
Health spending may suffer further because of Africa’s new debt crisis, driven partly by easy access to Chinese money. Zambia was the first country to default on international debt after COVID. It owed most of it to China, and that made renegotiation much harder. The deal is now done, but Zambia’s Parliamentary Budget Office said, “the executive should…consider managing the expenditure side of the budget to bridge the deficits and accelerate the country’s coming out of the debt crisis.” That’s code for: “health budgets have gone up, but don’t expect us to meet all of our social obligations soon.”
In Afrobarometer’s rigorous surveys, health is the second most important problem for the government to address, according to most Africans. Nowhere do budgets reflect this. For example, in Nigeria’s 2022 federal budget, defence received 2.3 trillion Naira, infrastructure 1.4 trillion, and health received about 880 billion. That is a dramatic improvement on previous years and a pleasant contrast to Uganda. There, Uganda Airlines burned through $68 million of state subsidies in two years, about a tenth of the total annual health budget. You’ll notice that better air travel is not what any Africans want their governments to provide.
Even as budgets stall, health products may be about to become significantly more expensive. In the wake of COVID, there is a major push by African governments to rely less on imports and more on continental production of medicines, vaccines and consumables. Europeans like the idea because they think it may improve health security in Africa’s north and because it disadvantages the Chinese, who compete with India to provide most of Africa’s drugs, vaccines and medical equipment today. The International Monetary Fund and regional financing institutions have put aside billions of dollars to invest, and national governments have even more. What could go wrong?
The African producers need a reliable regulator, or their products cannot be given WHO pre-qualification, a prerequisite for being bought by international organisations and donor-funded programmes. An African Medicines Agency has been announced, but it will take years to get it up to the standards of the FDA or the European Medicines Agency. In the meantime, African producers will be able to sell only to African governments willing to accept authorisations given by national regulators, most of which lack experience and expertise.
Even when the regulatory problem is solved, it will take decades for new producers to achieve the economies of scale of their Chinese and Indian competitors. Both established nations have domestic markets that are bigger than all of Africa. African policymakers tell me that they intend to protect their new industries behind tariff barriers and restrictions on imports. This is another echo of the 1980s when Africa was full of Peugeot 504s made at various locations, including one in Nigeria, and Soviet versions of 1960s-era Fiats. They were out-of-date, uncomfortable and overpriced because of barter deals. Then there was the dreaded Yugo, “the Mona Lisa of bad cars,” as the New York Times called it. I think my head may still have dents caused by the suspension systems. We may have 20 years of 504-like medicines and vaccines ahead in Africa.
Western overseas development assistance (ODA), which has displaced much national health funding since 2000, is now declining overall: in 2022, when aid relating to Ukraine is excluded, global ODA fell by about three percent, according to Development Initiatives. It will probably fall further as Western nations spend more on weapons and armies.
The amount of ODA going to Africa is falling even faster. The share of British bilateral aid going to Africa declined from 40 percent in 2017 to 24 percent in 2022 as more of it was spent at home on “administration” and the costs of looking after asylum seekers and refugees.
Other donors are doing better, but the OECD said in 2023 that its members and other providers of development co-operation may be facing a growing dilemma: how to balance country-driven demands for assistance with increasing pressures on aid budgets to deal with development-related global challenges.
Amidst these challenges, the clownish amateurism of much European and American NGO advocacy for global health spending means there is almost nothing for growing health threats such as the chronic diseases that come with an ageing population or to take advantage of the promise of artificial intelligence.
What we need to do
Most non-Africans thinking about health in Africa remain stuck back in the 1980s, too. There’s a belief that African problems can best be solved in Beijing, Paris or Washington — or, increasingly, Berlin. All the evidence is that most of what works comes from Africa. Foreign experts fly in; data modellers in Washington tell teams in Mozambique which villages to target with prevention campaigns; meetings in London discuss why African vaccine uptake is too low.
“Eventually, neither Western donors nor trade with China or India will develop Africa; only Africans can.…Africa does not need excellent governance, superb education, or top hospitals; what transforms a country is typically governance that is ‘good enough’, strong local low-tech health programmes, and decent education and jobs for men and women,” wrote Jakkie Cilliers, the African futurist, as part of the Norwegian development agency’s recent project on rethinking development.
Those of us researching health and sustainability policies and communicating about them should remember this. FINN Partners has set up Global Health Impact across its disciplines, which is, sadly, highly unusual: it has Africans and Asians at its very core. Work in Africa may involve digital experts in Mumbai or consumer strategists in New York. Still, it will always be led from Cameroon, Kenya, Morocco, South Africa, or one of the other 43 African countries where the FINN team has worked.
