1

The Health Crisis in Sub-Saharan Africa:

Role of Western Aid and Investment

Author: Khushi Desai

UID: 171114

Roll Number: 056

Subject Combination: TYBA Economics

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Table of Contents
Page Number Content
3 Abstract
3 Research Question
3 Methodology
4-5 Introduction
- Why is sub-Saharan Africa so
vulnerable to epidemics?
5-8 Analysis
5-6
- What is the role of an aid-based
development model in perpetuating this
health crisis?
7 - The state of the environment
8 - Structural weaknesses in the health
sector

8-11 Conclusion
8-9-10 -Why is the healthcare sector in sub- Saharan Africa
so under-developed?
10 -Limitations of study
10 -Transitory and Corrective measures
10 -Structural and Forward-looking measures
11-13 References
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Abstract

This paper aims to study the impact of Western foreign aid and investment in sub-Saharan Africa (46 African
countries) with a focus on the health sector. It incorporates a historical angle to the study of heath in the region,
and the political and economic underpinnings that have led Africa to the state it is in now. It ends with policy
suggestions that talk about aid that is well-targeted and well-intended to bring valuable change and redirect the
African subcontinent to development and progress.

Research Question
This paper aims to study the impact of American development aid into sub-Saharan Africa, with a focus on
health disparity and health poverty. Has Western aid been able to help these countries over the cyclical troubles
of absolute poverty, civil war and poor governance? What have been the hidden and negative effects of the
countries’ constant reliance on Western aid and political stakes?

Methodology
The following research is based on secondary literature derived from academic papers written by health and
development experts, data gathered by the United Nations, World Health Organization and other associated
agencies. For the purpose of this study, to avoid complexity, the two disorders used as illustrations are
HIV/AIDS and Ebola and they have been through the lenses of structural weaknesses in the health sector as
well as the impact of under-regulated economic activities. It goes on to prove that poorly targeted aid and
exploitation of the political economy in backward states has led to the West deriving economic benefits in
exchange for aid that does not work, or in some cases, is designed to have limited impact.
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Introduction
One of the most culturally, geographically and historically diverse continents on Earth, Africa, by experts in
various disciplines, is split into two descriptive territories. The countries that fall below the Sahara desert are
clubbed under the umbrella term of sub-Saharan Africa, consisting of 46 out of 54 African countries.
Traditionally, countries that lie above the Sahara are wealthier and economically and politically stronger due to
geographical advantages, despite having their own separate set of challenges— some definitions place North
Africa under the Arab world as well. However, contrastingly, sub-Saharan Africa has an increasingly growing
number of extremely poor people, while extreme and absolute poverty declines in all other regions of the world.
A World Bank forecast estimates that by 2030, 9 out of 10 extremely poor people will live in this region
(Wadhwa, 2018).

As a result, central and southern Africa has been a victim of many structural and cyclical problems, including
severe and repeated health crises. Of course, North Africa has also suffered in the process. History, especially
as far back as there are records of colonies setting shop in the subcontinent, suggest multiple outbreaks of
epidemics such as cholera, smallpox (1713 onwards, spread over two centuries), influenza (1918), HIV/AIDS
(1920 onwards), malaria and most recently, the Ebola outbreak in 2014 in Liberia. Interestingly, the prevalence
and impact (as per population numbers) of diseases and epidemics, has not seen much reduction even with the
consistent advancements in the medical field, including access and availability to medicines and medical
facilities, innovation in vaccinations and improvements in pharmaceutical products, research and development
investment around the world. In contrast, till date, there are just 170 medical schools spread across the 46
countries and a physician-to-population ration of about 1:5000 (Africa has about one doctor for every 5000
people, 2015).

Why is sub-Saharan Africa so vulnerable to epidemics?

Most of Africa’s land area falls in the tropical hemisphere around the Earth’s Equator. The hot and wet climate
is a breeding ground for pathogens and viruses. Resultantly, between the 1970s and early 2000s, there were at
least 30 new infectious diseases recorded around the world, most of which initiated in sub-Saharan Africa
(Laino, 1999) . On the other hand, HIV/AIDS, which is an immune-disorder spread by unprotected sexual
intercourse and irresponsible drug consumption, has been ravaging through most of Africa for decades, since
1920 as per some research, when a streak of it was learnt to have transferred from chimpanzees to humans. In
fact, in 2001, out of 40 million recorded patients of HIV/AIDS, 28.5 million resided in sub-Saharan Africa
(Goliber, 2002).

Figure 1. HIV Prevalence by gender and area of residence in sub-Saharan Africa (2007-2011)

Source: World Health Organization. Retrieved from

https://www.who.int/gho/urban_health/outcomes/hiv_prevalence/en/
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These two illustrations suggest that poor healthcare is prevalent through Africa in both categories, infectious as
well as non-infectious disorders. Health experts like Dr. David Heymann, Executive Director of the World
Health Organization’s Program on Communicable Diseases are of the opinion that much of this health picture
has to do with the destruction of natural environments and habitat, including the rapid decimation of Africa’s
rainforests and wildlife (Laino, 1999). In this process, the pathogens lodged within the depths of the forests and
within the animals spread into human environments. Moreover, the displacement of local tribal habitats and
communities and their forceful integration into modern, urban life, along with large-scale migration of non-
African residents has made the average African highly vulnerable to disease streaks that aren’t originally from
the African subcontinent.

Interestingly, most parts of sub-Saharan Africa have seen a culture of local doctors touring remote parts,
especially those most infected by major diseases to cure the problem at the source. While some viruses and
pathogens have been challenged through timely vaccines and new inventions in medicines, the very problem of
the matter is that it is recurring. For instance, the 2014 Liberian Ebola crisis, which killed almost 11,000 people
in Western Africa alone and led to an economic loss of US$ 2.2 billion, seemed to have been quelled with a
rushed development of a vaccine and strict quarantine measures (Hatchett, 2017). However, cases of Ebola
have been on the rise once again in the early months of 2019. Climate change has become another major factor
for this recurrence. The African subcontinent has been dealing with severe El Nino impact, including rising
water and temperature levels. Conflicts caused due to the climate crisis are further causes of epidemics. Rising
economic disparities create a situation that an average sub-Saharan African is simply not physiologically strong
enough to resist infectious diseases, due to consistently poor sanitation and malnutrition.

Analysis
What is the role of an aid-based development model in perpetuating this health crisis?
The question to be answered here is why the natural environments are being decimated in sub-Saharan Africa
and why development activity is haphazard enough to lead to a repeated health crisis. It is a matter of concern
for experts and governments far and wide because regions that are part of modern Africa are said to have been
home to the very first homo sapien and if the most established and advanced versions of the human are
suffering from abject poverty and conflict, the causes are likely to be human made rather than any misfortune
caused by nature (Harari, 2014).

This necessitates delving into Africa’s colonial history (Pearson, 2018). With the industrial revolution fast
underway in Europe and the limited expansionary capacity of domestic markets, colonial powers looked
outwards for economic and political growth and powers like Britain, France, Portugal, Spain and others entered
Africa, economically and demographically. Eventually, they came to dominate the political systems in sub-
Saharan Africa. These new age bureaucrats answered to their monarchies back home and some of the most
crippling examples of this in history are the British colony in Nigeria and French colony in Côte D’Ivoire. After
the two World Wars, as Europe’s power dissipated, the United States of America was more or less the ruling
power and held heavy economic and political stakes in sub-Saharan Africa, albeit not as a coloniser but a
modern form of involvement through development aid. Many other western countries have taken up this form
of involvement with Africa since the 1950s (Ewout, 2015).

Mark Green, the administrator of the United States AID programme (USAID), says, “The purpose of foreign
aid is to end the need for its existence.” (USAID) With this ethos, by 2015, American aid to the region had
heightened at US$ 40 billion, even as the total aid to sub-Saharan Africa has increased consistently since 1960
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(Gill, 2018). In comparison, the total GDP growth rate had been slow upto the 2000s, after which there were
major jumps. Interestingly, official development assistance to the region actually declined during the 1990s,
with the global restructuring of economies and liquidity crises. In the very next decade, some sub-Saharan
countries transformed from absolutely poor countries to middle-income countries, such as Nigeria, South
Africa, Zimbabwe etc. Prior to this change, nearly all of the sub-Saharan countries fell under the ‘bottom
billion’ category of the world population, the poorest billion people in the world (Collier, 2007).

Figure 2. Western Aid flows to Sub-Saharan Africa (1960-2016)

Source: Brookings Institution (2018). Retrived from https://www.brookings.edu/blog/future-

development/2018/01/19/the-end-of-aid/

Figure 3. GDP (US$ trillion) in Sub-Saharan Africa ( 1960-2018)

Source: World Bank National Accounts Data. Retrieved from

https://data.worldbank.org/indicator/NY.GDP.MKTP.CD?end=2018&locations=ZG&start=1960&type=shaded
&view=chart

Considering this contradiction, it is necessary to consult existing literature on the state of the environment and
the structural challenges in the sub-Saharan health sector. .
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The state of the environment

Consider the case of the HIV/AIDS epidemic across Africa that has lasted nearly a century. Known to have
originated in Democratic Republic of Congo, it is a disease that has reduced the average life expectancy in Sub-
Saharan Africa to just 47 years (Kharsany & Karim, 2016). Started with a transfer of HIV from chimpanzees to
humans, there were hardly any documented cases between 1920 and the 1970s. By then, estimates suggest that
around 300,000 people could already have been infected and spread to five continents. Research suggests that
the disorder might have been initiated by humans coming into contact with the blood of sick chimpanzees while
hunting, or travelling through forests (History of HIV and AIDS Overview, nd). Further, it spread through the
rivers as European traders traversed through the Congo river over time. By then the forceful migration of local
tribes was also common under colonial subjugation, leaving indigenous habitats at the mercy of exploitative
traders.

Since then, climatic disasters and conflicted areas have been common breeding ground of HIV/AIDS, as
reported by MSF. The DRC is till date, one of the poorest countries in the world, with complete economic
dependence on mineral mining and exports. The urban-rural disparities are wide and studies show that aid that
has flowed in has been mostly diverted into expanding these industries and urbanization, rather than on
structural economic changes. Although foreign investments in the natural resources industry are wide, the
political weaknesses have never been cured to regulate the industry and to avoid health crises that are not
limited to only HIV/AIDS. In fact, a poll by the Congo Research Group found that one third of its respondents
believed that the country would be better off in tackling its core issues of health, poverty and policy without
excessive and inefficient involvement of international non-profits and multilateral agencies (D'Onofria, 2016).
These numbers can be emulated in all countries in sub-Saharan Africa that have not been able to deal with the
HIV/AIDS epidemic in over 60 years.

Consider a second illustration of the Ebola outbreak in Western Africa in 2013. It originated in the western
coastal country of Guinea, in a child living in the small village of Meliandou, Guéckédou district. The virus was
unidentified for almost four months after reporting in December, 2013, when the baby died. Primarily a forest-
heavy region, the forests of Guinea have been surrendered to deep-rooted iron mining and lumbering (timber)
projects by foreign conglomerates in the last few decades. The Ebolavirus, through studies, is considered to be
hosted majorly in fruit bats, but the stain found in the Guinea Ebola cases was of the Zaire kind and researchers
ruled out the possibility of it having travelled from central Africa, where it is commonly found. In investigating
this child’s case, medical experts suggested that the child had been brought into contact with wild animals,
especially fruit bats, that wouldn’t usually stray into human habitats, even in the form of hunting and direct
consumption, which is prevalent in parts of Gabon and Guinea (One year into the Ebola epidemic: a deadly,
tenacious and unforgiving virus, 2015).

Historically, the native population were subjected to slavery by their French rulers in the 19th and early 20th
centuries and the rapid move to Independence in 1958, left the local population unprepared to take over
political responsibility, leading to the unbridled exploitation of mining resources. Meant to bring economic
prosperity to the people, these investments have caused massive displacement and conflict in the region
(Dearden, 2017). The decimation of the Guéckédou forests is a direct result of this, with major firms from USA,
France, Canada and Germany responsible for the irreversible damage. The loss of the forest cover has caused
major climate concerns, such as frequent flooding and extremely arid conditions that lead to animals straying
from remaining forest areas to seek shelter and water, especially with major diversion of rivers to dams and
hydroelectric projects. The story in Liberia and Sierra Leone, the other two epicentres of the Ebola breakout, is
much the same. All three of these countries fall below 170 out of 186 countries on the HDI and although most
of the impact has been quarantined, there are still cases of this haemorrhagic fever being reported.
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Structural weaknesses in the health sector

In this section, both of the above cases must be analysed from the standpoint of structural gaps in the healthcare
industry. If history is to be studied, most of sub-Saharan Africa has been a victim of severe civil war and
conflict— almost 550 conflicts since the 1950s. Before that, the colonial powers suppressed and systematically
transformed the culture, economy and polity of the continent, and most tribal practices, including those of
healthcare have been lost. The genetic demographies have changed through intermingling of various races. The
average African physiology has developed different responses to existing maladies and has become vulnerable
to newer maladies.

However, unlike most other parts of the world, which underwent infrastructural growth and development since
the 1950s, sub-Saharan Africa has lagged behind consistently. The GDP as well as the foreign aid flows has
been growing (as shown in Figure 2), but the investment in health sector development has not been in the same
proportion. In fact, the increasing presence of humanitarian agencies like Doctors without Borders and Red
Cross International have had limited impact in disease prevention, although they have played an important role
in controlling epidemics once they proliferate massively. A major reason for this is also the repeated damage
caused to existing facilities due to civil war

In the case of the Ebola outbreak in Guinea, the WHO, which is considered to be the world’s primary health
organization, was only just initiated into setting up of new healthcare facilities and was under-equipped to deal
with the sheer size of the crisis (Denney, 2014). Very few cases were initially reported and investigated, due to
the widespread lack of faith in the capacity of these agencies to help. Moreover, there is a certain social stigma
related to reporting being sick and isolated. With the infection reaching widely to cities of the three countries,
the transmission channels were not blocked in time and the rural areas were extremely isolated due to poor
road, transport and communication systems (Ramin, 2009). It must be noted that this crisis caused such havoc
in West Africa because of the lack of systems in place, in comparison to central Africa, which had seen other
forms of Ebola outbreaks in the past. The three countries had a doctor to patient ratio of just 1 or 2, per 100,000
people, which was further depleted when some of the primary healthcare workers were infected with the virus
(Bausch & Schwarz, 2014).

Similarly, in the case of the HIV/AIDS epidemic, the crippling lack of resources in the healthcare sector caused
the disorder to perpetuate. Low literacy rates have also created problems, as more people avoided contraception
and responsible drug consumption. Additionally, some of the foremost medicines and treatments for HIV/AIDS
were developed outside of Africa, in western countries that had the research infrastructure to do so and the most
common treatment today is the antiretroviral treatment (developed in New York, USA), which took almost two
decades to be available at subsidized and generic rates across Africa. Africa suffers from 30% of the world’s
disease burden, but spends on 1% on healthcare development and research and these numbers become more
dismal as one moves through health budgets of the poorest in sub-Saharan Africa.

Conclusion
Why is the healthcare sector in sub- Saharan Africa so under-developed?
The economic and political backwardness of the countries, as can be established from the above discussion,
goes back to colonial period. Once these countries started becoming independent, after the World Wars, the
transition was sudden and unsustainable with local ethnic and tribal rivalries abound. The leaders were
unprepared to take on the responsibility of developing countries from the scratch. On the other hand, these
countries were victim to their own ecological wealth and vested interests from the West have prevailed over all
its activities. Unbridled mining and mineral extraction projects, deforestation and under-planned infrastructural
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projects have destroyed the delicate ecological sanctity of sub-Saharan Africa, unleashing a series of healthcare
threats on its inhabitants. Most of the countries in the region are highly vulnerable to infectious diseases
(Bräutigam & Knack, 2004).

Figure 4. Infectious Disease Vulnerability Map (Most to Least vulnerable, 2016)

Source: RAND Corporation ( 2016). Retrieved from

https://www.rand.org/content/dam/rand/pubs/research_reports/RR1600/RR1605/RAND_RR1605.pdf

Meanwhile, healthcare aid projects have been virtually ineffective in preventing massive outbreaks and
investment from the West in this sector has been minimal. In fact, foreign aid is harming the region more than it
is helping it as per some studies by causing dependency and corruption (Lyons, 2014). Most countries in the
region are among the lowest in the Corruption Perception Index. This can be discussed within the age-old
debate between William Easterly and Jeffery D. Sachs. While Easterly, in his book, ‘White Man’s Burden’
dismantles the West’s need to intervene in Africa through aid as a self-serving motive in exchange for access to
its boundless natural resources, Sachs mentions that US$ 75 billion a year from the collective aid donors could
transform Africa (Sorens, 2007). Consolidating both these approaches is Paul Collier, who, in his Bottom
Billion Theory, suggests productive ways to make the West’s contribution actually worthwhile through better
programme design and targeting (Collier, 2007).

Figure 5. Corruption Perceptions Index (2018)

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Source: Transparency International (2018). Retrieved from https://www.transparency.org/cpi2018

Limitations of the study: Before moving into the policy recommendations, it is important to note the drawbacks
of the study. It does not consider the cases of many other disorder and diseases affecting other countries in sub-
Saharan Africa such as malaria, influenza and cholera due to limited space. Moreover, since economic and
health data from all of the 46 countries is either unavailable or cannot be studied in this short study, only two
case studies are studied in detail. While this may not exactly represent the wealthier regions such as South
Africa, the conclusions drawn from the study are at least historically true in these cases and might be true in
small parts of the same countries. All conclusions are based on the case studies and commentaries from
economic, medical, political and sociological experts on the same.

Policy Recommendations: What is the way forward?

Transitory and Corrective Measures:

Collier’s Theory might be a cautious but revolutionary step forward in the direction to develop sub-Saharan
Africa by firstly, remedying the existing loopholes in policy that allow exploitation by local and Western
(external) stakeholders. Ramping up Western foreign aid and investment targeted to healthcare through FDI and
academic collaborations may be a starting point, which may allow the expansion of the countries’ health
budgets. This dimension will necessitate the strong policy changes with regards to aid, including elements that
ensure accountability for the provision of basic services, reporting of any and all measures and fund transfers to
multilateral organizations. Collier suggests that Western opinions of sub-Saharan Africa must be shifted from
restrictive binaries such as the necessity of democracy for progress. He contests that, in fact, with the wealth of
Africa’s natural resources, democracy might even be a threat. In that case, he suggests that firstly, peace must
be forced into all the countries and side-by-side, structural changes encouraged.

Structural and Forward-looking measures:

On a wider note, innovation in the digital health sector would benefit the end-to-end health consumer in sub-
Saharan Africa greatly. The proliferation of technology is increasing in the region and as of 2018, there are 444
million mobile phone subscribers. If these circumstances can be channelized to improve access to healthcare, it
can improve health conditions. For instance, UNICEF has collaborated with the Ugandan government to start a
mobile application called mTrac that connects thousands of pharmacists and health practitioners to the common
Ugandan and informs them all of medicine stocks. They plan to expand the application to include more services
that improve supply-chain management (Jimenez, 2015).

Skilling the African youth in healthcare is essential. Western educational and research institutions will be
indispensable in this matter, when they collaborate with the more primitive African institutes as well as launch
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more new ones. Additionally, the African Union and other African policy conglomerates can collaborate on the
policy front with pharmaceutical companies that are foremost in innovation across the developed world, so as to
enhance resource and information-sharing without restrictive patents and royalties. On the other hand, the brain
drain from sub-Saharan Africa can be contained by incentivising existing medical stakeholders to open offices
and wings in the region itself. The USAID, for that matter, has been fairly inclusive in that sense, with regards
to its nutrition programme.

Lastly, limiting environmental exploitation by controlling Western investment and reviving the ecology is most
important at this point in time. Given its equatorial location, Africa has a wealth of renewable resources such as
major rivers like the Nile and Congo and year-round solar energy. The governments need to divert investments
in industry into these sunrise industries and make them competitive and hold exploitative industries like Rio
Tinto accountable for the damage they cause.

To end with a quote by Nelson Mandela, “In Africa there is a concept known as ‘ubuntu’ – the profound sense
that we are human only through the humanity of others; that if we are to accomplish anything in this world it
will in equal measure be due to the work and achievement of others.”

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