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RIDICULOUS SUMS OF MONEY: Why the War on Drugs has Failed

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The drug war

Nairobi, Kenya – CONSUMERS IN FINAL MARKET COUNTRIES HAVE NEVER HAD IT SO GOOD

The war on drugs has failed. It has failed to stop, or even slow, the production, trafficking and consumption of drugs. The specific aim to destroy and inhibit the international drug trade — making drugs scarcer and costlier, and thus unaffordable, has only been partially achieved.

Most experts agree that the drug war has prevented some drug abuse by making forbidden substances less readily accessible. It has made drugs like heroin and cocaine vastly more expensive than similar agricultural-based psychoactive products such as coffee or tea. One study shows that the increase in price per gram as cocaine moves down its distribution chain is up to 100,000% that of coffee. Also, the fact that illegal drugs are not readily available at your local chemist or supermarket has undoubtedly meant fewer users are able to access them.

However, this is only part of the story. In fact, consumers in final market countries have never had it so good. Overall, the price of most illegal drugs has actually plummeted while the drugs have become even more potent.

A study published in the British Medical Journal’s BMJ Open found that in the nearly two decades between 1990 and 2007, the purity of cocaine available in the United States increased by 11% while its price collapsed by 80%; the purity of heroin shot up by 60% while its price fell by a precipitous 81%; marijuana saw more than a tripling in purity accompanied by a similar drop in price to that of heroin and cocaine. The trends were similar across the Atlantic. In 18 European countries, the street price of cocaine halved over the same period. At the same time, in the decade between 2003 and 2013, the value of the global drug trade grew by over 35% from $320 billion to $435 billion, and, according to the UN, the drug business continues to be the third biggest in the world after oil and arms.

The war on drugs amounts to a transfer of the economic, political, social and environmental costs of prohibition from rich consumer countries to poorer producer and transit countries in return for a few dollars in aid

The number of people using drugs appears largely unaffected by the war on drugs. It is true that increased seizure and crop eradication, coupled with alternative development aimed at reducing the incentives for illicit cultivation, have reduced the amount of cocaine on offer.

TRAFFICKERS ARE FINDING NEW MARKETS AROUND THE WORLD

Still, although the 2016 UN World Drugs Report cautiously concluded that ‘the global cocaine market has indeed been shrinking,’ this is attributable both to declining production as well as changing consumption patterns across the globe, not to a reduction in the total numbers of drug users. Essentially, traffickers are finding new markets around the world even as consumption in the US and Europe stagnates, even declines. ‘The drug trade is becoming truly more global,’ Vanda Felbab-Brown, senior fellow at the Brookings Institute, told CNBC in 2013. However, while in mature markets a small proportion of users buy the bulk of the product, their new customers tend to take less cocaine less often. Similarly, the huge fluctuations in the availability of opium – whether due to increased enforcement or not – have not led to dramatic changes in the number of opiate users though for different reasons.

The rub of it is that rather than reduce the number of people on drugs, the drug war has instead funnelled massive amounts of money into the pockets of drug barons and cartels. The global cocaine trade, though utilising a fraction of the land and labor resources required by the coffee industry, rakes in an estimated $85 billion annually from supplying under 20 million consumers with about half a million kilos of the drug. Compare that with the roughly $100 billion the coffee industry shares from providing about 9 billion kilos to the hundreds of millions of coffee lovers. At its peak, the Medellín Cartel in Columbia supplied 80% of the worldwide cocaine market and is estimated to have been generating at least $60 million a day in revenue. In fact, illicit proceeds from the drugs trade now account for half of all income from international organised crime.

In Latin America, drug interdiction efforts are associated with increasing murder rates, not just in the countries where the interdiction is carried out but, when it is successful, in the countries to which the traffickers are displaced

Such ridiculous sums of money make drug dealers immensely powerful and menacing figures. In fact, the war on drugs amounts to a transfer of the economic, political, social and environmental costs of prohibition from rich consumer countries to poorer producer and transit countries in return for a few dollars in aid. These costs include violence, corruption and the loss of legitimacy of state institutions, population displacements and environmental degradation.

In Latin America, drug interdiction efforts are associated with increasing murder rates, not just in the countries where the interdiction is carried out but, when it is successful, in the countries to which the traffickers are displaced. For example, in Colombia, the war against the Medellin cartel in the late 1980s and early 90s saw the homicide rate nearly double between 1985 and 1991. Some 16 years later, a fresh wave of interdiction in Colombia displaced the cartels and associated violence to northern Mexico which, combined with the effect of local policies, saw the homicide rate there triple between 2006 and 2010.

Narco-traffickers are able to corrupt governments and law-enforcement agencies and purchase political influence and even political power. Pablo Escobar, head of the Medellin cartel, created a Robin Hood image for himself in the 80s by building houses and public facilities for the poor. He even got himself elected to the Colombian House of Representatives in 1982. In the Kenyan Parliament, in December 2010, five legislators, Harun Mwau, William Kabogo, Hassan Joho, Simon Mbugua and Mike Mbuvi, were named in connection with the trafficking of narcotics. Two of those have since gone on to become county Governors and one a county Senator. In Guinea-Bissau, which the UN branded Afrca’s first narco-state, the value of the drugs trade is greater than the national income. ‘You walk in, buy the services you need from the government, army and people, and take over,’ was the way one senior official at the US’s Drug Enforcement Agency put it.

Further, drug money distorts the economies it washes through, creating huge inequalities and devastating local living standards. According to a 2009 report by the Financial Transactions and Reports Analysis Centre of Canada, drug traffickers have laundered approximately $100 million per year through the Kenyan financial system. ‘The proceeds of drug trafficking move through the [Kenyan] banking system,’ John Githongo, the veteran anti-corruption campaigner, told Investigative Reporting Project Italy in 2015. ‘In terms of movement of drug money, Kenya now rates higher even than Nigeria due to the rise of narcotics moving in and through the country, but also because of the country’s sophisticated financial system.’ The effects of such flows are not hard to discern.

The drug money is a significant part of the illicit money entering Kenya from fraudulent trade invoicing, crime, corruption and shady business activities, which by 2013 roughly equalled 8% of Kenya’s economy. Much of this money ends up in the country’s real estate, where it has inflated prices and made decent and safe housing unaffordable for the vast majority of the urban population.

The drug money is a significant part of the illicit money entering Kenya from fraudulent trade invoicing, crime, corruption and shady business activities, which by 2013 roughly equalled 8% of Kenya’s economy

Neither has the war on drugs spared populations in the West where it has contributed to mass incarcerations, and the virtual criminalisation of large segments of the citizenry. In the US, the war on drugs mostly targets minorities, particularly African Americans who, though not more likely than others to use or sell drugs, are much more likely to be arrested and incarcerated for drug offenses.

Further it has led to the increased militarization of police forces and new police powers such as asset seizures – meant to turn drug dealers’ ill-gotten gains against them – have in many cases undermined civil liberties. As detailed in The Economist, in the wake of a sharp rise in drug-related violence in the US, in 1990 Congress ‘allowed the Defence Department to transfer military gear and weapons to local police departments if they were deemed suitable for use in counter-drug activities.’

A WAR DOOMED FROM THE START

The war on drugs was perhaps doomed from the start as it was built on dubious philosophical, moralistic and even racist foundations and made assumptions that those bearing the most costs would continue to be happy to do so.

In 1875, it was racist hysteria over accounts of Chinese immigrants luring white women into opium dens that led to California passing the first anti-opium law

International drug control efforts can be traced back to the 1912 Hague Opium Convention that entered into force in 1919 and targeted opium, morphine, cocaine and heroin. Over the next half century, a series of international agreements would expand the scope of the anti-drugs effort to include restrictions on cannabis (1925), synthetic narcotics (1948) and psychotropic substances (1971). Drug trafficking was made an international crime in 1936.

The treaties negotiated prior to 1945, while imposing some restrictions on exports, did not actually criminalise drug use or cultivation or, indeed, the substances themselves. Rather, despite fierce debate, they were predominantly concerned with regulating the licit trade and ensuring the availability of a range of drugs for medical purposes. (Heroin was created by chemists working for the German company Bayer, and marketed alongside aspirin as a remedy for coughs, colds and ‘irritation’ in children. Cocaine, was first isolated in 1859 by German chemist Albert Niemann, made its debut in toothache drops marketed to children and was famously an ingredient in Coca-Cola.)

While the US increasingly pushed the issue of recreational and traditional use of drugs, it was primarily dealt with through attempts to prevent the leakage of licit drugs into illicit channels. In 1925, the two most ‘prohibitionist’ countries at the time, US and China, withdrew from negotiations on the International Opium Convention, because they considered it insufficiently restrictive.

The US, then in the throes of domestic alcohol prohibition, had hoped to entice the rest of the world into quitting, not just drugs, but booze for good. In fact, the aim of the US was to extend its prohibitive domestic laws across the globe. It was the US that had convened the 1909 Shanghai Opium Commission – which laid the groundwork for the 1912 convention, just 15 days after Congress had passed the Act to Prohibit the Importation and Use Of Opium for Other Than Medicinal Purposes, the first in a long line of prohibitive drug legislation. However, it was opposed by France, Great Britain, Portugal and the Netherlands, whose colonies were then turning a handsome profit from legal as well as illicit sales of opiates to Europe and the US.

According to the report America’s Habit: Drug Abuse, Drug Trafficking, & Organized Crime, issued by the President’s Commission on Organised Crime in 1986, most of the opium reaching the US in the 1920s and 30s was coming from France, Asia and the Mideast.

US efforts to interdict the supply of cocaine – which the US had outlawed in 1914 – and to a limited extent, opium, also included trying to entice its southern neighbours to adopt similar policies. However, few were interested. As detailed by Maria Celia Toro in her book, Mexico’s ‘War’ On Drugs: Causes and Consequences, ‘Those early attempts to enlist the co-operation of Latin American governments in suppressing the drug market were for the most part unsuccessful.’ Some were happy to sign agreements but balked at actually implementing anti-drug policies.

A LUCRATIVE, ANCIENT AND LEGAL COCA LEAF MARKET

Further, Peru and Bolivia, then the largest producers of coca leaf and whose participation Washington prized most, ‘had little interest in curtailing a lucrative, ancient and legal coca leaf market.’ Only Mexico accepted. But not because it particularly agreed with the policy. According to Toro, ‘Rather than trying to appease the US or reduce drug consumption at home, Mexico was trying to influence US conduct regarding antidrug law enforcement.’

In 1916, the Mexican Revolution was still raging. The country had just emerged from a year-long civil war and was still battling an insurgent guerrilla group. The last thing it needed was conflict along its border. And border conflict is exactly what the US bans on cocaine and opium (and later alcohol) created. ‘What at the beginning of the century constituted legal exports of minimal value soon became a significant smuggling activity,’ writes Toro. Citing historian F. Arturo Rosales, Curtis Marez in his book Drug Wars: The Political Economy of Narcotics, describes it thus: ‘In the 1910s and 1920s, liquor and drug wars involving competing smugglers and US police … rivalled the border battles fought by political factions during the revolution. These contraband wars left numerous smugglers and border agents dead.’

But by joining the American prohibition bandwagon beginning with a ban on opium imports in 1916, Mexico created the very conditions for the violence and instability it was trying to avoid. Toro writes that smuggling ‘later turned into a black market problem after different Mexican administrations outlawed trade and production of opium and other drugs.’

John Ehrlichman: We knew we couldn’t make it illegal to be either against the war or black, but by getting the public to associate the hippies with marijuana and blacks with heroin, and then criminalising both heavily, we could disrupt those communities

Further, a distinctly racist attitude and fears of economic competition by minority groups informed US approaches to the regulation of drugs. In 1875, it was racist hysteria over accounts of Chinese immigrants luring white women into opium dens that led to California passing the first anti-opium law. Cocaine was similarly criminalised for its association with black communities. The white community’s economic fears of freed slaves gaining a foothold in the economy following the US civil war provided fertile ground for racist rumours of a drug that had the capacity to incite them to violence. With the New York Times running headlines warning ‘Negro Cocaine Fiends are a New Southern Menace,’ New Orleans became the first city to enact laws against cocaine in the early 1900s and the trend quickly spread. The banning of marijuana was a reaction to the influx of low-wage Mexican immigrants in the 1920s, sparked in part by the Mexican revolution. With the Great Depression creating massive unemployment, the ‘evil weed’ was the subject of lurid national campaigns that linked it to violence, crime and other socially deviant behaviours. By 1931, some 29 states had outlawed marijuana.

HOW PROHIBITION INCENTIVISED VIOLENCE AND DRUG SUPPLY

There are a number of things to note here. First, the US has been the primary driving force behind global prohibition efforts and has essentially sought to use international conventions to impose its drug puritanism on the globe and to export the problems drugs caused at home. Second, there was little appetite in the West, at least in Europe, for criminalising drugs when they were the countries that were benefiting from their illegal trafficking. Third, other countries initially resisted US-style prohibition and when Mexico caved in, it was for reasons other than the utility of prohibition in fighting drugs. Fourth, the effect of prohibition on drug prices immediately incentivised both violence and increased drug supply. In fact, the President’s Commission on Organised Crime acknowledged, ‘Heroin trafficking in this country first became big business in the 1920’s.’ And finally, the prohibition of drugs is fuelled at least as much by economic fears and cultural prejudice as by concerns over health effects and the social harm they cause.

All these trends have come to define the international drugs war in the decades after World War II. The US emerged from that conflict as the most powerful country in the world and the global prohibition of drugs was embedded into the DNA of the post-war order it crafted. However, unlike 20 years prior, it could now apply the necessary pressure to impose it on other countries via the United Nations system.

In 1961, the US initiated the United Nations Single Convention on Narcotic Drugs, which sought to consolidate the various international agreements into one regime governing the global drugs trade. But more than that, it included provisions that were not in previous treaties including controls over the cultivation of plants from which narcotics are derived, which placed a heavy burden on producer countries in the developing world where the cultivation and widespread traditional use of opium poppy, coca leaf and cannabis were concentrated at the time. The Single Convention institutionalised prohibition and targets for abolishing traditional and quasi-medical uses of opium, coca and cannabis within 25 years. The Convention was also notable, for it was the first time that penal provisions were included in a widely accepted international drug control treaty. Further it required countries to regulate not just production, manufacture and export, but also possession of drugs.

A decade after the Single Convention was signed, a parallel process started to emerge with the signing of the1971 Convention on Psychotropic Substances. Replicating the trends witnessed during the pre-war treaties, Western countries attempted, according to the President of the International Association of Penal Law, Cherif Bassiouni, ‘to impose strong controls over the cultivation, production and traffic of natural drugs originating in the developing countries, [but] were unwilling to impose the same types of control over their own chemical and pharmaceutical industries.

THE TARGET: ANTI-WAR HIPPIES AND BLACKS

That same year, President Richard Nixon famously declared what came to known as the ‘war on drugs’ in an address to Congress. Drug abuse, he said, was America’s ‘public enemy number one,’ despite the fact that consumption was not any worse than at any other time in history. What Nixon and his henchmen didn’t tell the public was that the ‘war’ was little more than a cynical ploy to fire up their political base using the tried and tested methods of the 1930s, and to curtail domestic dissent. John Ehrlichman, Nixon’s domestic policy chief who served time for his role in the Watergate scandal, made this stunning admission to journalist Dan Baum in 1994: ‘The Nixon campaign in 1968, and the Nixon White House after that, had two enemies: The anti-war left and black people. You understand what I’m saying? We knew we couldn’t make it illegal to be either against the war or black, but by getting the public to associate the hippies with marijuana and blacks with heroin, and then criminalising both heavily, we could disrupt those communities. We could arrest their leaders, raid their homes, break up their meetings, and vilify them night after night on the evening news. Did we know we were lying about the drugs? Of course we did.’

Seeing its political effectiveness, subsequent US presidents prosecuted the fake war, culminating in Ronald Reagan, who launched a period of mass hysteria over crack cocaine in the 1980s. As in the 1930s, the media painted crack users as violent, poor urban and most significantly, black. Crack and powder cocaine are the same drug. Crack is basically powder cocaine mixed with water and baking soda and the person who has the crack actually has less pure cocaine overall. For this reason, it is cheaper and preferred by low-income users. However, Congress, driven by the racist hysteria, concluded that crack was indeed the more dangerous drug and deliberately imposed much harsher penalties. The ‘Negro Cocaine Fiends’ of half a century before had become ‘crack-fiends,’ and mothers of ‘crack-babies.’ In three decades, the country quadrupled its prison population — all with no change in the rates of crime or drug use.

JUST LEGALISE IT, FOR GOD’S SAKE

Still, as discussed earlier, it has been producer and transit nations that have paid the highest price for the war of drugs. But many have begun balking at this and are openly questioning whether prohibition has been worth the cost. In 2009, three former presidents, Ernesto Zedillo of Mexico, César Gaviria of Colombia and Fernando Henrique Cardoso of Brazil declared that prohibition was simply not worth it. ‘Prohibitionist policies based on eradication, interdiction and criminalisation of consumption simply haven’t worked,’ they said. ‘The revision of US-inspired drug policies is urgent in the light of the rising levels of violence and corruption associated with narcotics.’

It is not surprising; Latin America, the region that perhaps more than any other, has suffered the consequences of prohibition. To understand how they feel, consider this thought experiment related by Daniel Mejia and Pascual Restrepo in their essay, Why Is Strict Prohibition Collapsing? ‘Suppose for a moment that all cocaine consumption in the US disappears and goes to Canada. Would the US authorities be willing to confront drug trafficking networks at the cost of seeing the homicide rate in cities such as Seattle go up from its current level of about five homicides per 100,000 individuals to a level close to 150 in order to prevent cocaine shipments from reaching Vancouver? If your answer to this question is ‘perhaps not,’ well… this is exactly what Colombia, Mexico and other Latin American countries have been doing over the past 20 years.’

Across the continent, many are rethinking their approach to drugs and rolling back prohibition. In 2010, Argentina’s Supreme Court ruled it unconstitutional to punish people for personal use of marijuana. Mexico has legalised limited amounts of all drugs for personal use. But it is probably in Europe that the greatest challenges to the prohibition orthodoxy have emerged.

The Dutch famously decriminalised cannabis in the early 70s and it has been available for recreational use in certain ‘coffee shops’ since 1976. Though technically illegal, possession of up to 5 grams for personal use is decriminalised. Italy too has decriminalised possession of less than half a gram of most illegal substances. Switzerland, Germany, and the Netherlands have successfully made heroin legally available to addicts through networks of government-run dispensaries.

However Portugal provides the most extensive, and most successful, example of decriminalisation. In July 2001, the country decriminalised all drugs, including cocaine and heroin. As is the case in several other European jurisdictions, purchase and possession for personal use and drug usage itself are still legally prohibited, but are dealt with as administrative, not criminal violations. Drug trafficking, however, is still a serious criminal offense.

No other country has gone so far, and Portugal is still the only country in the EU with a law explicitly declaring drugs to be ‘decriminalised.’ The results have been jaw-dropping. The expected tsunami of drug tourists never arrived. In a white paper for the libertarian think tank Cato Institute, constitutional lawyer and journalist Glenn Greenwald cites empirical data indicating that ‘decriminalisation has had no adverse effect on drug usage rates in Portugal, which, in numerous categories, are now among the lowest in the EU, particularly when compared with states with stringent criminalisation regimes.’

Dan Baum writes that ‘the lifetime prevalence of adult drug use in Portugal rose slightly, but problem drug use — that is, habitual use of hard drugs — declined after Portugal decriminalised, from 7.6 to 6.8 per 1,000 people. Compare that with nearby Italy, which didn’t decriminalise, where the rates rose from 6.0 to 8.6 per 1,000 people over the same time span. Because addicts can now legally obtain sterile syringes in Portugal, decriminalisation seems to have cut radically the number of addicts infected with HIV, from 907 in 2000 to 267 in 2008, while cases of full-blown Aids among addicts fell from 506 to 108 during the same period.’

Prohibition, and its misbegotten offspring, the war on drugs, have failed to bring about the promised drug-free world and have instead visited misery upon millions of the poorest people on the planet

Prohibition is under attack even in the US itself, though to a much lesser extent. Several states, including the District of Columbia, have allowed a legal trade in marijuana though at the federal level it remains prohibited. ‘We’re confronted now with the fact that the US cannot enforce domestically what it promotes elsewhere,’ a member of the UN’s International Narcotics Control Board, which monitors international compliance with the conference’s directives, told Baum.

GOOD RIDDANCE TO BAD LAWS

It is clear that prohibition, and its misbegotten offspring, the war on drugs, have failed to bring about the promised drug-free world. That they have instead visited misery upon millions of the poorest people on the planet is a fact that is only now starting to dawn on global policy makers. However, there is no consensus on how to move forward and in places like China and various Muslim nations where drug offences still attract draconian sanctions including the death penalty, there is little to suggest a changing mindset.

Still, the growing recognition of the failure has opened up the policy space and given reformers the room to imagine different approaches to dealing with drugs. No country is yet willing to experiment with full legalisation, but a broad spectrum of policy choices now exists under the banners of decriminalisation and de-penalisation (which eliminates jail terms for drug offences). One thing we can say for sure – the days of a simplistic, moralistic, one-size-fits-all solution to the challenge posed by the availability of drugs are very much over. Good riddance!

Mr. Gathara is a social and political commentator and cartoonist based in Nairobi.

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ALL THE PRESIDENT’S MEN: Uhuru Kenyatta’s proposed Cabinet raises serious constitutional and legal questions

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ALL THE PRESIDENT’S MEN: Uhuru Kenyatta’s proposed Cabinet raises serious constitutional and legal questions

On January 5, 2017 President Uhuru Kenyatta started the process of constituting his second-term Cabinet by naming some of his nominees. The President’s announcement is unusual in two significant respects. First, it was a partial list; he only announced nine nominees even though the Constitution demands a minimum of 14 and allows him to name up to 22 Cabinet Secretaries (his last Cabinet had 18).

Second, the President said he was “retaining” some Cabinet Secretaries and as such he would not be sending the names of all his Cabinet nominees to the National Assembly for vetting. His statement implied an existing Cabinet whose term continued uninterrupted through the 2017 general elections even though a December 2015 High Court decision held that the tenure of all appointed members of Cabinet ended on August 8, 2017. In attempting to retain some members of the previous Cabinet and exempting them from National Assembly approval, President Kenyatta is acting in contravention of the High Court judgment and the law. (It is also interesting to note that all the Cabinet Secretaries that the President “retained” are men, which also raises the issue of gender parity, which the Constitution explicitly encourages.)

Nominating Cabinet Secretaries and constituting a Cabinet is a constitutional obligation of the President contained in Articles 129, 130, 131 and 132. Article 152(1) defines the Cabinet as the President, the Deputy President, the Attorney General and not fewer than fourteen and not more than twenty-two Cabinet Secretaries. Note also that Article 152(1) provides that there shall be a “minimum” number of Cabinet Secretaries, indicating that the President has no discretion to have zero or no Cabinet Secretaries. The constituting of a Cabinet is, therefore, a mandatory function of the President, which must be performed as required by the Constitution.

In attempting to retain some members of the previous Cabinet and exempting them from National Assembly approval, President Kenyatta is acting in contravention of the High Court judgment and the law.

Article 129 of the Constitution provides that all “executive authority is derived from the people of Kenya and shall be exercised only in accordance with this Constitution.” This provision reminds the executive that executive power is delegated and has limited authority: it is delegated by the people and may not be legally exercised outside of the limits set by Constitution.

Article 130 defines the national executive as including the President, the Deputy President and “the rest of the Cabinet”, thereby emphasising that the Cabinet is integral to the national executive. Article 131 provides that the president exercises executive authority “with the assistance of the Deputy President and Cabinet Secretaries”, emphasising the necessity of the Cabinet as an instrument for the exercise of executive authority. Additionally, Articles 131(2a) and 131(2e) obligate the President to respect and uphold the Constitution and ensure the “rule of law”.

Furthermore, Article 132(2) explicitly vests powers to appoint the Cabinet in the President, providing that s/he “shall nominate, and with the approval of the National Assembly, appoint” Cabinet Secretaries in accordance with Article 152.

So, while the President has the power to nominate he cannot, without the approval of the National Assembly, appoint anyone to the Cabinet. In establishing the Cabinet, the President must follow the process in the Constitution and in law, which includes relevant judicial decisions.

Judicial decisions regarding the process of constituting a Cabinet would, therefore, apply to the President as he undertakes this function. On December 20, 2016, the Constitutional and Human Rights Division of the High Court in Petition 566 of 2015[1] held that the Cabinet was unconstitutional, as its composition violated Article 27(8) of the Constitution that says that “the State shall take legislative and other measures to implement the principle that not more than two-thirds of the members of elective or appointive bodies shall be of the same gender”.

The High Court was asked to address two issues: the constitutionality of the process of constituting Cabinet and of the composition of Cabinet. In addition to finding the Cabinet unconstitutional, the High Court found that “the actions of the President and the National Assembly…in nominating, approving and appointing the Cabinet” were unconstitutional. As such, the process of establishing the Cabinet and the resulting Cabinet were both declared unconstitutional.

Nothing precludes the President from naming all, some or none of the members of the previous Cabinet; however, all proposed members of the Cabinet, other than the Deputy President, must be nominated again and their names must be submitted to the National Assembly for approval prior to their appointment.

However, the High Court, citing public interest, suspended the judgement for “a period of eight months or until such a time a new Cabinet will be constituted either by the present government or by the new government to be elected into office in August 2017.” The effect of this judgement was that it provided temporary legal permission for the Cabinet’s continued existence, with such permission set to automatically expire if the President named a new Cabinet or if a general election was held.

Therefore, the term for all appointive members of the Cabinet ended on August 8, 2017 by judicial order. As such, the President must, by law, name all appointive members of his proposed Cabinet afresh (a minimum of 15 and a maximum of 26, including the Attorney General). Nothing precludes the President from naming all, some or none of the members of the previous Cabinet; however, all proposed members of the Cabinet, other than the Deputy President, must be nominated again and their names must be submitted to the National Assembly for approval prior to their appointment.

The decision of the High Court in Petition 566 of 2015 found that both the President and National Assembly had violated their obligations in the process of constituting a Cabinet (nominating, approving and appointing the last Cabinet). The High Court, in holding that the National Assembly had failed to perform its role in approving Cabinet nominees, found that the National Assembly must “…apply a strict scrutiny in approving of any action of the executive and where the action involves appointment to public posts a most searching examination in all aspects must be invoked by the National Assembly.” Therefore, the National Assembly cannot be a rubber stamp of Presidential nominees but must exercise the highest legal standard in the vetting and approval, or rejection, of executive nominees.

The President hasn’t violated the law by providing only a partial list of nominees. However, by failing to submit the names of all proposed Cabinet nominees to the National Assembly for approval, and asserting the existence of a valid Cabinet after August 8, 2017, the President is acting in deliberate contravention of the Constitution and the law.

The High Court was explicit that in some cases it is the role of the National Assembly to correct the President: “The National Assembly must exercise that perfect overseer role and tap the President on the shoulder where he is about to slip.” The National Assembly, therefore, has a constitutional obligation to remind the President that all proposed nominees must undergo the entire process of nomination, vetting and approval by the National Assembly prior to their appointment. In addition, the High Court clarified that the National Assembly must reject a proposed Cabinet whose composition would violate the law.

The President hasn’t violated the law by providing only a partial list of nominees. However, by failing to submit the names of all proposed Cabinet nominees to the National Assembly for approval, and asserting the existence of a valid Cabinet after August 8, 2017, the President is acting in deliberate contravention of the Constitution and the law. These actions are especially worrisome considering the opposition’s refusal to recognise the President as legitimately elected. By his actions, the President is providing additional reasons for challenging his legitimacy.

With his announcement, the President has sent important political and legal messages about his second term. It is surprising he is trying to evade the National Assembly given the Jubilee Party enjoys a majority in both houses of Parliament. It would appear that, despite a parliamentary majority, the President is not confident that his nominees will be confirmed by the National Assembly. This anxiety may stem from Jubilee party politics, including the jostling for the 2022 succession, and betrays fears that these intra-party conflicts would play out in the National Assembly approval process. It is also possible that the President may be concerned about the opposition’s ability to utilise parliamentary processes to delay, block or undermine the eventual approval of his Cabinet nominees.

It would appear that, despite a parliamentary majority, the President is not confident that his nominees will be confirmed by the National Assembly.

For an administration whose legitimacy ultimately rests on a judicial decision, the President’s wilful disregard of a court order is also evidence that the battle with the Judiciary continues. It is an assertion of executive exceptionalism saying that the decisions and actions of the President and executive are effectively beyond judicial review. It is troubling that the President isn’t averse to confrontation with the judicial branch, and courting constitutional crises, given the just concluded experiences of the electoral period and the ongoing political uncertainty.[2]

The message is clear: This is not business as usual. If successful, the attempt by the President to bypass Parliament and nominate and appoint a Cabinet in contravention of the Constitution would result in the imposition of an unconstitutional and illegitimate national executive.

An unconstitutional national executive would create unprecedented uncertainty as to the legality of its national and international actions. It would also exacerbate existing political conflicts while signalling to other parties that it is acceptable to resort to extra-constitutional means to resolve political and other conflicts.

By wilfully weakening so many institutions – the Judiciary, the Cabinet, the National Assembly and the Constitution – in a single swoop, the executive is potentially triggering a cycle of political conflict and social instability.

Unchecked, the failure by the President and the National Assembly to accept the constitutional limitations of their authority will lay the foundation for a systematic breakdown in the rule of law. By wilfully weakening so many institutions – the Judiciary, the Cabinet, the National Assembly and the Constitution – in a single swoop, the executive is potentially triggering a cycle of political conflict and social instability. The President and the National Assembly would be best advised to reverse the current course and ensure strict compliance with the Constitution in the process of establishing a new Cabinet.

 

[1] Marilyn Muthoni Kamuru & 2 others v Attorney General & another [2016] eKLR http://kenyalaw.org/caselaw/cases/view/129670/

[2] The August 8, 2017 presidential election was nullified by the Supreme Court on September 1, 2017. Uhuru Kenyatta won the subsequent election on October 26, 2017. This election was also challenged but this time the Supreme Court, on November 14, 2017, upheld his election paving the way for his assumption of office on November 28, 2017.

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(D)EVOLVED HEALTHCARE: Makueni’s trailblazing experiment in providing universal health coverage

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(D)EVOLVED HEALTHCARE: Makueni’s trailblazing experiment in providing universal health coverage

Universal health coverage is by many measures considered to be the Holy Grail of delivering quality healthcare. In fact, achieving universal health coverage by 2030 – ensuring that all people have access to the health services they need without the risk of financial hardship – was included as part of the Sustainable Development Goals (SDGs) adopted by the United Nations in 2015. Writing a year later, Marie-Paule Kieny, Assistant Director-General at the World Health Organization (WHO), described it as “the linchpin of the health-related SDGs; the one target that, if achieved, will help deliver all the others by providing both population- and person-centred high-quality services that are free at the point of delivery and designed to meet the realities of different people’s lives.” WHO estimates that about 150 million people around the world suffer financial catastrophe annually from out-of-pocket expenditure on health services, while 100 million people are pushed below the poverty line.

According to the 2013 Kenya Household Health Expenditure and Utilisation Survey, medical expenses account for more than 40 per cent of non-food bills in over half the counties in the country.

In Kenya, though access to quality healthcare is a constitutional right, the scarcity of quality public and private health facilities, as well as the high cost of care even when it is available, means that universal health coverage remains little more than words on paper for much of the population. President Uhuru Kenyatta has made achieving universal health coverage by 2022 a major part of his second term agenda and indicated in his inauguration speech that this would be achieved by expanding coverage under the National Health Insurance Fund (NHIF). The president said that half a century after it was established in 1966, the Fund has only attracted 6.8 million beneficiaries. The World Bank estimates that only a fifth of Kenyans have any sort of medical cover, which means that as many as 35 million Kenyans are vulnerable to the financial devastation occasioned by a medical emergency.

Related stories: Behind the Makueni Healthcare Revolution

When illness eventually strikes, it takes a huge financial toll. According to the 2013 Kenya Household Health Expenditure and Utilisation Survey, medical expenses account for more than 40 per cent of non-food bills in over half the counties in the country. In fact, direct payments by citizens accounted for a third of the country’s total health expenditure in the same year, according to Dr. Izaaq Odongo, the head of the Department of Curative and Rehabilitative Health Services at the Ministry of Health, with the balance being made up by government (36 per cent), donors (20 perc ent) and employers (10 per cent). As a result, many Kenyans are forced to resort to selling off property, relying on networks of relatives and friends, or even making desperate appeals on social media to raise the necessary funds. Hence the large, and seemingly never-ending appeals all Kenyans make when clearing medical bills. Despite this, according World Bank Country Director, Diarietou Gaye, the number of those thrust into poverty by medical expenses is close to one million.

Kenya’s network of public healthcare facilities has traditionally been hierarchically organised into 6 levels, with the lowest unit being community health workers embedded within communities. At level 2, dispensaries and clinics provide the link between community-based healthcare and the formal health system. Together with level 3 facilities – health centres, maternity clinics and nursing homes – these make up the primary healthcare units. Levels 4-6 are sub-county, county and national referral hospitals. It is at the lower levels that the majority of people interact with the healthcare system and it especially at the primary healthcare facilities that national government interventions with regard to cost have been most consequential.

Since independence, Kenya has blown hot and cold on the abolition of user fees and decentralisation, both of which, given the economic circumstances of most Kenyans as well as the devolution introduced by the 2010 constitution, are prerequisites for universal health coverage. In 1965, according to the paper “Reforming health systems: The role of NGOs in decentralization – lessons from Kenya and Ethiopia by Richard G. Wamai of the Harvard School of Public Health, “a free access policy abolished the KSh5 co-payment operative in the colonial healthcare system… [and] proposed expanding coverage through centralizing the delivery responsibilities from the counties and municipalities to the Ministry of Health”. Eighteen years later, the provision of health services was again decentralised as part of the District Focus for Rural Development programme and in December 1989, user fees were reintroduced in an effort to inject money into crumbling health facilities. The “cost-sharing” programme was part of a comprehensive health financing strategy that also included social insurance, efficiency measures and private sector development. The fees would, the argument went, generate additional revenue, incentivise use of low-cost primary healthcare services rather than the more expensive referral facilities and improve targeting of resources by reducing unnecessary demand.

Still, implementation problems led to the suspension of the policy less than a year later though it was gradually reintroduced in 1991. A 1996 study found that despite revenue increases and facilities being allowed to budget for three-quarters of the money they remitted to the districts, this did not necessarily result in improved quality of care because the funds were used to offset a fall in government funding for basic care. As evidence mounted that despite a waiver policy to protect the poor and children under five, user fees were proving to be a significant barrier to access, the government – in what came to be known as the 10/20 policy – again reversed course and in 2004 eliminated all fees in dispensaries and health centres, save for a minimum registration fee of KSh10 and KSh20, respectively. By 2007, it had instituted a maternity waiver allowing for free deliveries in public health facilities and introduced the Health Sector Service Fund (HSSF) to compensate these facilities for lost revenue.

Since October 2014, Makueni has been offering its one million residents free healthcare across all its public facilities, including county and sub-county hospitals.

However, as a study published in 2015 showed, this was largely ignored by health facilities for whom user fees represented almost all the cash income they used to cover basic operating costs. As a result, most patients ended up being charged for more than the specified amount while very few received waivers. In 2013, the government abolished all user fees in public dispensaries and health centres and allocated KSh 700 million to the HSSF.

The picture was further complicated by the fact that health is one of the services devolved by the 2010 constitution. This means that while the national government is still responsible for policy and managing two Level 5 referral facilities, namely, the Kenyatta National Hospital and the Moi Teaching and Referral Hospital, the bulk of public healthcare in Kenya is delivered in facilities run by county governments. A history of skewed investment that marginalised some counties, as well as the lack of policy coordination between the various counties and between the counties and the national government, have left a rather confused picture of access to healthcare across the country.

There have, however, been some wins. For the first time since independence, residents of historically marginalised counties, such as Lamu and Mandera, now have access to Caesarean section procedures within their county. There have been problems too: from the controversy arising from the national government forcing counties to lease equipment they neither wanted nor had the resources to use, to ambulance purchases that seemed more about burnishing a governors’ image than delivering care to constituents, to the First Lady’s much trumpeted Beyond Zero initiative that today is in shambles, with many of the facilities either abandoned or turning patients away.

The Makueni model

Nonetheless, an ambitious experiment in the provision of universal health coverage is underway in Makueni, a county that borders Kajiado, Machakos, Kitui and Taita-Taveta counties. Since October 2014, Makueni has been offering its one million residents free healthcare across all its public facilities, including county and sub-county hospitals. It is a model well worth examining if President Kenyatta is serious about expanding access to medical care across the country.

“When we took over in 2013, we realised that 40 per cent of the people of Makueni would sell land and exhaust family income to pay medical bills for relatives,” says Makueni’s Governor, Prof. Kivutha Kibwana. Given that medical services in dispensaries and health centres were already free and paid for by the national government, the county government figured that if it doubled the 100 million that its Level 4 sub-county hospitals were collecting in user fees, it could offer free, across the board healthcare to its residents.

Thus MakueniCare, as the county government has labelled it, was conceived. It piggybacks on the national government’s free primary healthcare policy and the national coverage provided by NHIF to plug the gap in between with the aim of providing seamless cover across all public health services.

Thus, for an annual subscription of KSh500 per household, which covers parents and all their children under the age of 18 years (or up to 24 years in case of students), Makueni residents can access free primary healthcare at dispensaries and health centres courtesy of the national government, free treatment, including inpatient care and ambulatory services, at the 13 level 4 hospitals within the county paid for by the county government, and, if they’re subscribed to NHIF, free care at referral facilities outside the county. The Level 4 hospitals provide free care and bill the county government, which also supplies them as well as the primary healthcare facilities with drugs, equipment and medical staff.

LISTENBehind the Makueni Healthcare Revolution

However, universal health coverage is more than eliminating out-of-pocket expenditure; it is also about ensuring access to healthcare. According to Dr. Cyrus Matheka, the head of the county’s Health Promotion Services, MakueniCare took two years to plan and was preceded and piloted by a programme offering free care to those over the age of 65 without a requirement for registration. Within that time, the county government invested in expanding facilities, from dispensaries and health centres to sub-county hospitals, and has continued to do so. In under five years, it has more than doubled the number of health facilities built by the colonial and national governments over the last 50 years. Apart from an additional 113 dispensaries and health centers, the county now boasts 13 Level 4 hospitals and has employed 160 doctors, compared to just 38 doctors and 3 hospitals in 2013. At KSh2.3 billion, health is the county’s single largest budget item.

All this means that the county can offer a wide array of free services to residents, from hospital admission, surgical procedures, X-ray imaging, laboratory testing, to dental and counselling services. Even in death, patients benefit from 10 days of free mortuary services. However, the cover does not apply to specialised care and equipment that are not available at the hospitals, including dialysis for patients suffering from kidney failure, intensive care units, implants, as well as auxiliary devices, such as wheelchairs.

Insurance schemes are essentially funds where people pay into a pool when they are healthy – in this case through both taxes and direct contributions – which they can draw on when sick. The Makueni recruitment model reversed this, thus courting adverse selection, or the tendency of people to get insurance only when they are seriously sick, which can consume huge resources.

Dr. Andrew Mutava Mulwa, the County Minister of Health, estimates that MakueniCare covers at least 93 per cent of the county’s healthcare needs. He says it is built on a platform of ensuring adequate provision of primary care by increasing facilities, improving services and ensuring that medicines are available. “Someone who is sorted at the dispensary will not find their way to the hospital,” he says, adding that only 35 per cent of patients in Makueni need to seek care in the secondary institutions covered by MakueniCare or in tertiary referral facilities outside the county.

Challenges

However, the programme has had its share of challenges. The first, rather surprisingly, was low uptake. In March last year, when The Elephant visited Makueni, less than 10,000 households had signed up for the programme out of a potential 200,000. The scheme had a mere 30,000 beneficiaries. Part of the reason for this was the decisions taken to make the coverage voluntary, to register subscribers at county hospitals when they sought care and to make the cover active immediately upon registration and payment. Initially there did not seem to be much of a public campaign to get residents to register: there were no posters announcing the programme in all the hospitals The Elephant visited and, despite officials claiming to advertise on vernacular radio, most residents we spoke to had not heard about MakueniCare.

Julia Musau of Kaselia village, who we met at the Tawa Sub-County Hospital, is a typical case. She had been unaware of the scheme until a month prior to our visit. She found out about it after she took a patient to the Makueni General Hospital in Wote, and had difficulty settling the bill. It was another woman whose child had been admitted there who told her about MakueniCare. That was when she enrolled her family immediately.

However, even those who know about it opt to wait till they or their dependents get ill to register since there is no penalty as the cover is activated immediately and registration is done at the hospitals, anyway. This made registration vulnerable to industrial action by medical personnel. For example, during the nationwide strikes, first by doctors and then nurses, fewer people went to the hospitals as there was little expectation of receiving care. In any case, According to Dr. Matheka, less than 5 per cent of the county’s population seeks medical care at any one time, and many of these are over the age of 65, a group that already enjoys free care. This means registration will inevitably be slow unless there is a serious epidemic.

The Makueni model also faces other challenges. Insurance schemes are essentially funds where people pay into a pool when they are healthy – in this case through both taxes and direct contributions – which they can draw on when sick. The Makueni recruitment model reversed this, thus courting adverse selection, or the tendency of people to get insurance only when they are seriously sick, which can consume huge resources. This brings into question the sustainability of the programme. However, in more recent times, according to Wambua Kawive, a former Makueni County Minister, the county government has ramped up its recruitment efforts and has now launched a mass registration exercise targeting 100,000 registrations by the end of the year.

Another challenge the system needed to cope with was an initial influx of patients into hospitals once the policy was implemented. Tawa Sub-County Hospital Administrator, Justus Kilonzo, told The Elephant that the workload at the hospital had increased, which necessitated the recruitment of more staff. Further, there has been an influx of people from neighbouring counties who sought to take advantage of the system. Geoffrey Kirui, the Health Administrative Officer at Makindu Hospital next to the busy Nairobi-Mombasa highway, spoke about having to filter out patients from other counties, especially Taita Taveta, Kajiado and Kitui. Still, trying to determine someone’s place of residence using identification cards, birth certificates and a ward administrator’s or chief’s letter is an inexact science and one gets the sense that this too was not well thought through.

MakueniCare also faces a hazard where, having paid the subscription, patients will head to the hospital for even minor complaints that can be addressed at lower levels, adding stresses to the system.   They may also engage in risky behaviour knowing that there is the safety net of free care. Such behaviour may be inadvertently complemented by a shift in focus from preventative to curative care by hospitals seeking to generate more revenue and county officials seeking to make political hay from the scheme.

The latter is particularly important. It is crucial to note that MakueniCare is undergirded by an administrative structure that was created to deliver a different type of healthcare where users contributed directly. Suddenly eliminating such fees can have unintended deleterious effects on both the facilities and their ability to deliver quality services. One study on the effect of the removal of user fees found that although the revenue generated was generally low, it served to ensure that facilities met the costs of services and salaries for support staff not directly funded through the government’s budget.

There is also a legitimate fear that the political priority placed on MakueniCare may be diverting resources from primary and preventative care at the health centre and dispensary levels.

In Makueni, a doctor-turned-administrator who did not want to be named told The Elephant that MakueniCare had created a mismatch of skills, with doctors having to do administrative tasks rather than attend to patients. When MakueniCare was first proposed, the doctor told us, there was much resistance from hospitals, which were concerned about the lack of a clear system as well as lack of necessary training and preparation. “Why the rush to launch in October 2016?” asked the doctor, concluding that the timing had largely been influenced by the interests of county politicians vying in the August general election.

MakueniCare essentially transfers control over funds and decision-making away from hospitals to bureaucrats at county headquarters in Wote town. Hospitals not only have to worry about delays in receiving reimbursements for resources spent in providing care – which can happen if, for example, the national government delays disbursements to the county governments – but also about losing their largely autonomous decision-making power on the equipment they need to procure and the staff they need to recruit. Similarly, where and when new facilities are built may reflect more the political priorities of those running the county government rather than the genuine health needs of the populace. Lastly, as with all government-driven procurement decisions, the spectre of corruption is never far away.

There is also a legitimate fear that the political priority placed on MakueniCare may be diverting resources from primary and preventative care at the health centre and dispensary levels. Ilatu dispensary, which was built by the Kenya Pipeline Company and opened in March 2014, may be a case in point. In September 2015, the facility was handed over to the county government that provided staff and equipment. Adjacent to a settlement scheme, it is the busiest facility in Kibwezi West and offers outpatient, maternal and child health, family planning as well as HIV testing and counselling services. The staff of two nurses and one laboratory technologist attend to between 70 and 100 patients every day. The county government is upgrading it to a health centre and building a 40-bed inpatient facility.

Jacinta Mbula is the nurse in-charge. She says staffing and resources are big challenges. When The Elephant visited the facility, her fellow nurse was on maternity leave and she was running the facility on her own. She said that there is only enough accommodation for one nurse to stay at the facility and take care of overnight maternity cases, and that nurse still has to report to work the next day. Although they receive adequate supplies of essential medicines from the county government, they do sometimes run out of non-essential drugs.

Further, she only gets KSh60,000 – “peanuts” – every quarter from the county government to pay casual labourers and purchase essential supplies. She currently employs one casual worker and one watchman but says she actually needs – but cannot afford – two casuals and a groundsman to manage the 10-acre facility. And because it was not built by the national government, the dispensary is not entitled to access the HSSF, despite its workload, though other less busy facilities do. Ilatu does, however receive, as all facilities do, reimbursement from the national government for maternal deliveries –KSh2,500 each.

Dr. Matheka says the average distance to a health facility has been nearly halved, from 9km to 5km in the last 4 years. However, having more facilities will not necessarily improve health outcomes for the people of Makueni if the quality of care they provide begins to decline as a result of underinvestment.

So as the county keeps building more dispensaries and health centres, questions must be asked about whether underfunded facilities can truly serve as the bedrock for universal health coverage even though access has been improved. Dr. Matheka says the average distance to a health facility has been nearly halved, from 9km to 5km in the last 4 years. However, having more facilities will not necessarily improve health outcomes for the people of Makueni if the quality of care they provide begins to decline as a result of underinvestment. Further, especially as the county expands the number of Level 4 hospitals, one must wonder whether this is being done at the expense of funding primary healthcare.

Makueni officials say some of the potential pitfalls are ameliorated by enhancing public participation. Governor Kibwana says local committees of citizens participate in co-supervision of projects and must, along with technical people and administrators, give approval. This, Kawive asserts, removes politics from the equation and makes bureaucrats and hospital administrators directly accountable to citizens. While it is definitely a good idea to involve local communities, true accountability must be accompanied by real access to information as well as consequences for those who are implicated in wrongdoing.

Though MakueniCare faces its share of challenges, everyone The Elephant spoke with in Makueni who was aware of the programme was full of praise for its ambition, including those who were critical of its implementation. The fact is, as Kenya ponders the way to achieve universal health coverage, the country would do well to pay attention to the lessons from Makueni. The expansion of NHIF cover by itself will not suffice; the national government must work with county governments to outline a plan that creates a seamless spectrum of cover at every level of care and provides the necessary resources at the appropriate time.

Further, there should be horizontal cooperation among counties in providing healthcare and any plan must strive for equity but without punishing the counties that have taken serious strides. Criteria for eligibility for county programmes should be clearly spelt out and counties should be encouraged to collaborate in designing their schemes within the framework of the national plan.

Thirdly, the system should primarily invest in and direct resources towards building the capacities of the public health sector, not in creating opportunities to generate private profits. It should embrace a rights-based approach that seeks to deal with health as a human right rather than an industry. That shifts the focus away from the needs of “investors” to those of citizens. As Ann Wanyoike notes, “an expanded role for the private sector became a health sector reform theme of the 1990s” but this resulted in “a dichotomous health structure that was characterised by the rich opting for high-cost private healthcare providers, with a majority of the populace who had no such means relying on the publicly run health institutions”. This means that those who can contribute the most to a national universal health coverage scheme have little incentive to do so, especially if such contributions are voluntary. More on that later.

In addition, it does no good to simply superimpose universal health coverage on a system designed for hospitals to generate revenue. The latter must be fundamentally retooled to suit the former and this will take both time and resources.

Fourth, the plan must prioritise prevention and care at the lower levels. In 2013, according to the Kenya Service Availability and Readiness Assessment Mapping report, less than 6 out of 10 health facilities in the country have the capacity to provide the Kenya Essential Package for Health (KEPH) – a standardised comprehensive package of health services – and less than half have the basic amenities to provide healthcare services. And while two-thirds have half the basic equipment required, 59 per cent do not have essential medicines. Only 2 per cent of facilities are providing all KEPH services required to eliminate communicable diseases. Providing universal healthcare on such a foundation would be building on sand.

Universal healthcare requires a substantial increase in the resources both levels of government commit to health. The point is not that both levels of government should spend more on health at the expense of other social services; rather they should increase spending on the full range of human rights and social determinants of health. For example, Kenya’s Health Policy identifies reducing the burden of violence and injuries as one of the top objectives and notes that this will require addressing causes. Given that road crashes account for between 45 and 60 per cent of all admissions to surgical wards, comprehensively addressing the problems on our roads would free up considerable resources in the health sector.

According to Djesika Amendah, an associate research scientist at the African Population and Health Research Centre, Kenya spends most of its health budget on salaries, allowances, drug supplies and other recurrent costs; only 7 per cent of the budget goes towards capital expenditure to improve the quality of healthcare by building new facilities or purchasing equipment to care for more people in the future.

How the money that is allocated to the health sector and how it is spent should also change. According to Djesika Amendah, an associate research scientist at the African Population and Health Research Centre, Kenya spends most of its health budget on salaries, allowances, drug supplies and other recurrent costs; only 7 per cent of the budget goes towards capital expenditure to improve the quality of healthcare by building new facilities or purchasing equipment to care for more people in the future.

In addition, the country spends nearly four times as much on curative care as it does on disease prevention and “we devote a higher share of our health shillings (20 per cent) on governance, health system and financing administration; in other words, paying people in the ministries of health who actually do not see any patients rather than spending money on preventing diseases or promoting health.” Further, although most Kenyans live in rural areas, government health expenditure has in the past tended to favour urban areas. Given the country’s limited resources, more prudence will need to be exercised if universal access to care is to be guaranteed to all.

Along the same lines, there should be an emphasis on getting Kenyans to pay into the system when they are healthy and not to wait till they get sick to get the cover. This also means making it easier for people to register and pay. For example, one can currently download a registration from the NHIF website but one then has to deliver it physically to their offices. There appears to be no way to pay via mobile money or credit/debit card. With nearly all Kenyans able to access the internet though their mobile phones, allowing online registrations and payments would be an easy way to bring in more registrations.

Further, whether the scheme should be voluntary or compulsory is a matter for serious debate. While Makueni’s system is completely voluntary, the NHIF is compulsory only for those in formal employment. Yet the WHO’s 2010 World Health Report titled “The Path to Universal Coverage” says that “there is strong evidence that raising funds through compulsory prepayment provides the most efficient and equitable path towards universal coverage. In the countries that have come closest to achieving universal health coverage, prepayment is the norm, organised though general taxation and/or compulsory contributions to health insurance.”

Makueni teaches us that universal health coverage is doable and that we do not need to have the resources of an industrialised country to achieve it.

There is also the question of whether, like in Makueni, everyone pays the same amount regardless of income, and whether wealthier people are asked to pay a little bit more in order to lighten the load on the poor. As the WHO notes, “financial risk protection is determined by how funds are raised and whether and how they are pooled to spread risks across population groups” and “rais[ing] funds equitably … usually implies a degree of progressivity (where the rich contribute a higher proportion of their income than the poor)”. The NHIF, rather strangely, only has a graduated scale for contributions from those in formal employment; others who join pay a flat monthly fee regardless of income. This is curious for a country where, according to the United Nations’ Economic Commission for Africa, only a quarter of workers are in the formal sector.

Fifth, accountability must permeate the entire system. Implementation of the scheme should not become, as we have seen with the free primary education reintroduced in 2003 and the Standard Gauge Railway, hostage to political priorities. Kenyans must accept that if it is to be done well, it will not be done overnight. Public participation at every stage should be encouraged and resources, especially human resources, should be utilised in the most appropriate and effective manner. Effective public participation as well as transparency will be indispensable if the country is to avoid universal health coverage becoming another avenue for looting by the state.

While universal health coverage focuses on reducing the financial burdens of patients, more will be required if access to the healthcare system is to be expanded. As the World Health Report notes, “eliminating direct payments will not necessarily guarantee financial access to health services, while eliminating direct payments only in government facilities may do little to improve access or reduce financial catastrophe in some countries. Transport and accommodation costs also prevent poor people using services, as do non-financial barriers, such as restrictions on women travelling alone, the stigma attached to some medical conditions and language barriers.”

Finally, Makueni teaches us that universal health coverage is doable and that we do not need to have the resources of an industrialised country to achieve it. All that is needed is a belief that Kenya should be run for the benefit of all Kenyans and that Kenyans are just as capable as any other people of imagining and creating better worlds and better futures. This may be the greatest lesson we can learn from Makueni County.

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POT CALLING THE KETTLE BLACK? France’s shady deals in Africa

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POT CALLING THE KETTLE BLACK? France’s shady deals in Africa

“I think the corruption of Africa is taken totally out of context, Africa is no more corrupt than any other place around us. For every African leader who is corrupt, we have a 1000 European, American, Chinese business people who are corrupt, where are those guys? Why only talk about African corruption? What about the Chinese corruption, American corruption and European corruption? We need to be really fair in looking at this issue of corruption. What about companies not paying taxes in Africa? What about profit shifting, mispricing? There is a whole lot of corruption around us. What about anonymous companies? Companies whose official ownership is not known, where people hide their stolen money. All that are issues of corruption, so that is all that needs to be discussed and let’s get away from the scenario that only African leaders have a monopoly on corruption which is not true”.

These words came from the mouth of Mo Ibrahim, the Sudanese-British businessman who in 1998 founded the telecommunications company Celtel International and is now the chairman and founder of the Mo Ibrahim Foundation, established in 2006 to support good governance and exceptional leadership on the African continent. Since 2013, Mo Ibrahim has been measuring and monitoring governance performance in African countries through the Ibrahim Index of African Governance (IIAG). He is an iconic figure: he represents African efficiency and good entrepreneurship.

The point made by Mo Ibrahim is clear: corruption is a global issue that is making the world sick. Targeting the sickness should be a priority of the whole planet. There is no moral superiority here: each country should blame itself for something. There are countries that behave like strong boxes protecting the financial secrecy of the rich world; others are still trying to colonise the poor while some allow a tiny elite to control the rest of the population.

There is a tendency to view Africa as corrupt. No doubt lack of ethical leadership and economic and political neocolonialism are key factors in the high levels of corruption on the continent. However, treating the corruption issue as an African peculiarity is unfair. Especially if the one complaining is a European country.

Related stories: Special Reports from Reuters journalists around the world

European companies are part and parcel of corruption in African countries. The most recent example concerns Eni SpA, the partially-national Italian oil company and the partially-national Dutch Royal Dutch Shell PLC. On December 20 this year, the Court of Milan indicted Royal Dutch Shell PLC, the chief executive of the Italian oil and gas company Eni SpA and other industry executives on corruption charges connected to a 2011 deal to acquire drilling rights off the coast of Nigeria. “Prosecutors say in court documents that Eni CEO Claudio Descalzi and the other executives at both Shell and Eni knew that most of the $1.3 billion Eni and Shell paid to the Nigerian government to acquire the drilling rights would be distributed as bribes. Prosecutors will argue that Goodluck Jonathan, the Nigerian president at the time of the deal, received part of the kickbacks, according to court documents”, FoxBusiness reported.

There is a tendency to view Africa as corrupt. No doubt lack of ethical leadership and economic and political neocolonialism are key factors in the high levels of corruption on the continent. However, treating the corruption issue as an African peculiarity is unfair. Especially if the one complaining is a European country.

Nigeria is ranked among the most corrupt countries in the world. Corruption has remained rampant in Nigeria, and became worse under the rule of Goodluck Jonathan. In the 2011 case connected to Eni and Shell, there are also several prominent Nigerian figures mentioned in the alleged bribing scheme.

In the European mindset, corruption is a vicious circle: nobody seems to be interested in breaking the bribe rule because it is considered “normal” and it secures success, especially in countries where impunity is the norm. Yet Western countries that have invested in Africa always claim moral superiority: they have better governance, accountable and efficient systems, and they bring jobs. But this supposed superiority is just a veneer that allows these countries to be corrupt and opaque abroad.

France is globally recognised as among the most corruption-free countries. However, there are questions being raised in Kenya concerning whether the France-based company OT-Morpho paid bribes to officials of the Independent Electoral and Boundaries Commission (IEBC) in order to be granted the contract for the electronic voting system used in the 2017 election.

The French government has also in the past been accused of being infiltrated by mafia-like groups that use bribery as a tool to influence politics. Recently, the strongest criticism of France’s dealings abroad came from the broadcaster Arte, which aired a documentary called “Mafia et Republique”.

The French government has also in the past been accused of being infiltrated by mafia-like groups that use bribery as a tool to influence politics. Recently, the strongest criticism of France’s dealings abroad came from the broadcaster Arte, which aired a documentary called “Mafia et Republique”. The historical investigation started in 1929, when in Marseille, Southern France, two friends, Carbone and Spirito, started a criminal group: the very first group of Corsican mafia. In the beginning, this was a gang dedicated to drug trafficking, but the next generation of mobsters in the ‘60s found some politicians who were closer to their interests. The most prominent one was Charles Pasqua, the former interior minister (‘86-’88 and ‘93-‘95) and congressman for almost 35 years. When he died in 2015, he was called the Godfather of Francafrique – the term coined by the former Ivorian president Félix Houphouët-Boigny to define the colonial-style influence that France has in some former French colonies in West Africa. Tchad, Cameroun, Centrafrican Republic, Gabon, Angola – these are some of the African kleptocracies, some still in power, that began their rule in these years. The other important Godfather of Francafrique was Robert Feliciaggi, the middleman between politicians and mafia gangs. He ran casinos with Michel Tomi in Western Africa and died in uncertain circumstances in Ajaccio, Corsica, in 2006.

From 1980 to 1994, France was shaken by the Elf affair, probably the biggest political and corporate sleaze scandal to hit a Western democracy since the Second World War that exposed bribes paid by the national oil company all over the world. In Africa, the intermediaries for the illicit payments were Feliciaggi and Tomi. “Elf’s former chairman, Loik Le Floch-Prigent, 60, was sentenced to five years in jail and fined €375,000 (£260,724); his principal bag-man, the former director Alfred Sirven, was given the same prison term and ordered to pay €1m. The company’s ‘Mr Africa’, André Tarallo, was jailed for four years and fined €2m”, reported the Guardian in 2003. After an eight-year investigation and four-month trial, 30 out of 37 defendants were jailed for embezzling €305 million. This case is a concrete example of an organised, hierarchical mafia-like syndicate that is able to penetrate the so-called grey zone where criminals, politicians and businesses merge together.

According to Reuters’ findings, “Areva’s mines pay no export duties on uranium, no taxes on materials and equipment used in mining operations, and pay a royalty of just 5.5 percent on the uranium they produce. A spokesman for Areva declined to confirm the authenticity of the documents and did not comment on their contents”.

Sometimes corruption is simply a matter of money and power, without criminals or gangs involved. These cases are harder to prosecute because often finding the money is impossible. One such case was reported by Reuters in 2014. The main character was Areva, the mining company that is the global leader in uranium extraction. Areva-Niger’s agreements had never made public and in 2014 they expired. According to Reuters’ findings, “Areva’s mines pay no export duties on uranium, no taxes on materials and equipment used in mining operations, and pay a royalty of just 5.5 percent on the uranium they produce. A spokesman for Areva declined to confirm the authenticity of the documents and did not comment on their contents”. Profits without expenses.

Reuters reported that Areva said that a higher royalty rate would have made the business unprofitable. “Mining Minister Omar Hamidou Tchiana, leading the negotiations for Niger, told Reuters the government wants to increase uranium revenues to at least 20 percent of the budget, from just 5 percent at present…‘For 40 years, Niger has been one of the world’s largest uranium producers, but it’s still one of the poorest countries on the planet,’ he said. ‘At the same time, Areva has grown to be one of the world’s largest companies. You see the contrast?’”.

On his last trip to Burkina Faso, the French president Emmanuel Macron said he wanted to reset French-African relations and get rid of Francafrique-style dealings. “I haven’t come here to tell you what is France’s African policy because there no longer is one, there is only a continent that we need to look straight in the face”, he said in his November 2017 speech in Ouagadougou.

How did Areva obtain these privileges? The answer has never been found.

In 2017 Oxfam France’s report called “La transaprence à l’état brut” exposed the lack of transparency in Areva’s taxes paid in Niger. The same report also mentioned some questionable tax payments by Total in Angola.

On his last trip to Burkina Faso, the French president Emmanuel Macron said he wanted to reset French-African relations and get rid of Francafrique-style dealings. “I haven’t come here to tell you what is France’s African policy because there no longer is one, there is only a continent that we need to look straight in the face”, he said in his November 2017 speech in Ouagadougou. He added: “The crimes of European colonisation are unquestionable . . . It’s a past that needs to pass.”

Despite this new approach, there are still enormous biases that divide France from its former colonies. The first one is the colonial approach of the French multinational corporations, as listed above. The second is more symbolic and maybe more important. France is still hiding secrets from its former colonies. There are strong suspicions about a French role in the conspiracy to kill Thomas Sankara, Burkina Faso’s Che Guevara, in 1987. The French government has also been accused of being involved in the Rwandan genocide in 1994. (However, the military documents that can prove that France supplied some militias with arms are still classified.) People protesting in Togo blame the French authorities of supporting President Faure Gnassigbé, the kleptocrat who has refused to follow the constitution, according to his opponents. The same situation applies to other West African ruling families who are heavily criticised at home, but who have good allies in Paris.

Corruption is criminal and immoral. While European countries benefit from this vice, African countries are left to deal with its devastating consequences.

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