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(D)Evolved Healthcare: Makueni’s Trailblazing Experiment in Providing Universal Health Coverage

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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.

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(D)Evolved Healthcare: Makueni’s Trailblazing Experiment in Providing Universal Health Coverage
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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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Mr. Gathara is a social and political commentator and cartoonist based in Nairobi.

Politics

Beyond Political Freedom to Inclusive Wealth Creation and Self-Reliance

Malawi can alleviate poverty and become a model for development and democracy by investing in and improving the quality of human capital, the quality of infrastructure, and the quality of institutions.

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Beyond Political Freedom to Inclusive Wealth Creation and Self-Reliance
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The Tonse Alliance that made history in June by winning the rerun of the presidential election, the first time this has happened in Africa. It represented a triumph of Malawian democracy, undergirded, on the one hand, by the independence of the judiciary, and on the other, by the unrelenting political resilience and struggles of the Malawian people for democratic governance. In short, we can all be proud of Malawi’s enviable record of political freedom. However, our democratic assets are yet to overcome huge developmental deficits. Our record of economic development and poverty eradication remains dismal, uneven, and erratic.

Malawi’s persistent underdevelopment does not, of course, emanate from lack of planning. In 1962, Dunduzu Chisiza convened “what was perhaps the first international symposium on African Economic Development to be held on the continent”. It brought renowned economists from around the world and Africa. In attendance was a young journalist, Thandika Mkandawire, who was inspired to study economics, and rose to become one of the world’s greatest development economists. I make reference to Chisiza and Mkandawire to underscore a simple point: Malawi has produced renowned and influential development thinkers and policy analysts, whose works need to be better known in this country. If we are to own our development, instead of importing ready-made and ill-suited models from the vast development industry that has not brought us much in terms of inclusive and sustainable development, we have to own the generation of development ideas and implementation.

I begin, first, by giving some background on the county’s development trajectory; and second, by identifying the three key engines of development – the quality of human capital, the quality of infrastructure, and the quality of institutions – without which development is virtually impossible.

Malawi’s development trajectory and challenges

Malawi’s patterns of economic growth since independence have been low and volatile, which has translated into uneven development and persistent poverty. A 2018 World Bank report identifies five periods. First, 1964-1979, during which the country registered its fastest growth at 8.79%. Second, 1980-1994, the era of draconian structural adjustment programmes when growth fell to 0.90%. Third, 1995-2002 when growth rose slightly to 2.85%. Fourth, 2003-2010, when growth bounced to 6.25%. Finally, 2011-2015, when growth declined to 3.82%. Another World Bank report, published in July 2020, notes that the economy grew at 3.2% in 2017, 3.0% in 2018, an estimated 4.4% in 2019, and will likely grow at 2.0% in 2020 and 3.5% in 2021.

Clearly, Malawi has not managed to sustain consistently high growth rates above the rates of population growth. Consequently, growth in per capita income has remained sluggish and poverty reduction has been painfully slow. In fact, while up to 1979 per capita GDP grew at an impressive 3.7%, outperforming sub-Saharan Africa, it shrunk below the regional average after 1980. It rose by a measly 1.5% between 1995 and 2015, well below the 2.7% for non-resource-rich African economies. Currently, Malawi is the sixth poorest country in the world.

While the rates of extreme poverty declined from 24.5% in 2010/11 to 20.1% in 2016/17, moderate poverty rates increased from 50.7% to 51.5% during the same period. Predictably, poverty has a gender and spatial dimension. Women and female-headed households tend to be poorer than men and male-headed households. Most of the poor live in the rural areas because they tend to have lower levels of access to education and assets, and high dependency ratios compared to urban dwellers, who constitute only 15% of the population. Rural poverty is exacerbated by excessive reliance on rain-fed agriculture and vulnerability to climate change because of poor resilience and planning. In the urban areas, poverty is concentrated in the informal sector that employs the majority of urban dwellers and suffers from low productivity and incomes, and poor access to capital and skills.

While the rates of extreme poverty declined from 24.5% in 2010/11 to 20.1% in 2016/17, moderate poverty rates increased from 50.7% to 51.5% during the same period. Predictably, poverty has a gender and spatial dimension.

The causes and characteristics of Malawi’s underdevelopment are well-known. The performance of the key sectors – agriculture, industry, and services – is not optimal. While agriculture accounts for two-thirds of employment and three-quarters of exports, it provides only 30% of GDP, a clear sign of low levels of productivity in the sector. Apparently, only 1.7% of total expenditure on agriculture and food goes to extension, and one extension agent in Malawi covers between 1,800 and 2,500 farmers, compared to 950 in Kenya and 480 in Ethiopia. As for irrigation, the amount of irrigated land stands at less than 4%.

Therefore, raising agricultural productivity is imperative. This includes greater crop diversification away from the supremacy of maize, improving rural markets and transport infrastructure, provision of agricultural credit, use of inputs and better farming techniques, and expansion of irrigation and extension services. Commercialisation of agriculture, land reform to strengthen land tenure security, and strengthening the sector’s climate resilience are also critical.

In terms of industry, the pace of job creation has been slow, from 4% of the labour force in 1998 to 7% in 2013. In the meantime, the share of manufacturing’s contribution to the country’s GDP has remained relatively small and stagnant, at 10%. The sector is locked in the logic of import substitution, which African countries embarked on after independence and is geared for the domestic market.

Export production needs to be vigorously fostered as well. It is reported that manufacturing firms operate on average at just 68 per cent capacity utilisation. This suggests that, with the right policy framework, Malawi’s private sector could produce as much as a third more than current levels without needing to undertake new investment.

After independence, Malawi, like many other countries, created policies and parastatals, and sought to nurture a domestic capitalist class and attract foreign capital in pursuit of industrialisation. The structural adjustment programmes during Africa’s “lost decades” of the 1980s and 1990s aborted the industrialisation drive of the 1960s and 1970s, and led to de-industrialisation in many countries, including Malawi. The revival and growth of industrialisation require raising the country’s competitiveness and improving access to finance, the state of the infrastructure, the quality of human capital, and levels of macroeconomic stability.

Over the last two decades, Malawi has improved its global competitiveness indicators, but it needs to and can do more. According to the World Bank’s Ease of Doing Business, which covers 12 areas of business regulation, Malawi improved its ranking from 132 out of 183 countries in 2010 to 109 out of 190 countries in 2020; in 2020 Malawi ranked 12th in Africa. In the World Economic Forum’s Global Competitiveness Index, a four-pronged framework that looks at the enabling environment – markets, human capital, and the innovation ecosystem – Malawi ranked 119 out of 132 countries in 2009 and 128 out of 141 countries in 2019.

Access to finance poses significant challenges to the private sector, especially among small and medium enterprises that are often the backbone of any economy. The banking sector is relatively small, and borrowing is constrained by high interest rates, stringent collateral requirements, and complex application procedures. In addition, levels of financial inclusion and literacy could be greatly improved. The introduction of the financial cash transfer programme and mobile money have done much to advance both.

Corruption is another financial bottleneck, a huge and horrendous tax against development. The accumulation of corruption scandals – Cashgate in 2013, Maizegate in 2018, Cementgate and other egregious corruption scandals in 2020 – is staggering in its mendacity and robbery of the county’s development and future by corrupt officials that needs to be uncompromisingly uprooted.

Malawi’s infrastructure deficits are daunting. Access to clean water and energy remains low, at 10%, and frequent electricity outages are costly for manufacturing firms that report losing 5.1% in annual sales; 40.9% of the firms have been forced to have generators as backup. The country’s generating capacity needs massive expansion to close the growing gap between demand and supply. Equally critical is investment in transport and its resilience to contain the high costs of domestic and international trade that undermine private sector development and poverty reduction.

Digital technologies and services are indispensable for 21st century economies, an area in which Malawi lags awfully behind. According to the ICT Development Index by the International Telecommunications Union, in 2017 Malawi ranked 167 out of 176 countries. There are significant opportunities to overcome the infrastructure deficits in terms of strengthening the country’s transport systems through regional integration, developing renewable energy sources, and improving the regulatory environment. Developing a digitally-enabled economy requires enhancing digital infrastructure, connectivity, affordability, availability, literacy, and innovation.

Malawi’s infrastructure deficits are daunting. Access to clean water and energy remains low, at 10%, and frequent electricity outages are costly for manufacturing firms that report losing 5.1% in annual sales.

The services sector has grown rapidly, accounting for 29% of the labor force in 2013 up from 12% in 1998. It is dominated by the informal sector which is characterized by low productivity, labor underutilization, and dismal incomes. The challenge is how to improve these conditions and facilitate transition from informality to formality.

Enablers and drivers of development

The challenges of promoting Malawi’s socio-economic growth and development are not new. In fact, they are so familiar that they induce fatalism among some people as if the country is doomed to eternal poverty. Therefore, it is necessary to go back to basics, to ask basic questions and become uncomfortable with the county’s problems, with low expectations about our fate and future.

From the vast literature on development, to which Thandika made a seminal contribution, there are many dynamics and dimensions of development. Three are particularly critical, namely, the quality of human capital, the quality of infrastructure, and the quality of institutions. In turn, these enablers require the drivers embodied in the nature of leadership, the national social contract, and mobilisation and cohesiveness of various capitals.

The quality of human capital encompasses the levels of health and education. Since 2000, Malawi has made notable strides in improving healthcare and education, which has translated into rising life expectancy and literacy rates. For the health sector, it is essential to enhance the coverage, access and quality of health services, especially in terms of reproductive, maternal, neonatal, and early child development, and public health services, as well as food security and nutrition services.

The introduction of free primary education in 1994 was a game changer. Enrollment ratios for primary school rose dramatically, reaching 146% in 2013 and 142% in 2018, and for secondary school from 44% in 2013 to 40% in 2018. The literacy rate reached 62%. But serious challenges remain. Only 19% of students’ progress to Standard Eight without repeating and dropout rates are still high; only 76% of primary school teachers and 57% of secondary school teachers are professionally trained. Despite increased government expenditure, resources and access to education remain inadequate.

Consequently, in 2018 Malawi’s adult literacy was still lower than the averages for sub-Saharan countries (65%) and the least developed countries (63%). This means the skill base in the country is low and needs to be raised significantly through increased, smart and strategic investments in all levels of education. Certainly, special intervention is needed for universities if the country, with its tertiary education enrollment ratio of less than 1%, the lowest in the world, is to catch up with the enrollment ratios for sub-SaharanAfrica and the world as a whole that in 2018 averaged 9% and 38%, respectively.

Human capital development is essential for turning Malawi’s youth bulge into a demographic dividend rather than a demographic disaster. Policies and programmes to skill the youth and make them more productive are vital to harnessing the demographic dividend. Critical also is accelerating the country’s demographic transition by reducing the total fertility rate.

As for infrastructure, while the government is primarily responsible for building and maintaining it, the private sector has an important role to play, and public-private-partnerships are increasingly critical in many countries. It is necessary to prioritise and avoid wish lists that seek to cater to every ministry or constituency; to concentrate on a few areas that have multiplier effects on various sectors; and ensure the priorities are well-understood and measurable at the end of the government’s five-year term. Often, the development budget doesn’t cover real investment in physical infrastructure and is raided to cover over-expenditure in the recurrent budget.

The quality of institutions entails the state of institutional arrangements, which UNDP defines as “the policies, systems, and processes that organizations use to legislate, plan and manage their activities efficiently and to effectively coordinate with others in order to fulfill their mandate”. Thus, institutional arrangements refer to the organisation, cohesion and synergy of formal structures and networks encompassing the state, the private sector, and civil society, as well as informal norms for collective buy-in and implementation of national development strategies. But setting up institutions is not enough; they must function. They must be monitored and evaluated.

Human capital development is essential for turning Malawi’s youth bulge into a demographic dividend rather than a demographic disaster. Policies and programmes to skill the youth and make them more productive are vital to harnessing the demographic dividend.

The three enablers of development require the drivers of strong leadership and good governance. Malawi has not reaped much from its peace and stability because of a political culture characterised by patron-clientelism, corruption, ethnic and regional mobilisation, and crass populism that eschews policy consistency and coherence, and undermines fiscal discipline. Malawi’s once highly regarded civil service became increasingly politicised and demoralised. Public servants and leaders at every level and in every institutional context have to restore and model integrity, enforce rules and procedures, embody professionalism and a high work ethic, and be accountable. Impunity must be severely punished to de-institutionalise corruption, whose staggering scale shows that domestic resources for development are indeed available. To quote the popular saying by Arthur Drucker, “organisational culture eats strategy”.

Also critical is the need to forge social capital, which refers to the development of a shared sense of identity, understanding, norms, values, common purpose, reciprocity, and trust. There is abundant research that shows a positive correlation between the social capital of trust and various aspects of national and institutional development and capabilities to manage crises. Weak or negative social capital has many deleterious consequences. The COVID-19 pandemic has made this devastatingly clear – countries in which the citizenry is polarised and lacks trust in the leadership have paid a heavy price in terms of the rates of infection and deaths.

Impunity must be severely punished to de-institutionalise corruption, whose staggering scale shows that domestic resources for development are indeed available. To quote the popular saying by Arthur Drucker, “organisational culture eats strategy”.

The question of social capital underscores the fact that there are many different types of capital in society and for development. Often in development discourse the focus is on economic capital, including financial and physical resources. Sustainable development requires the preservation of natural capital. Malawi’s development has partly depended on the unsustainable exploitation of environmental resources that has resulted in corrosive soil erosion and deforestation. Development planning must encompass the mobilisation of other forms of capital, principally social and cultural capital. The diaspora is a major source of economic, social and cultural capital. In fact, it is Africa’s largest donor, which remitted an estimated $84.3 billion in 2019.

In conclusion, Malawi’s development trajectory has been marked by progress, volatility, setbacks, and challenges. For a long time, Malawi’s problem has not been a lack of planning, but rather a lack of implementation, focus and abandoning the very basics of required integrity in all day-to-day work. Also, the plans are often dictated by donors and lack local ownership so they gather the proverbial bureaucratic dust.

Let us strive to cultivate the systems, cultures, and mindsets of inclusion and innovation so essential for the construction of developmental and democratic states, as defined by Thandika and many illustrious African thinkers and political leaders.

This article is the author’s keynote address at the official opening of the 1st National Development Conference presided by the State President of Malawi, His Excellency Dr. Lazarus Chakwera, at the Bingu International Convention Centre, Lilongwe, on 27 August, 2020.

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Kenya’s Gulag: The Dehumanisation and Exploitation of Inmates in State Prisons

Kenyan prisons today carry the DNA of their forebears – the colonial prisons and Mau Mau detention camps. They are about brutalising prisoners into submission and scaring the rest of society into compliance with the state. And like their colonial predecessors, they are also sites of forced labour.

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The influx of the Mau Mau transformed the prison population in Kenya from one predominantly made up of recidivist petty criminals and tax defaulters to one composed largely of political prisoners, many of whom had no experience of prison life and who brought with them new forms of organisation.

Prison life was harsh, with its share of brutalities and fatalities. Between 1928 and 1930, about 200 prisoners in Kenya died. According to British historian David Anderson, “Kenya’s prisons were already notably violent before 1952 [when the Mau Mau uprising began], more violent than other British colonies.”

However, the incorporation of prisons and detention camps into the “Pipeline” (the system developed by the colonial state to deal with the Mau Mau insurgents and to try and break them using terror and torture) inevitably led to the institutionalisation of the methods of humiliation and torture.

As Anderson notes, “Most of the staff in both the Prison Service and in the [Mau Mau] detention camps were Africans. Some were even Kikuyu. They certainly ‘learned’ these methods during their periods of early employment.” He goes on to say that “those who ran the service by the 1960s and early 1970s were all men who had been recruited and trained during the Mau Mau period”. He thinks it “very likely that these individuals practiced what they had learned as cadets and trainees in the 1950s…I think the Mau Mau experience certainly hardened Kenya’s prison system and introduced a greater range of punishments and harsher treatment for prisoners as a consequence of the conditions off the Emergency”.

Compare, for example, this account of the treatment of Mau Mau detainees in the 1950s published in Caroline Elkins’ book, Britain’s Gulag: The Brutal End of Empire in Kenya:

Regardless of where they were in the Pipeline (the system of camps established for deradicalizing Mau Mau detainees and prisoners), roll call meant squatting in groups of five with their hands clasped over their heads. The European commandants would then walk through the lines, counting and beating the detainees. “The whole thing was just so ridiculous,” recalled one former detainee from Lodwar. “Whitehouse [the European in charge] would just count us over and over again.”

It bears stark similarities to this account published in the Daily Nation about conditions in Kenyan prisons 65 years later:

Omar Ismael, 64, a former Manyani inmate who served nine years till his exoneration in 2017, says he woke up at 5am, despite his advanced aged. They then squat in groups of five to be counted and checked by guards. “My knees are still hurting to date. I have a joint problem too as a result,” he says. He says they had at least six head counts per day. The first one at 5am, followed by 10am, noon, 4pm, 6pm and 7pm.

Kenyan prisons today carry the DNA of their forebears – the colonial prisons and Mau Mau detention camps. They are about brutalising prisoners into submission and, along with the police and military, scaring the rest of society into compliance with the state. They are places of dehumanisation, abandonment and retribution. And like their colonial parents, they prefer to employ the least educated. (At present, out of a staff complement of 22,000, the Kenya Prison Service only has about 700 graduate officers.) As of 2015, according to the World Prison Population List prepared by the Institute for Criminal Policy Research, Kenya has incarcerated more of its citizens per 100,000 population than any other country in Eastern Africa with the exception of Rwanda and Ethiopia.

Notably, about 50 per cent of Kenya’s 54,000 prisoners are pre-trial detainees or those held in remand as they await trial – people legally considered innocent. By comparison, the median proportion of pre-trial prisoners in Africa is 40 per cent and nearly 30 per cent globally. In Eastern Africa, only Uganda and Ethiopia have a higher proportion of pre-trial detainees than Kenya. As in colonial times, pre-trial detention is driven by two factors – the need to extract resources from the populace and the subjugation of the native through criminalisation of ordinary life.

In 1933, submissions to the Bushe Commission provided some flavour of how the threat of arrest and imprisonment was ever-present among the natives.

Relates one Ishmael Ithongo:

Once I was arrested by a District Officer on account of my hat because I did not see him approaching. He came from behind and threw it down. I asked him why because I did not know him. He called an askari and asked for my name. It was in a district outside. He asked me, “Don’t you know the law here that you should take off your hat when you see a white man?” Then he asked me, “Have you got your kipandi?’ I said “No, Sir.” So I was sent to prison… When an askari thinks that you look smart he asks if you have your kipandi. I have seen natives who are going to church in the morning who have changed their coat and forgotten their kipandi. They meet an askari. “Have you got your kipandi?” “No.” “Ah right” and they are marched off to prison.

This will sound familiar to many Kenyans today whose encounters with the police often begin with demands for the production of the kipande (ID card) and end with a stint in overcrowded police cells. However, there are some differences. An audit of pre-trial detention by the National Council on the Administration of Justice found that police generally arrested and charged people for petty offences, with close to half of those arrests occurring over weekends. Most releases from police custody also happened over the weekend with no reason recorded for two-thirds of those releases. Further, only 30 percent of all arrests actually elicited a charge, the vast majority for petty offences. This implies that most police detentions today are something of a catch-and-release programme designed to create opportunities to extract bribes rather than labour.

However, for those who get incarcerated, matters are somewhat different. The exploitation of prisoners’ labour continues. Like the Mau Mau detainees, they are required to work for a token amount determined by the government, which, unlike its colonial ancestor, does not even pretend that the 30 Kenyan cents per day is meant as a wage, with the Attorney-General declaring in court that “prison labour is an integral component of the sentence”. The courts have held that it is entirely compatible with the protection of fundamental rights for the Prison Service to do this as well as to deny convicts basic supplies such as soap, toothpaste, toothbrushes, and toilet paper. Apparently, the conditions the convicts are experiencing cannot be called forced labour and servitude because, the strange reasoning goes, “the Constitution and the Prisons Act do not permit forced labour or servitude”.

Notably, about 50 per cent of Kenya’s 54,000 prisoners are pre-trial detainees or those held in remand as they await trial – people legally considered innocent…In Eastern Africa, only Uganda and Ethiopia have a higher proportion of pre-trial detainees.

Like in colonial times, the beneficiaries of this prison industrial complex are the state and those who control it. Remandees and convicts are liable to be put to work cleaning officials’ compounds and there have been persistent rumours of them being compelled to provide free labour for the private benefit of prison officers and other well-connected government officials, as is the case in Uganda.

While in 1930 earnings from convicts’ labour accounted for a fifth of the total cost of the Prisons Department, the official goal today, as declared by the Ministry of Interior, is for the Department to transform into a “financially self-sustaining entity”. To achieve this, President Uhuru Kenyatta has created the Kenya Prisons Enterprise Corporation with the aim of “unlocking the revenue potential of the prisons industry” and to “foster ease of entry into partnership with the private sector”.

This basically entails deeper exploitation of prisoners’ labour. And even though Kenyatta speaks of improving remuneration, it is notable that this is not a free exchange. Whatever the courts might say, it is clear that the state and its owners feel entitled to the labour of those they have incarcerated, much like their predecessors (the colonial regime and the European settlers) once felt entitled to African labour.

This will sound familiar to many Kenyans today whose encounters with the police often begin with demands for the production of the kipande (ID card) and end with a stint in overcrowded police cells. However, there are some differences. An audit of pre-trial detention…found that police generally arrested and charged people for petty offences, with close to half of those arrests occurring over weekends.

In this regard, the attitude is very like that of the white settler in Kiambu, Henry Tarlton, who told the 1912 Native Labour Commission regarding desertion by African workers that “this is my busiest season and my work is entirely upset, and it is hardly surprising if I am in a red-hot state bordering on a desire to murder everyone with a black skin who comes within sight”. Another white settler, Frank Watkins, in a letter to the East African Standard in 1927 boasted of his “methods of handling and working labour”, which included “thrash[ing] my boys if they deserve it”.

This brutality, especially directed towards African males, was paired with forced labour from the very onset of the colonial experience. (Brett Shadle, Professor and Chair of the Department of History at Virginia Tech, notes that the settlers were much more reticent about their violence on African women, which tended to be sexual in nature.) These settlers were already pushing the colonial state to institute unpaid forced labour on public works projects in the reserves (which it eventually did) as a means of driving Africans to wage employment for Europeans.

But it was within the prison system and Mau Mau detention camps that the practice of forced labour found its full expression. According to Christian G. De Vito and Alex Lichtenstein, “Conditions inside the detention camps created in Kenya in the 1910s and 1920s and in the prison camps opened in 1933 depended on the assumption that forced labour, together with corporal punishment, could actually serve as the only effective forms of penal discipline.” The influx of Mau Mau detainees, they explained, overwhelmed the system “since police repression by far exceeded the capacity of the already overcrowded prisons, and the colonial government decided to establish a network of camps, collectively called the ‘Pipeline’, characterized by violence, torture, and forced labour.”

These are the footsteps in which the Kenyan state is walking. Nelson Mandela once said that a nation should not be judged by how it treats its highest citizens but by how it treats its lowest ones. By that measure, the current Kenyan state is no different from its colonial predecessor.

“It is also worth thinking about what happens to the prison at the end of colonialism,” says Prof Anderson. “There is no movement for prison reform in Kenya after 1963 – rather the opposite: the prison regime becomes harsher and is even less well funded than it was in colonial times. By the end of the 1960s, Kenya is being heavily criticised by international groups for the declining state of its prison system and the tendency to violence and abuse of human rights within the system.”

Prof Daniel Branch stresses that “post-colonial prisons urgently need a history. The Mau Mau period rightly gets lots of attention, but there’s very little by scholars on the post-colonial period”.

It is critical, as Kenya marks a decade since the promulgation of the 2010 constitution, that we keep in mind Mandela’s words and ask whether, if at all, it has changed how those condemned by society – “our lowest ones” – are treated. That will, in the end, be the true measure of our transformation.

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The Myth of Unconditionality in Development Aid

Based on interviews and ethnographic fieldwork in Western Kenya, Mario Schmidt argues that local interpretations of Give Directly’s unconditional cash transfer program unmask how the NGO’s ‘myth of unconditionality’ obscures structural inequalities of the development aid sector. Schmidt argues that in order to tackle these structural inequalities, cash transfers should be ‘ungifted’ and viewed as debts repaid and not as gifts offered.

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The New York Times praises the US-American NGO GiveDirectly (GD), a GiveWell top charity, for offering a ‘glimpse into the future of not working’ and journalists from the UK to Kenya discuss GD’s unconditional cash transfer program as a revolutionary alternative in the field of development aid. German podcasts as well as international bestsellers such as Rutger Bregman’s Utopia for Realists portray grateful beneficiaries whose lives have truly changed for the better since they received GD’s unconditional cash and started to invest it like the business people they were always meant to be. At first glance, GD indeed has an impressive CV.

Since 2009, the NGO has distributed over US$160 million of unconditional cash transfers to over tens of thousands of poor people in Kenya, Rwanda, Uganda, the USA and Liberia in an allegedly unbureaucratic, corrupt-free and transparent way. Recipients are ‘sensitized’ in communal meetings (baraza), the cash transfers are evaluated by teams of internationally renowned behavioral economists conducting rigorous randomized controlled trials (RCTs) and the money arrives in the recipients’ mobile money wallets such as the ones from Mpesa, Kenya’s celebrated FinTech miracle, without passing through the hands of local politicians.

In 2015 and after finalizing a pilot program in the Western Kenyan constituency Rarieda (Siaya County), GD decided to penetrate my ethnographic field site, Homa Bay County. On the one hand, they thereby hoped to enlarge their pool of potential beneficiaries. On the other hand, they had planned to conduct further large-scale RCTs (one RCT implemented in the area, studied the effects of motivational videos on recipients’ spending behavior). To the surprise of GD, almost 50% of the households considered eligible for the program in Homa Bay County refused to participate. As a result, the household heads waived GD’s cash transfer which would have consisted of three transfers amounting to a total of 110,000 Kenyan Shillings (roughly US$1,000).

In order to understand what had happened in Homa Bay County and why so many households had refused to participate, I teamed up with Samson Okech, a former field officer of Innovations for Poverty Action (IPA) who had conducted surveys for GD in Siaya. Samson had been an IPA employee for over ten years and belongs to the extended family I work with most closely during fieldwork. During our long qualitative interviews with recipients of GD’s cash transfer and former field officers as well as Western Kenyans who refused to be enrolled in the program, the celebratory reports by journalists and scholars were replaced by a bleaker picture of an intervention riddled with misunderstandings and problems.

Before I offer a glimpse into what happened on the ground, I want to emphasize that I am neither politically nor economically against unconditional cash transfers which, without a doubt, have helped many individuals in Western Kenya and elsewhere. It is not the what, but the how against which I direct my critique. The following two sections illustrate that a substantial part of Homa Bay County’s population did not consider GD’s intervention as a one-time affair between themselves and GD. In contrast, they interpreted GD’s program either as an invitation into a long-term relationship of patronage or as a one-time transfer with obscured actors.

These interpretations should make us aware of ethical problems entailed in conducting social experiments (see Kvangraven’s piece on Impoverished Economics, Chelwa’s and Muller’s The Poverty of Poor Economics or Ouma’s reflection upon GD’s randomisation process in Western Kenya). They can also crucially encourage us to think about ways of radically reconfiguring the political economy of development aid in Africa and elsewhere.

Instead of framing relations between the West and the Rest as relations between charitable donors and obedient recipients, in my conclusion I propose to ‘ungift’ unconditional cash transfers as well as development aid as a whole. Taking inspiration from rumors claiming that Barack Obama, whose father came from Western Kenya, has created GD in order to rectify historical injustices, I suggest rethinking cash transfers as reparations or debts repaid. Consequently, recipients should no longer be used as ‘guinea pigs’ but appreciated as equal partners and autonomous subjects entitled to reap a substantial portion of the value produced in a global capitalist economy that, historically as well as structurally, depends on exploiting them.

Why money needs to be spent on ‘visible things’

Those were guidelines on how to use the money. It was important that what you did with the money was visible and could be evaluated’, William Owino explained to us after we had asked him about a ‘brochure’ several other respondents had mentioned. One of the studies on the impact of GD’s activities in Siaya also mentions these brochures. In order to ‘emphasize the unconditional nature of the transfer, households were provided with a brochure that listed a large number of potential uses of the transfer.’ 

When being asked which type of photographs and suggestions were included in these brochures, respondents mentioned photographs of newly constructed houses with iron sheets, clothes, food and other gik manenore (‘visible things’). When we inquired further if the depicted uses included drinking alcohol, betting, dancing or other morally ambiguous goods and services, the majority of our respondents dismissed that question by laughing or by adding that field officers had also advised them against using the money for other morally dubious services such as paying prostitutes or bride wealth for a second or third wife.

One of our respondents in Homa Bay took the issue of gik manenore to its extreme by expressing the opinion that GD’s money must be used to build a house with a fixed amount of iron sheets and according to a preassigned architectural plan so that GD, in their evaluation, would be able to identify the houses whose owners had benefited from their program quickly and without much effort. Such practices of ‘anticipatory obedience’ are also implicitly at work in the rationalizations of another respondent. He expected that GD’s field officers who had asked him questions about what he intended to do with the money during the initial survey – questions whose answers had, in his opinion, qualified him to receive the cash transfer – would one day return to see if he had really used the money according to his initially stated intention. The logic employed is clear: The ‘unconditional’ cash transfers needed to be spent on useful and, if possible, visible and countable things so that GD would return with further funds after a positive evaluation.

Recipients understood the relation with GD not as a one-off affair, but as an entrance into a long-term relation of fruitful dependency. In contrast to GD which, like most neoliberal capitalists, understands unconditional cash as a context-independent techno-fix, the inhabitants of Homa Bay framed money as an entity embedded in and crystallizing social power relations.

From such a perspective, free money is not really free, but like Marcel Mauss’ famous gifts, an invitation into a ‘contract by trial’ which has the potential to turn into a long-term relationship benefitting both partners if recipients pass the test and reciprocate with obedience. While some actors framed the offer of unconditional cash as a test that could lead into an ongoing patron-client relationship between charitable donors and obedient recipients, others, the majority who refused to accept GD’s offer, interpreted it as a direct exchange relation with unseen actors.

Why money is never free

‘People in the market and those I met going home told me it is blood money’, Mary, a 40-year old mother remembered. After she had been sampled, Mary had never received money from GD but failed to understand why and believed the village elder had ‘eaten’ her money. She further told us that rumors about ‘blood money’ circulated in church services and funeral festivities. ‘Blood money’ refers to widespread beliefs that accepting GD’s cash implied entering into a debt relation with unknown actors such as a local group sacrificing children or the devil.

Comparable rumors playing with the well-known anthropological trope of money’s (anti)-reproductive potential circulate widely in Homa Bay: Husbands who wake up only to see their wives squatting in a corner of the room laying eggs, a huge snake that lives in Lake Victoria and vomits out all the money GD uses, mobile phones that can be charged under the armpit or find their way into the recipient’s bed if lost or thrown away (many people allegedly threw their phones away in order to cut the link to GD), money that replenishes automatically or a devilish cult of Norwegians that abducts Kenyan babies and transports them to Scandinavia where they are adopted into infertile marriages.

All of these rumors, which are epitomized in a phrase some recipients considered to be GD’s slogan, Idak maber, to idak matin – (‘You live well, but you live short’) – revolve around the same paradox: Money initially offered with no strings attached, but whose reproductive potential will soon demand blood sacrifice or lead to a fundamental change in one’s own reproductive capacities.

Local attempts to ‘conditionalize’ GD’s unconditional cash as well as rumors about tit-for-tat exchanges with the devil undermine GD’s assumption that their cash transfers are perceived by recipients as unconditional. This has two consequences. On the one hand, it questions the validity of studies trying to prove that the program was successful as an unconditional cash transfer program. On the other hand, it urges us to focus on the unintended consequences caused by GD’s intervention. While Western Kenyans who have given consent to participate in the intervention invested their hopes in an ongoing charitable relation with GD, those who have refused to participate – as well as some who did – have been haunted by fear and anxiety triggered by situating GD’s activities in a hidden sphere.

All this raises ethical and political questions about GD’s intervention in Homa Bay County. Did GD, an actor that is neither democratically elected nor constitutionally backed up, have the right to intervene in an area where almost 50 % of the population refused to participate? Did the program really reach the poorest members of society if accepting the offer depended on understanding the complex networks of NGOs that constitute the aid landscape? Should it not be considered problematic that a US-American NGO uses whole counties of an independent country as laboratories where they experimentally test the feasibility of unconditional cash transfers in order to assure their donors that recipients of unconditional cash ‘really’ do not spend donations on alcohol and prostitutes?

Apart from raising these and other ethical and political questions, the reactions of the inhabitants of Homa Bay County can be understood as mirrors reflecting a distorted but illuminating image of the development aid sector. Narratives about women laying eggs and satanic cults sacrificing children exemplify an awareness of the fact that, on a structural level, the development aid sector is shot through with inequalities and obscure hierarchical power relations between donating and receiving actors. At the same time, recipients’ anticipatory obedience to use the cash on ‘visible things’ unmasks a system that appears overwhelmed by the necessity to constantly evaluate projects in order to secure further funding.

By ‘conditionalizing’ cash transfers as long-term patronage relations or tit-for-tat exchanges with the devil, inhabitants of Homa Bay unmask GD’s ‘myth of unconditionality’ and thereby relocate GD into the wider development aid world in which they have never been equal partners.

Why we must ‘ungift’ development aid

‘I think it was because of Obama’, a former colleague of Samson who had administered the surveys of GD in Siaya County told me while we enjoyed a meal in a restaurant along Nairobi’s Moi Avenue after I had asked him why the rejection rates of GD’s program in Siaya had been so low. According to rumors that circulated widely during GD’s first years in Siaya, Barack Obama, whose father came from a village in Siaya County, had teamed up with Raila Odinga, an almost mythical Luo politician, in order to channel US-American funds ‘directly’ to Western Kenya, i.e. without passing through the Central Kenyan political elite who had – in 2007 as well as 2013 – ‘stolen’ the elections from Raila.

As a consequence, at least some recipients did not agree with interpretations of the cash transfers as market exchanges with shadowy actors or invitations into long-term relationships of patronage. Rather, they conceptualized the transfers as reparations originating in Obama’s attempt to recoup losses accumulated by the Luo community due to political injustices provoked by the actions of what many consider to be a corrupt Kikuyu elite. This conjuring of a primordial ethnic alliance between Obama and Western Kenyans might strike many as chimerical.

Be that as it may, we should acknowledge that the rumor of Obama’s intervention situates the cash transfers in a social relation between two equals who accept their mutual indebtedness and act accordingly by putting things straight. By reinterpreting GD as a clandestine operation invented by their political leaders, Barack Obama and Raila Odinga, inhabitants of Siaya portray themselves as belonging to a community of interdependent equals whose members are entitled to what the anthropologist James Ferguson has called their ‘rightful share’.

How would development aid look like if we dared to transfer this idea of a community whose members acknowledge their equality and mutual indebtedness to our global economic system? One way to redeem the fact that we all live in a highly connected capitalist economic system spanning the whole globe and depending on exploiting a huge portion of the global community would be to follow in the footsteps of the inhabitants of Siaya and rebrand cash transfers as reparations being paid for historical and structural injustices.

By way of conclusion, I want to suggest the idea of ‘ungifting’ development aid, i.e. to reframe it as a duty and to accept that recipients of cash transfers have the right to receive their share of the value produced by the global capitalist economic system. Consequently, cash transfers should be considered as debts repaid and not as gifts offered.


Names of individuals in this article have been anonymized.

This article was first published in the Review of African Political Economy.

Names of individuals in this article have been anonymized.

 

 

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