The Elephant


NOT YET UHURU: What Kenya can learn from Cuba’s healthcare system

By Francis Omondi

NOT YET UHURU: What Kenya can learn from Cuba’s healthcare system

In his famous song Ayee Africa ee Africa oo Lipanda? (Ah Africa where is your independence?), the young Congolese musician Franklin Boukaka questioned the essence of independence from oppressive colonial rule. Why would the new African leaders indulge in luxuries and power while the masses they led were confined to squalor in his native Congo Brazzaville?

This, of all of Boukaka’s songs, was most popular on radio in the 1970s and remains to date. I doubt that the Voice of Kenya (VoK) radio presenters knew that they were playing a song outlawed in the country of its origin. A nimbus of sweetness in the music concealed the song’s subversive message. The emphatic climax of the song posed three questions: “I thought the colonisers left? Who then became independent? Ayee Africa where is your independence?”

The singer rebukes the insensitivity of the leaders to the needs of their citizens. One of the most beautiful African voices was, however, extinguished forever.  His song earned him silence on February 22, 1972.   Boukaka was executed on the orders of Joachim Opango in the crisis following a coup d’état that failed to topple Marien Ngouabi. However, his voice will continue to haunt our present context in Kenya and Africa as long as the benefits of our freedom are not realised.

Time has revealed the yawning gulf between the independence aspirations our forbearers struggled for and the realities we have experienced. The promissory note of freedom and prosperity has been unhonoured. The majority of Kenyans could not cash it. To paraphrase American civil rights icon Rev. Dr. Martin Luther King Jnr., it has been returned marked “insufficient funds”.  What was the point of the sacrifice for self-rule if wananchi (ordinary Kenyans) would be subjugated to oppressive poverty?  Whose independence was this?

Time has revealed the yawning gulf between the independence aspirations our forbearers struggled for and the realities we have experienced. The promissory note of freedom and prosperity has been unhonoured. The majority of Kenyans could not cash it.

The African leaders of the colonial days were clear about what they demanded. Freedom. While attending the American Committee of Africa’s Freedom Day in 1959, Hon. Tom Mboya, the then Secretary General of the Kenya African National Union (KANU) – who had just been elected head of the Pan-African people’s Congress in Accra, Ghana – gave a revealing interview to American journalists in a session with the National Broadcasting Corporation’s The Press. He was articulate, expressing an urgent need for independence. Mboya understood freedom to be achieving the right to self-determination and to have a government elected by the people, not imposed on them and, therefore, one that was responsible for and accountable to the people. That was the reason for the struggle for independence all over Africa.

The colonialist perceived Africans to be too tribal to rule themselves without resorting to chaos. Perhaps this is why the host, during the interview, pejoratively reminded Hon. Mboya that with freedom there goes responsibility for self-government. She expressed her apprehension about the ability and readiness of Africans to self-govern with these questions: “Now, how can you say that people are prepared for such a responsibility when illiteracy is 90 per cent in many parts of Africa? When governmental experience personally for many is tribal and there is major dependence for foreign aid for economic development…?”

Hon. Mboya concurred with her when he recognised the need for literacy and development in form of better roads and schools. He pointed out that “… the motive behind our struggle for independence is our recognition that these things are not possible under colonialism.” He refuted her characterisation of Africans, identifying it as a colonial fallacy.

The vision of achieving independence to advance ordinary African people described development in terms of people’s welfare, not economic indicators, such as Gross Domestic Product and Gross National Product or economic growth. It concurred with latter-day economists like Edgar Owens (1987) who suggests that development occurs when there is development of people (human development) and not development of things. According to the World Development Report (WDR 1991), “The challenge of development, is to improve the quality of life, better education, higher standards of health and nutrition, less poverty, a cleaner environment, more equality of opportunity, greater individual freedom, and a richer cultural life.”

It is this nexus between development and independence that Hon. Mboya had in mind when he said: “It is when people have attained independence that programmes such as more education, more hospitals, better roads, better houses can be implemented by a government concerned for its people.”

The Cuban example

The Cuba experience backs Hon. Mboya’s assertion, although he spoke before the Cuban revolution had taken place. The 1959 Cuban revolution that brought Fidel Castro to leadership transformed the tiny Caribbean Island of seven million people. Castro created a socialist programme that focused on transforming the lives of ordinary Cubans. Consequently, they were provided a completely free education system uniquely adapted to Cuban needs, from nursery to university. Douglas Kellner’s, in Ernesto ‘Che” Guevara World Leaders Past and Present, explains how prior to 1959, the official literacy rate for Cuba was between 60 per cent and 76 per cent. This was occasioned by both lack of education access in rural areas and a shortage of instructors. The Cuban government under Fidel Castro, beginning in 1961, focused on the countryside by constructing schools and training new teachers who taught the predominantly illiterate peasants (guajiros). At the end of the campaign, the national literacy rate rose to 96 per cent. By 2009, according to a 2012 Central Intelligence Agency report, literacy levels across the population of Cuba were 99.83 per cent. This became the foundation of the development of the Cuban people. Again, it was the citizens who volunteered to achieve this.

According to the World Health Organization (WHO), Cuba’s healthcare system is an example for all countries of the world. It is recognised for its excellence and efficiency. Those responsible for its success include family physicians, nurses and other health workers who labour to deliver primary healthcare and preventive services to their cluster of patients. It is a very localised system; the patients and their caregivers live in the same community. There are now about 2,500 patients per physician-headed office at the primary care level. Their healthcare is premised on the preventive health system, which has produced positive results. As a result, Cuba’s vaccination rates are among the highest in the world. The country’s life expectancy of 77 years is exceedingly impressive for a developing country. The infant mortality rate in Cuba has fallen from more than 80 per 1,000 live births in the 1950s to less than 5 per 1,000. The improved health outcomes are also be attributed to improvements in nutrition and education, which are key variables that address the social determinants of health. Today, health education is part of the mandatory school curriculum.

Despite its extremely limited resources and the negative impact of the American blockade and economic sanctions for more than half a century, Cuba has managed to guarantee access to healthcare for all segments of the population, which has enabled the country to obtain results similar to those of the most developed nations.

Cuba’s experience mocks our post-independence achievements. Our literacy levels are most disturbing. The key findings of Kenya’s national adult literacy survey in 2007 indicated that, on average, 38.5 per cent of the Kenyan adult population is illiterate, implying that more than one in three adults cannot read or write. This is despite the fact that they have been major increases in enrolment in educational institutions at all levels, and a plethora of education commissions constituted to rectify the education conundrum Kenya has faced since independence. Shockingly, this was almost where Cuba was in 1959.

Despite its extremely limited resources and the negative impact of the American blockade and economic sanctions for more than half a century, Cuba has managed to guarantee access to healthcare for all segments of the population, which has enabled the country to obtain results similar to those of the most developed nations.

President Uhuru Kenyatta’s decision to invite 100 Cuban doctors to serve Kenyans, therefore, speaks to us with a forked tongue. We are grateful that these specialists are contributing to ease the pressing healthcare needs in our hospitals. However, it should concern us gravely that the government refuses to undertake the arduous task of developing Kenya’s healthcare system to Cuban levels. Why import Cuban doctors when adopting their system is within our reach?

The celebrated Universal Healthcare proposal in the Jubilee government’s Big 4 Agenda misses the point of our healthcare needs. It assumes a solution by availing financial resources. It, therefore, proposes to reduce the cost and ensure universal access to quality and affordable healthcare by 2022. The government plans to ensure that every Kenyan is covered under the National Hospital Insurance Fund (NHIF) medical insurance cover. This plan will require: a strong collaboration between the NHIF and private sector insurance providers; reviewing the rules governing private insurers; lowering the cost of coverage; protecting both the government and Kenyans from fraud and abuse; and letting private insurers to invest more in providing medical coverage.

This solution is set up to profit the insurers and other supplies of medical products rather than ordinary Kenyans. We stumble not for lack of examples to emulate, but for refusal to care. WHO notes that lack of access to healthcare in most parts of the world springs not from lack of resources, but from a lack of political will on the part of leaders to protect their most vulnerable populations.

With limited resources, the Cuban health care system has solved problems that ours has yet to address. Even though their healthcare system addresses those problems in ways that grew out of Cuba’s peculiar political and economic history, the system they have created — with a physician for everyone, an early focus on prevention, and clear attention to community health — may inform progress in other countries as well.

With the strict economic embargo, Cuba has developed its own pharmaceutical industry and now not only manufactures most of the medications in its basic pharmacopeia but also invests in developing biotechnology expertise to become competitive with advanced countries.

On July 14, 2014, WHO General Director Margaret Chan urged nations to follow the example of Cuba and phase out the curative model, which is ineffective and more expensive. She noted that Cuba’s healthcare system is based on preventive medicine and the results achieved are outstanding. “We sincerely hope that all of the world’s inhabitants will have access to quality medical services, as they do in Cuba,” she said.

Shouldn’t we have developed access to health services first? Shouldn’t we have provided for effective and relevant personnel and medicine before provision of funding? Shouldn’t we be demanding an effective healthcare system that puts the lives of Kenyans above “tenderpreneurs”?

The spectre of revolt looms large

What did our leaders do once in power?  What can explain the obscene affluence of a few in the sea of poor Kenyans?  A 2014 survey conducted over a span of eight years by New World Wealth, a South African-based research firm exposed a grim picture of wealth distribution in Kenya. It showed that 46 per cent of the country’s 43.1 million people live below the poverty line, surviving on less than Sh172 ($2) a day. The report further stated that: “nearly two-thirds of Kenya’s Sh4.3 trillion ($50 billion) economy is controlled by a tiny clique of 8,300 super-wealthy individuals, highlighting the huge inequality between the rich and the poor”.

Shouldn’t we have developed access to health services first? Shouldn’t we have provided for effective and relevant personnel and medicine before provision of funding? Shouldn’t we be demanding an effective healthcare system that puts the lives of Kenyans above “tenderpreneurs”?

Inequality is immoral.  Moreover, the proportions we have here kills. Göran Therborn, who has appropriately titled his book The Killing Fields of Inequalityhighlights several ways in which inequality kills. It violates basic human rights. It excludes “people from possibilities produced by human development.”  It is divisive; it tears people and families apart, it creates exorbitant squandering, self-indulgent profligacy and, therefore, dehumanises both the poor and the rich.

This appalling situation is a result of political leadership bereft of a moral guiding philosophy. Leadership is viewed in transactional and contractual terms; it is a means to acquire wealth. This may explain why we are confronted on a daily basis with grand scandals of greed, corruption, and looting of public or state resources. Isn’t this what Jean-Francois Bayart described as the “politics of the belly”?  Do leaders care that they took an oath to serve the people of Kenya?

Prof. Aloo Mojola of St. Paul’s University in Limuru, Kenya, explains our reality as one “peopled with many atomistic leaders and a populace whose one and only preoccupation is personal gain and aggrandisement at whatever cost.” He further observes that for the vast majority, the present African situation could simply be characterised as Hobbesian. This description is derived from the words of the English political philosopher Thomas Hobbes (1588-1679), who in the mid-17th century wrote in his classic text Leviathan (1651): “The condition of man … is a condition of everyone against everyone…in such a condition there is no place for industry…” Sadly, for these Hobbesians, “the notion of right and wrong, justice and injustice have there no place…force and fraud are…(the) two cardinal virtues”.

This appalling situation is the result of political leadership bereft of a moral guiding philosophy. Leadership is viewed in transactional and contractual terms; it is a means to acquire wealth. This may explain why we are confronted on a daily basis with grand scandals of greed, corruption, and looting of public or state resources.

Unless our leaders adopt a covenantal approach that obliges leadership to better the lives of ordinary citizens, we will be stuck in this quagmire. Our leaders must develop a political philosophy that puts Kenyans at the centre of their agenda. The depth of our problem is explicit, particularly when government policies lean more towards sustaining local and foreign entrepreneurs rather than solving citizens’ problems.

What options remain for citizens when their government fails perpetually to secure their wellbeing? Thomas Jefferson and his colleagues in the American Declaration for the Independence of 1776 were emphatic that the task of government was securing its citizens’ rights to certain unalienable rights which were: “Life, Liberty and the Pursuit of Happiness.” It further provided for redress if the government fails to live up to this call when it stated: “That whenever any Form of Government becomes destructive of these ends, it is the Right of the People to alter or abolish it and to institute new government, laying its foundation on such principles, and organizing its powers in such form, as to them shall seem most likely to effect their safety and happiness.”

The spectre of revolt looms large over Kenya. The youth have lost faith in law reforms or societal reorganisation. They dismiss the “building of bridges” – the now famous handshake between President Uhuru Kenyatta and Rt. (Hon.) Raila Odinga – as a political gimmick that is slowing down the country’s transformation. Revolution is what they are working at. I doubt that they have thought through the end-product of their craving.

Tanzania’s founding President Dr. Julius Nyerere was disturbed and horrified when he realised that he had become the architect of a government-sponsored system of inequality. He was moved to do something about it. His Ujamaa system of African socialism offered a response and attempt to remedy this situation. Aren’t our political leaders able to develop a coherent philosophy to shape our nation’s development agenda?

The spectre of revolt looms large over Kenya. The youth have lost faith in law reforms or societal reorganisation. They dismiss the “building of bridges” – the now famous handshake between President Uhuru Kenyatta and Rt. (Hon.) Raila Odinga – as a political gimmick that is slowing down the country’s transformation.

Since political leaders have failed Kenyans in this respect, can religious leaders provide alternative leadership and nudge the country towards the poor who are perpetually left out? The similarities between Kenya and Latin American countries are striking. David Tombs, in Latin American Liberation Theology, illustrates how the great Latin American independence movements, which had promised liberation and new hope through independence from the Iberian empire, only benefitted an elite sector of society. Here the Creole class assumed governance replacing the peninsulares, yet they did little to alleviate the struggles of the lower classes.

The clergy and theologians in Latin America were on the vanguard of change in addressing the grievances of the poor and transformation of their society. During the Conference of Latin American Bishops held in 1968 in Medellin, Colombia, the bishops agreed that the Church should take “a preferential option for the poor”.  One of the architects of this movement was Father Gustavo Gutierrez, a Roman Catholic priest from Peru, who acknowledged to have been inspired by the Cuban revolution of 1959.  He laid out clearly the concepts he referenced during this talk in 1968 in his 1971 magnum opus, “A Theology of Liberation”. Consequently, liberation theology emerged as a new way of “being human and Christian”.  In proposing a “preferential option for the poor,” the Church was encouraged to extend its work to directly address the struggles of the impoverished and to work specifically to ameliorate “physical and spiritual oppression”.

Rather than small ineffective reforms, liberation theology supported work towards systemic change and even the possibility of revolution as a means of freeing the poor from oppression. While violence was not encouraged, it was justified as a possible last resort or necessity of the revolution.

We must credit liberation theology for changing the role of the Church in Peru and all of Latin America forever. By giving a voice to the impoverished, liberation theology held the Church accountable for the welfare of the lower classes, recognising the essential role of social justice in Christian teachings. The Christians demanded that the Church do more than simple charity and work towards playing a more active role in the promotion of systemic change. This movement realigned the power structures of Latin American society and showed that religion could deliver change in society by forcing the hands of politics.

Where are the Kenyan theologians who will develop a theology that will focus the Church away from solely eternal salvation to the more pressing necessity of earthly liberation of the poor from oppression and suffering? The genius of the religious figures like Gustavo Gutiérrez was in integrating the liberation of the working class into Biblical interpretation.

Independence in Kenya has proved not to be the low-lying fruit ordinary folks anticipated. Prof. Micere Githae Mugo’s (1973) poem “I Took My Son by the Hand”, in David Rubadiri (ed), (1989), depicts this sorry state in the dialogue between a mother and her son who yearned for the fruits of independence.

“Mother?” he asked, “Do we have matunda ya uhuru in our hut?”

Mother: “I laughed foolishly”

Son: “Mother!”

Mother: “Yes son? ”

Son: “Do we have some?”

Mother: “Silence…”

Son: May I eat one, when we get there?

Mother: “Move on son darkness is looming fast around us”.

There is a possibility to reorient the policies of our nation towards the vulnerable. It should take all of us to achieve this – the government, civil society, and religious communities. If we do not sincerely address the dire challenges faced by the poor, we must get ready for chaos.


Published by the good folks at The Elephant.

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