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COVID-19: Uganda Must Take Robust Measures to Defeat the Coronavirus Pandemic

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The coronavirus pandemic will end but without strong public services, Uganda will remain vulnerable to the next epidemic, pandemic or extreme climate event. The health, water and sanitation and all other sectors must be transformed into robust, life-enhancing government services.

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COVID-19: Uganda Must Take Robust Measures to Defeat the Coronavirus Pandemic
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The onset of the COVID-19 pandemic has challenged the public service infrastructure as never before. We commend the government for the efforts it has made to limit the contagion. In particular, we commend health service personnel for their tireless round-the-clock monitoring, testing and treatment of those affected by the disease.

I appreciate the 300 water points rolled out by the National Water and Sewerage Corporation and Kampala Capital City Authority on Friday 27 March. NWSC must be funded to enable them to continue to offer handwashing points in urban areas.

It is heartening to observe the positive public response to the Ministry of Health guidance and directives. I join the President of Uganda in emphasising that the contagion can only be stopped if we collectively practice physical distancing, frequent handwashing and avoiding touching our faces. These are the only preventive measures possible. There is no cure available so far.

The Director of the World Health Organisation, which is at the forefront of the fight against the pandemic, has described lockdowns as “extreme social & economic restrictions”.

In Uganda, our first confirmed case of COVID-19 was detected on 21 March 2020. As of Friday 3 April, Uganda had 48 confirmed cases. It is not easy for public servants and it is not easy for the ordinary citizen, but if we continue to cooperate, the pandemic will end. Uganda is among the countries with fewer than 100 cases and we stand a good chance of overcoming this crisis if we make the right policy choices now.

We agree with the WHO that the lockdown provides a window of opportunity to curb and finally defeat the disease but also to prevent a resurgence of infections once the lockdown is lifted. We believe it is necessary to “Refocus the whole of government on suppressing and controlling Covid19”, as Dr Tedros Ghebreyesus, Director-General of the WHO, has advised.

The World Health Organisation, which is at the forefront of the fight against the pandemic, has described lockdowns as “extreme social & economic restrictions”

We agree that “on their own, these measures will not extinguish epidemics”. We adopt the recommendation that, to be effective, the lockdown must be accompanied by measures aimed at strengthening the health service. It is our view that Uganda’s response to this pandemic can lay the foundations for a healthier and better-prepared country.

In everything we do, we must prioritise the safety of the health workers at the frontline. We therefore propose that they are provided with daily transport, risk and other duty-facilitating allowances, as well as personal protective equipment (PPE). In his address to the nation on 31 March, the President reported that health workers in upcountry facilities are avoiding suspected COVID-19 cases because they lack protective gear. This is unfortunate and must be addressed immediately at all Regional Referral Hospitals. It was shocking to hear in the Presidential Address on Friday 3 March that Uganda only has 10 per cent of the PPE required at this time.

We also support the call by some members of Parliament to pay health workers a motivational allowance, on time and during this crisis, not in arrears.

It may not be possible in the short term to expand, train and deploy our healthcare and public health workforce as recommended but the recruitment process can begin. The news that hundreds of healthcare workers are being recruited at all levels is welcome. Hopefully, the majority are clinicians and nurses.

What is possible in Uganda in the short-term is to continue efforts to “find, isolate, test, treat and trace” those who may have been exposed to the virus and who together with their families are at risk. Of the 48 cases, nearly all were incoming travellers and contacts of travellers arriving mostly from Dubai, 15 from the United Kingdom, three from the United States, one from Kenya. By 28 March, only three confirmed cases were not incoming travellers. We wish them all an easy recovery.

Uganda is among the countries with fewer than 100 cases and we stand a good chance of overcoming this crisis if we make the right policy choices now

In the two weeks prior to the airport closure, 2,661 high-risk travellers entered the country. Also, there are others that had not been identified before Dubai emerged as a high-risk country. Less than 1,000 of these people have been quarantined and tested. It would help to offer amnesty to the hundreds remaining to encourage them to come forward. The security services need only be deployed if there is further failure to cooperate after the amnesty is announced. In any event, the forces should endeavour to treat citizens with the respect they deserve. Wanton violence of the type we have seen contributes nothing to disease control and undermines faith in the government to lead us out of this crisis.

As has been noted, the more tests done, the greater the number of positive diagnoses. While we appreciate the donation of testing equipment from the WHO and Jack Ma, we note that we remain vulnerable as long as our capacity to test depends on donations. We recommend that Uganda seeks short-term measures to find funds for test kits. The public needs to be informed whether all the tests being used are WHO-approved. There is some concern about the potential for false negative results and, being a “fragile State” that is receiving multiple donations, we need assurance that all equipment is up to par.

Regional Referral Hospitals, and Naggulu and Mulago Specialised Hospitals, have been tasked with the management of COVID-19 cases. The input of the Uganda Medical Association, whose members are at the frontline of this battle, is required in signing off those entities equipped to take on the task. This will ensure healthcare workers at those designated facilities have adequate equipment, drugs and PPE. It is hoped that funds will be made available to provide testing facilities in hospitals outside Entebbe.

Wanton violence of the type we have seen contributes nothing to disease control and undermines faith in the government to lead us out of this crisis

Biosafety professionals should be involved in setting up any quarantine sites outside hospital settings to avoid healthcare-associated infections after the pandemic passes. The same should apply to General Hospitals and all Health Centre IVs if the need arises. Regional quarantine and treatment centres are needed to ensure everyone has a good chance of survival wherever in the country they may live as transporting patients across the country puts health workers at risk. Moreover, disinfection of markets, taxi parks and, where possible, other public places should take place before the lockdown is lifted.

Funding the fight

To fund the interventions we request that money currently allocated to Ministries, Departments and Agencies for non-essential activities be reallocated to increasing the number of tests carried out per day and providing transport and PPE for health workers. For example, fuel expenditure saved by grounding government vehicles and cancelling bench-marking trips, conferences, and treatment abroad for ailments that are treatable in Uganda, should also be reallocated to the health sector. Above all, we should minimise waste; expenditure on advertising in the media, printing official bulletins and so on, is not a priority. As WHO recommends, the way forward is “find, isolate, test, treat & trace”.

Most challenging, however, is the third recommendation from WHO: “Expand, train & deploy your health care & public health workforce”. Currently, we have five hospital beds per 10,000 people, 200 intensive care units and less than one (0.9) doctor per 10,000 people. To further complicate matters, other affected countries will seek to import our doctors to combat COVID-19 in their countries. The United States has already invited work visa applications from doctors. The US has 25.9 doctors per 100,000 people but 300,000 COVID-19 cases. Robust interventions on our part will serve in the current crisis and during any future health crises.

As WHO recommends, the way forward is “find, isolate, test, treat & trace”

The immediate sizeable source of funds would be the suspension of the Lubowa Specialised Hospital Project targeting health tourists. The total project cost is Sh1.4 trillion ($379 million). After the first payment of Sh327 billion ($87million), there remains a balance of Sh139 billion. These funds are needed to provide primary healthcare, intensive care and emergency care for Ugandans. (The existing budget for the 41 hospitals to be built in 39 districts is Sh1.3 trillion.) The reallocation from Lubowa Hospital should take place as soon as possible and should the lender decline, the rest of the loan should be cancelled.

Easing the Economic Impact of COVID-19

The majority of Ugandans are employed in the informal sector. In fact, 83 per cent of non-agricultural workers are in the informal sector (World Bank Databank). The majority of workers (75.2 per cent) are classified as being in “vulnerable employment” (Human Development Report 2019, UNDP). What this means is they do not have health insurance and are unlikely to have savings or any other form of social safety net. For the fishermen and small traders who pay annual licence fees, Uganda Revenue Authority could consider extending the validity of those licences to take account of trade lost during the pandemic.

Borrowers from the Youth Livelihood Programme and the Women’s Entrepreneurship Programme present a problem. The 83,000 participants in the government-funded loan schemes such as the Youth Livelihood Programme were already having difficulties making repayments and the majority defaulted. During this time we request that the government suspends the pursuing of defaulters and resumes collections when normal work resumes.

Those in debt to micro-finance companies can be assisted by freezing interest accumulation during the lockdown and extending repayment periods once work resumes. Boda boda riders who have bought their motorcycles on credit fall into this category.

Formal Small and Medium Enterprises face similar loan repayment challenges and require similar consideration. The Bank of Uganda has the responsibility to use those mechanisms as are within in its powers to maintain economic stability. It should ensure that SMEs are not forced out of business by enabling banks to extend repayment periods for loans. In this connection, borrowers forced to default should not be penalised and listed by the Credit Rating Bureau.

Both the formal and informal sectors increasingly use digital means to do business. To reduce the use of potentially infectious money, and to make transactions more affordable, we request that the government lift the OTT tax (excise duty on over-the-top services). The government is also urged to reach an agreement with Telcos to further reduce their rates for all telephony.

Mortgages and rent

Without work, the informal sector and struggling SME owners may be unable to pay rent and may face eviction. Bear in mind landlords too may rely on the rent to repay building loans and cater for their families. Therefore, for those in the informal sector we request that the government works out an arrangement with landlords to grant a month’s grace period for those forced to default on rent. The government could take on the debt for the period of the lockdown. For those in the formal sector, the government should consider guaranteeing the rent and mortgage payments and later recover them from salary or from the National Social Security Fund (NSSF) savings of the tenant. Moreover, the NSSF Act needs to be amended to give members access to their savings during emergencies in future.

Utilities

Payment of electricity and water bills will become more difficult in the days ahead. The National Water and Sewerage Corporation has explained that it is unable to waive water charges because it too must meet its obligations to employees and suppliers.

What is needed are subsidies for consumers in difficulty. Two options are possible for a fixed period: a VAT waiver on water and electricity or selective subsidies through Yaka credits and water credits for those most in need. It should be possible to apply online or to regional offices and be granted these credits according to criteria agreed upon between the government and the utilities providers.

Social protection of the most vulnerable

We note the relief being distributed to the vulnerable in Kampala and Wakiso districts. It is true that many urban dwellers have been suddenly deprived of incomes and require support. However, rural people in vulnerable employment are also affected by the lockdown through loss of income. Many depend on roadside markets between towns and cities, traffic which no longer exists.

The elderly are the most vulnerable because globally fatalities have been most prevalent among this demographic and also because their caregivers will be unable to provide for them as before. Yet many of the elderly are themselves caregivers to grandchildren and employers of farm workers. The government has already compiled a list of the aged to which it pays a monthly grant. This Senior Citizens’ Grant is vital in keeping the rural economy afloat and for children being cared for during this time and therefore it must be paid in full and in a timely manner.

The incapacitated and those whose caregivers are themselves incapacitated by illness will need to be added to the list of the vulnerable as will the unemployed who will lose caregiver support. Nearly all Ugandans are at risk of financial disaster if they were to become seriously ill. The Human Development Report states that 75 per cent of Ugandans are at risk of catastrophic expenditure – expenditure which wipes them out financially – were they to require surgery. COVID-19 may not require surgery but in the worst cases (should they appear) it will require intensive care. With a reported 200 ICU beds nationally and most probably all occupied, the situation is dire.

In the absence of public transport, a special public transportation plan for patients and expectant mothers travelling to hospitals and medical centres should be put in place. The beginnings have been difficult as travel passes have not been easy to obtain. We propose hiring and branding vehicles for delivering COVID-19 patients to health facilities. The modalities can be worked out by the Joint Task Force. People Power Co-ordinators will be available to assist in locating those who require transport to health facilities.

The 21 per cent of people living in poverty forms a large part of the vulnerable section of the population. Undernourishment (caloric intake below minimum energy requirements) has been steadily rising for the last 14 years, from 29 per cent to 41 per cent. We have been advised by the Ministry of Health that people have a better chance of surviving COVID-19 infection if they are adequately nourished. To exclude them from the lockdown-affected persons requiring assistance is unfair and counter-productive as they are more likely to succumb to infection.

Disaster preparedness

We cannot afford not to be prepared for other disasters. The shortage in medical masks, respirators, gowns and goggles caught Uganda unprepared yet this was forecast by the World Health Organisation on 27 February.

A resurgence of the desert locust plague in the region was forecast to begin in early May. A swarm entered Amudat district for the second time on 3 April. If it grows, there will be food shortages.

Extreme climate events such as mudslides this rainy season cannot be ruled out either. Our preparedness should reflect the seriousness of the situation and funds set aside to deal with any eventualities. A government statutory contingency fund must be put in place with immediate effect.

On an individual level, to increase food security, owners of uncultivated land are requested to either plant staple foods or allow food to be planted on their land during this rainy season. This arrangement would be limited to this season that is coinciding with the lockdown period.

Funding the safety net

To fund the social safety net, it will be necessary for the government itself to get debt relief on the national debt. Currently over 65 per cent of revenues goes towards debt payment. While we appreciate the World Bank’s call for suspension of debt repayments to development partners and offer of a loan package to finance the campaign against COVID-19, this is not a time to acquire more debt. Lenders are aware that Uganda is a fragile state and, therefore, negotiations for debt cancellation to enable us to provide a social safety net must go ahead and they must succeed. The absence of a social safety net is the direct result of ill-advised development policies.

Long-term interventions: Rehabilitation of the Health Care System

People Power has long argued that the stagnation in health and other services must be addressed as a matter of urgency, not in 2022 or in 2026 but now. This pandemic will end but without strong health and other public services, we shall remain vulnerable to the next epidemic, pandemic or extreme climate event. So we would like all interventions to go beyond the COVID-19 pandemic to cater for future needs.

The health, water and sanitation and all other sectors must be transformed into robust, life-enhancing government services.

Health expenditure

Our expenditure on health decreases nearly every year. That trend must be reversed. We must go from spending 6 per cent of GDP on the health service to spending the 15 per cent we signed up to in the Abuja Declaration.

Not surprisingly, a review of the hospitals around the country reveals that the majority have faulty equipment. To finance a health service that meets national requirements, the health insurance scheme that has been in the pipeline for over a decade needs to be rolled out.

We must go from spending 6 per cent of GDP on the health service to spending the 15 per cent we signed up to in the Abuja Declaration.

We need to develop the capacity to manufacture items for clinical use, e.g. protective gear for health workers. We have the capacity. In 2019 young Ugandans developed life-saving and cost-saving bio-medical equipment. All are important because of the nationwide shortage of medical equipment especially in rural areas. Olivia Koburongo and Brian Turyabagye developed the Mama-Ope smart jacket for digital pneumonia diagnosis. In 2018 Phyllis Kyomuhendo invented M-Scan a portable ante-natal ultrasound device. Brian Gitta and colleagues developed a bloodless malaria test (Winner of the Africa Prize for Engineering Innovation, founded by the Royal Academy of Engineering in the UK); we often cannot afford reagents used to test blood. In 2014 Dr Chris Nsamba developed an incubator for premature babies which he donated to the government. It is in use at Mukono Health Centre IV whereby last year it had saved the lives of 243 critically ill babies. Uganda has one of the highest rates of premature deaths in the world.

In 2019 young Ugandans developed life-saving and cost-saving bio-medical equipment

However, Dr Nsamba failed to get any government funding although a government agency later claimed to have sponsored the development. The government should make a firm commitment to support local innovators by buying their products while following procurement rules to give all innovators a competitive chance.

Water and Sanitation

Only 18 per cent of the population has access to basic sanitation services with which to keep themselves and their homes healthy. Of every 100,000 deaths, 31 are related to unsafe water and poor sanitation and hygiene services. Of every 100,000 deaths, 159 are caused by household and air pollution (Human Development Report 2019, UNDP).

In the long term, there needs to be an investment in the water sector that meets the needs of the 82 per cent without access to basic sanitation services.

We are grateful for the government’s transparency in admitting that the limited water supply to homes has been caused by “poor planning and implementation of programmes over the years”. As a result, the water and environment sector now needs at least nine times the present level of funding every year for the next 12 years to meet national development targets (Budget Monitoring and Accountability Unit Briefing Paper 30/19, Ministry of Finance, June 2019).

Environment

During the lockdown many will struggle to get fuel for cooking. Under normal circumstances, less than 1 per cent of Ugandans has access to clean fuels and technologies for cooking. Apart from being unsustainable environmentally, the daily search for firewood, like the daily trip for water, takes away time children would otherwise have spent in school, acquiring skills to innovate for our survival as a people.

Human Development

We have an opportunity to reflect on the type of nation we want to be. Are we willing to invest in our human development and well-being or will we forever belong to WHO’s category of “the most fragile and vulnerable countries”?

Human development costs money. We will only see a change if we manage our resources better, this goes both to government and to the population. We must eliminate non-essential expenditure; expenditure on salaries of political appointees and on electioneering – cash handouts in return for votes. We must eradicate waste; last year vehicles were bought at a cost of $5.5 million for the Commonwealth Parliamentarians Conference. It was said that they would thereafter be used for government work but they have not been surrendered to the pool for use in fighting COVID-19. The recent budget proposals for the desert locust emergency, especially by the ICT ministry, show that we have not learned this yet.

As a Nation, we need to reflect on the wisdom of splintering the country into tiny entities paying salaries for MPs, and public service but remaining financially unable to maintain decent health centres, hospitals or roads, or to deliver quality education in most local government institutions.

As individuals, each one of us must have as much integrity as we expect from our leaders. In the last four years, Uganda lost Sh28 billion in the Youth Livelihood Programme. An audit of a sampling of Youth Livelihood Project groups which received loans found that 64 per cent were non-existent (representing 71 per cent of the value of the loans). Another 25 per cent had embezzled the funds. This means that repayments were not available for re-lending to new Youth Interest Groups.

We must never again be found without sufficient medical facilities. We must never again find ourselves lacking water with which to wash our hands and prevent disease.

The physical environment in which we live and work can and must be transformed. Unsanitary working conditions in markets and other public places must be addressed beginning with the NWSC/KCCA handwashing points which we expect will become a permanent feature.

We must never again find ourselves lacking water with which to wash our hands and prevent disease.

A durable solution to the broken public transport system is needed, especially in cities and towns. This pandemic has taught us that public transport is a public good that must be supplied, regulated, maintained and sanitised by the government. Supplementary systems are well and good, but the primary responsibility for public transport lies with the government.

On behalf of the millions of People Power foot soldiers across the country, I call upon the government of Uganda and all Ugandans to reflect and consider the proposals I have laid out here.

For God and My Country.

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Robert Kyagulanyi Sentamu, AKA Bobi Wine, is the Member of Parliament for Kyadondo East and leader of Uganda’s People Power Movement.

Politics

Kenya Chooses Its Next Chief Justice

The search for Kenya’s next Chief Justice that commenced Monday will seek to replace Justice David Maraga, who retired early this year, has captured the attention of the nation.

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Kenya Chooses Its Next Chief Justice
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Since Monday, the 12th of April 2021, interviews to replace retired Chief Justice David Maraga for the post of the most important jurist in Kenya and the president of the Supreme Court have been underway.

The Judiciary is one of the three State organs established under Chapter 10, Article 159 of the Constitution of Kenya. It establishes the Judiciary as an independent custodian of justice in Kenya. Its primary role is to exercise judicial authority given to it, by the people of Kenya.

The institution is mandated to deliver justice in line with the Constitution and other laws. It is expected to resolve disputes in a just manner with a view to protecting the rights and liberties of all, thereby facilitating the attainment of the ideal rule of law.

The man or woman who will take up this mantle will lead the Judiciary at a time when its independence and leadership will be paramount for the nation. He/she will be selected by the Judicial Service Commission in a competitive process.

KWAMCHETSI MAKOKHA profiles the ten candidates shortlisted by the JSC.

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Politics

IMF and SAPs 2.0: The Four Horsemen of the Apocalypse are Riding into Town

Stabilisation, liberalisation, deregulation, and privatisation: what do these four pillars of structural adjustment augur for Kenya’s beleaguered public health sector?

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IMF and SAPs 2.0: The Four Horsemen of the Apocalypse are Riding into Town
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The International Monetary Fund’s announcement on the 2nd of April 2020 that it had approved a US$ 2.3 billion loan for Kenya prompted David Ndii to spell it out to young #KOT (Kenyans on Twitter) that “the loan Kenya has taken is called a structural adjustment loan (SAPs). It comes with austerity (tax raises, spending cuts, downsizing) to keep Kenya creditworthy so that we can continue borrowing and servicing debt”, adding that the “IMF is not here for fun. Ask older people.” With this last quip, Ndii was referring to the economic hardship visited on Kenyans under the structural adjustment programmes of the 80s and 90s.

Well, I’m old enough to remember; except that I was not in the country. I had left home, left the country, leaving behind parents who were still working, still putting my siblings through school. Parents with permanent and pensionable jobs, who were still paying the mortgage on their modest “maisonette” in a middle class Nairobi neighbourhood.

In those pre-Internet, pre-WhatsApp days, much use was made of the post office and I have kept the piles of aerogramme letters that used to bring me news of home. In those letters my parents said nothing of the deteriorating economic situation, unwilling to burden me with worries about which I could do nothing, keeping body and soul together being just about all I could manage in that foreign land where I had gone to further my education.

My brother Tony’s letters should have warned me that all was not well back home but he wrote so hilariously about the status conferred on those men who could afford second-hand underwear from America, complete with stars and stripes, that the sub-text went right over my head. I came back home for the first time after five years — having left college and found a first job — to find parents that had visibly aged beyond their years and a home that was palpably less well-off financially than when I had left. I’m a Kicomi girl and something in me rebelled against second-hand clothes, second-hand things. It seemed that in my absence Kenya had regressed to the time before independence, the years of hope and optimism wiped away by the neoliberal designs of the Bretton Woods twins. I remember wanting to flee; I wanted to go back to not knowing, to finding my family exactly as I had left it — seemingly thriving, happy, hopeful.

Now, after eight years of irresponsible government borrowing, it appears that I am to experience the effects of a Structural Adjustment Programme first-hand, and I wonder how things could possibly be worse than they already are.

When speaking to Nancy* a couple of weeks back about the COVID-19 situation at the Nyahururu County Referral Hospital in Laikipia County, she brought up the issue of pregnant women having to share beds in the maternity ward yet — quite apart from the fact that this arrangement is unacceptable whichever way you look at it — patients admitted to the ward are not routinely tested for COVID-19.

Nancy told me that candidates for emergency caesarean sections or surgery for ectopic and intra-abdominal pregnancies must wait their turn at the door to the operating theatre. Construction of a new maternity wing, complete with its own operating theatre, has ground to a halt because, rumour has it, the contractor has not been paid. The 120-bed facility should have been completed in mid-2020 to ease congestion at the Nyahururu hospital whose catchment area for referrals includes large swathes of both Nyandarua and Laikipia counties because of its geographical location.

According to Nancy, vital medicine used to prevent excessive bleeding in newly delivered mothers has not been available at her hospital since January; patients have to buy the medication themselves. This issue was also raised on Twitter by Dr Mercy Korir who, referring to the Nanyuki Teaching and Referral Hospital — the only other major hospital in Laikipia County — said that lack of emergency medication in the maternity ward was putting the lives of mothers at risk. Judging by the responses to that tweet, this dire situation is not peculiar to the Nanyuki hospital; how much worse is it going to get under the imminent SAP?

Kenya was among the first countries to sign on for a SAP in 1980 when commodity prices went through the floor and the 1973 oil crisis hit, bringing to a painful halt a post-independence decade of sustained growth and prosperity. The country was to remain under one form of structural adjustment or another from then on until 1996.

Damaris Parsitau, who has written about the impact of Structural Adjustment Programmes on women’s health in Kenya, already reported in her 2008 study that, “at Nakuru District Hospital in Kenya, for example, expectant mothers are required to buy gloves, surgical blades, disinfectants and syringes in preparation for childbirth”. It would appear that not much has changed since then.

The constitution of the World Health Organisation states that “the enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion, political belief, economic or social condition” and that “governments have a responsibility for the health of their peoples which can be fulfilled only by the provision of adequate health and social measures.”

The WHO should have added gender as a discrimination criteria. Parsitau notes that “compared to men, women in Kenya have less access to medical care, are more likely to be malnourished, poor, and illiterate, and even work longer and harder. The situation exacerbates women’s reproductive role, which increases their vulnerability to morbidity and mortality.”

With economic decline in the 80s, and the implementation of structural adjustment measures that resulted in cutbacks in funding and the introduction of cost sharing in a sector where from independence the government had borne the cost of providing free healthcare, the effects were inevitably felt most by the poor, the majority of who — in Kenya as in the rest of the world — are women.

A more recent review of studies carried out on the effect of SAPs on child and maternal health published in 2017 finds that “in their current form, structural adjustment programmes are incongruous with achieving SDGs [Sustainable Development Goals] 3.1 and 3.2, which stipulate reductions in neonatal, under-5, and maternal mortality rates. It is telling that even the IMF’s Independent Evaluation Office, in assessing the performance of structural adjustment loans, noted that ‘outcomes such as maternal and infant mortality rates have generally not improved.’”

The review also says that “adjustment programmes commonly promote decentralisation of health systems [which] may produce a more fractious and unequal implementation of services — including those for child and maternal health — nationally. Furthermore, lack of co-ordination in decentralised systems can hinder efforts to combat major disease outbreaks”. Well, we are in the throes of a devastating global pandemic which has brought this observation into sharp relief. According to the Ministry of Health, as of the 6th of April, 325,592 people had been vaccinated against COVID-19. Of those, 33 per cent were in Nairobi County, which accounts for just 9.2 per cent of the country’s total population of 47,564,296 people.

The Constitution of Kenya 2010 provides the legal framework for a rights-based approach to health and is the basis for the rollout of Universal Health Coverage (UHC) that was announced by President Uhuru Kenyatta on 12 December 2018 — with the customary fanfare — as part of the “Big Four Agenda” to be fulfilled before his departure in 2022.

However, a KEMRI-Wellcome Trust policy brief states that UHC is still some distance to achieving 100 per cent population coverage and recommends that “the Kenyan government should increase public financing of the health sector. Specifically, the level of public funding for healthcare in Kenya should double, if the threshold (5% of GDP) … is to be reached” and that “Kenya should reorient its health financing strategy away from a focus on contributory, voluntary health insurance, and instead recognize that increased tax funding is critical.”

These recommendations, it would seem to me, run counter to the conditionalities habitually imposed by the IMF and it is therefore not clear how the government will deliver UHC nation-wide by next year if this latest SAP is accompanied by budgetary cutbacks in the healthcare sector.

With the coronavirus graft scandal and the disappearance of medical supplies donated by Jack Ma still fresh on their minds, Kenyans are not inclined to believe that the IMF billions will indeed go to “support[ing] the next phase of the authorities’ COVID-19 response and their plan to reduce debt vulnerabilities while safeguarding resources to protect vulnerable groups”, as the IMF has claimed.

#KOT have — with outrage, with humour, vociferously — rejected this latest loan, tweeting the IMF in their hundreds and inundating the organisation’s Facebook page with demands that the IMF rescind its decision. An online petition had garnered more than 200,000 signatures within days of the IMF’s announcement. Whether the IMF will review its decision is moot. The prevailing economic climate is such that we are damned if we do take the loan, and damned if we don’t.

Structural adjustment supposedly “encourages countries to become economically self-sufficient by creating an environment that is friendly to innovation, investment and growth”, but the recidivist nature of the programmes suggests that either the Kenyan government is a recalcitrant pupil or SAPs simply don’t work. I would say it is both.

But the Kenyan government has not just been a recalcitrant pupil; it has also been a consistently profligate one. While SAPs do indeed provide for “safeguarding resources to protect vulnerable groups”, political choices are made that sacrifice the welfare of the ordinary Kenyan at the altar of grandiose infrastructure projects, based on the fiction peddled by international financial institutions that infrastructure-led growth can generate enough income to service debt. And when resources are not being wasted on “legacy” projects, they are embezzled on a scale that literally boggles the mind. We can no longer speak of runaway corruption; a new lexicon is required to describe this phenomenon which pervades every facet of our lives and which has rendered the years of sacrifice our parents endured meaningless and put us in debt bondage for many more generations to come. David Ndii long warned us that this moment was coming. It is here.

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Politics

East Africa: A ‘Hotbed of Terror’

African states are involved in the War on Terror more than we think. They’re surrounded by an eco-system of the war industry.

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East Africa: A ‘Hotbed of Terror’
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In late January, reports circulated on social media about a suspected US drone strike in southern Somalia, in the Al-Shabaab controlled Ma’moodow town in Bakool province. Debate quickly ensued on Twitter about whether the newly installed Biden administration was responsible for this strike, which was reported to have occurred at 10 p.m. local time on January 29th, 2021.

Southern Somalia has been the target of an unprecedented escalation of US drone strikes in the last several years, with approximately 900 to 1,000 people killed between 2016 and 2019. According to the nonprofit group Airwars, which monitors and assesses civilian harm from airpower-dominated international military actions, “it was under the Obama administration that a significant US drone and airstrike campaign began,” coupled with the deployment of Special Operations forces inside the country.

Soon after Donald Trump took office in 2017, he signed a directive designating parts of Somalia “areas of active hostilities.” While the US never formally declared war in Somalia, Trump effectively instituted war-zone targeting rules by expanding the discretionary authority of the military to conduct airstrikes and raids. Thus the debate over the January 29 strike largely hinged on the question of whether President Joe Biden was upholding Trump’s “flexible” approach to drone warfare―one that sanctioned more airstrikes in Somalia in the first seven months of 2020 than were carried out during the administrations of George W. Bush and Barack Obama, combined.

In the days following the January 29 strike, the US Military’s Africa Command (AFRICOM) denied responsibility, claiming that the last US military action in Somalia occurred on January 19, the last full day of the Trump presidency. Responding to an inquiry from Airwars, AFRICOM’s public affairs team announced:

We are aware of the reporting. US Africa Command was not involved in the Jan. 29 action referenced below. US Africa Command last strike was conducted on Jan. 19. Our policy of acknowledging all airstrikes by either press release or response to query has not changed.

In early March, The New York Times reported that the Biden administration had in fact imposed temporary limits on the Trump-era directives, thereby constraining drone strikes outside of “conventional battlefield zones.” In practice, this means that the US military and the CIA now require White House permission to pursue terror suspects in places like Somalia and Yemen where the US is not “officially” at war. This does not necessarily reflect a permanent change in policy, but rather a stopgap measure while the Biden administration develops “its own policy and procedures for counterterrorism kill-or-capture operations outside war zones.”

If we take AFRICOM at its word about January 29th, this provokes the question of who was behind that particular strike. Following AFRICOM’s denial of responsibility, analysts at Airwars concluded that the strike was likely carried out by forces from the African Union peacekeeping mission in Somali (AMISOM) or by Ethiopian troops, as it occurred soon after Al-Shabaab fighters had ambushed a contingent of Ethiopian troops in the area. If indeed the military of an African state is responsible for the bombing, what does this mean for our analysis of the security assemblages that sustain the US’s war-making apparatus in Africa?

Thanks to the work of scholars, activists, and investigative journalists, we have a growing understanding of what AFRICOM operations look like in practice. Maps of logistics hubs, forward operating sites, cooperative security locations, and contingency locations―from Mali and Niger to Kenya and Djibouti―capture the infrastructures that facilitate militarism and war on a global scale. Yet what the events of January 29th suggest is that AFRICOM is situated within, and often reliant upon, less scrutinized war-making infrastructures that, like those of the United States, claim to operate in the name of security.

A careful examination of the geographies of the US’s so-called war on terror in East Africa points not to one unified structure in the form of AFRICOM, but to multiple, interconnected geopolitical projects. Inspired by the abolitionist thought of Ruth Wilson Gilmore, who cautions activists against focusing exclusively on any one site of violent exception like the prison, I am interested in the relational geographies that sustain the imperial war-making infrastructure in Africa today. Just as the modern prison is “a central but by no means singularly defining institution of carceral geography,” AFRICOM is a fundamental but by no means singularly defining instrument of war-making in Africa today.

Since the US military’s embarrassing exit from Somalia in 1993, the US has shifted from a boots-on-the ground approach to imperial warfare, instead relying on African militaries, private contractors, clandestine ground operations, and drone strikes. To singularly focus on AFRICOM’s drone warfare is therefore to miss the wider matrix of militarized violence that is at work. As Madiha Tahir reminds us, attack drones are only the most visible element of what she refers to as “distributed empire”—differentially distributed opaque networks of technologies and actors that augment the reach of the war on terror to govern more bodies and spaces. This dispersal of power requires careful consideration of the racialized labor that sustains war-making in Somalia, and of the geographical implications of this labor. The vast array of actors involved in the war against Al-Shabaab has generated political and economic entanglements that extend well beyond the territory of Somalia itself.

Ethiopia was the first African military to intervene in Somalia in December 2006, sending thousands of troops across the border, but it did not do so alone. Ethiopia’s effort was backed by US aerial reconnaissance and satellite surveillance, signaling the entanglement of at least two geopolitical projects. While the US was focused on threats from actors with alleged ties to Al-Qaeda, Ethiopia had its own concerns about irredentism and the potential for its then-rival Eritrea to fund Somali militants that would infiltrate and destabilize Ethiopia. As Ethiopian troops drove Somali militant leaders into exile, more violent factions emerged in their place. In short, the 2006 invasion planted the seeds for the growth of what is now known as Al-Shabaab.

The United Nations soon authorized an African Union peacekeeping operation (AMISOM) to “stabilize” Somalia. What began as a small deployment of 1,650 peacekeepers in 2007 gradually transformed into a number that exceeded 22,000 by 2014. The African Union has emerged as a key subcontractor of migrant military labor in Somalia: troops from Burundi, Djibouti, Ethiopia, Kenya, and Uganda deployed to fight Al-Shabaab are paid significantly higher salaries than they receive back home, and their governments obtain generous military aid packages from the US, UK, and increasingly the European Union in the name of “security.”

But because these are African troops rather than American ones, we hear little of lives lost, or of salaries not paid. The rhetoric of “peacekeeping” makes AMISOM seem something other than what it is in practice—a state-sanctioned, transnational apparatus of violent labor that exploits group-differentiated vulnerability to premature death. (This is also how Gilmore defines racism.)

Meanwhile, Somali analyst Abukar Arman uses the term “predatory capitalism” to describe the hidden economic deals that accompany the so-called stabilization effort, such as “capacity-building” programs for the Somali security apparatus that serve as a cover for oil and gas companies to obtain exploration and drilling rights. Kenya is an important example of a “partner” state that has now become imbricated in this economy of war. Following the Kenya Defense Forces (KDF) invasion of Somalia in October 2011, the African Union’s readiness to incorporate Kenyan troops into AMISOM was a strategic victory for Kenya, as it provided a veneer of legitimacy for maintaining what has amounted to a decade-long military occupation of southern Somalia.

Through carefully constructed discourses of threat that build on colonial-era mappings of alterity in relation to Somalis, the Kenyan political elite have worked to divert attention away from internal troubles and from the economic interests that have shaped its involvement in Somalia. From collusion with Al-Shabaab in the illicit cross-border trade in sugar and charcoal, to pursuing a strategic foothold in offshore oil fields, Kenya is sufficiently ensnared in the business of war that, as Horace Campbell observes, “it is not in the interest of those involved in this business to have peace.”

What began as purportedly targeted interventions spawned increasingly broader projects that expanded across multiple geographies. In the early stages of AMISOM troop deployment, for example, one-third of Mogadishu’s population abandoned the city due to the violence caused by confrontations between the mission and Al-Shabaab forces, with many seeking refuge in Kenya. While the mission’s initial rules of engagement permitted the use of force only when necessary, it gradually assumed an offensive role, engaging in counterinsurgency and counterterror operations.

Rather than weaken Al-Shabaab, the UN Monitoring Group on Somalia observed that offensive military operations exacerbated insecurity. According to the UN, the dislodgment of Al-Shabaab from major urban centers “has prompted its further spread into the broader Horn of Africa region” and resulted in repeated displacements of people from their homes. Meanwhile, targeted operations against individuals with suspected ties to Al-Shabaab are unfolding not only in Somalia itself, but equally in neighboring countries like Kenya, where US-trained Kenyan police employ military tactics of tracking and targeting potential suspects, contributing to what one Kenyan rights group referred to as an “epidemic” of extrajudicial killings and disappearances.

Finally, the fact that some of AMISOM’s troop-contributing states have conducted their own aerial assaults against Al-Shabaab in Somalia demands further attention. A December 2017 United Nations report, for example, alleged that unauthorized Kenyan airstrikes had contributed to at least 40 civilian deaths in a 22-month period between 2015 and 2017. In May 2020, senior military officials in the Somali National Army accused the Kenyan military of indiscriminately bombing pastoralists in the Gedo region, where the KDF reportedly conducted over 50 airstrikes in a two week period. And in January 2021, one week prior to the January 29 strike that Airwars ascribed to Ethiopia, Uganda employed its own fleet of helicopter gunships to launch a simultaneous ground and air assault in southern Somalia, contributing to the deaths—according to the Ugandan military—of 189 people, allegedly all Al-Shabaab fighters.

While each of the governments in question are formally allies of the US, their actions are not reducible to US directives. War making in Somalia relies on contingent and fluid alliances that evolve over time, as each set of actors evaluates and reevaluates their interests. The ability of Ethiopia, Kenya, and Uganda to maintain their own war-making projects requires the active or tacit collaboration of various actors at the national level, including politicians who sanction the purchase of military hardware, political and business elite who glorify militarized masculinities and femininities, media houses that censor the brutalities of war, logistics companies that facilitate the movement of supplies, and the troops themselves, whose morale and faith in their mission must be sustained.

As the Biden administration seeks to restore the image of the United States abroad, it is possible that AFRICOM will gradually assume a backseat role in counterterror operations in Somalia. Officially, at least, US troops have been withdrawn and repositioned in Kenya and Djibouti, while African troops remain on the ground in Somalia. Relying more heavily on its partners in the region would enable the US to offset the public scrutiny and liability that comes with its own direct involvement.

But if our focus is exclusively on the US, then we succumb to its tactics of invisibility and invincibility, and we fail to reckon with the reality that the East African warscape is a terrain shaped by interconnected modes of power. The necessary struggle to abolish AFRICOM requires that we recognize its entanglement in and reliance upon other war-making assemblages, and that we distribute our activism accordingly. Recounting that resistance itself has long been framed as “terrorism,” we would do well to learn from those across the continent who, in various ways over the years, have pushed back, often at a heavy price.

This post is from a partnership between Africa Is a Country and The Elephant. We will be publishing a series of posts from their site once a week.
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