Africa's Post-Conflict Formal and Informal Health Institutions

Overview of Africa's Post-Conflict History and Colonial Legacies

Colonial legacies persist in Africa despite the post-colonial era (Austin, 2010). These legacies have continued to shape post-conflict Africa's history. In Africa, there has been no single unifying factor bringing individuals together, primarily because of the communal nature of society throughout the continent. Community exists and can be found everywhere in Africa. Structural, dramaturgical, and institutional factors in the formal institutionalization of health care in Africa have emerged as a result of investment, development, and political stability (Ratcliffe, 2013). The relationship among cultural traditions, the laws of society, and symbolic boundaries has served to create the structural meanings behind formal institutions; the expressive dimension, communicative properties, and interaction of these elements make up the dramaturgical; and the actors and organizations themselves constitute the institutional. An example of this dynamic can be seen in Nigeria.

Structurally, dramaturgically, and institutionally, Africa has undoubtedly been impacted by the West over the past few centuries. It has not been untouched by the modern era, and in nations like South Africa one can see just how much Western influence has shaped African society (Bratton & Van de Walle, 1997). Yet other parts of Africa — such as Eritrea — offer a quality of life for their people that, in some respects, compares favorably to that found in South Africa (Morrison & Stevenson, 1972; Ratcliffe, 2013). This may be because of a closer adherence to native dramaturgical and structural meanings. To make such an argument, however, one must define what is meant by these meanings (Southall, 2003). To do that, one must examine the lives of the people in question — what they themselves value and how well they succeed in attaining those values — rather than applying external values shaped by hundreds of years of experience on another continent and assuming those values will hold significance for the people in question (Southall, 2003). To have a sense of the rules of a community, one must have a sense of the people themselves (Afro-centric Alliance, 2001). There is a community basis for development that is entirely missed by progressive reformers who seek to modernize Africa in accordance with Westernized development models.

Africa has its own mythological leaders and figures. As Prempeh (2007) points out, "the assault on constitutionalism was spearheaded by Africa's larger-than-life founding fathers, leaders like Osagyefo (Victorious Warrior) Kwame Nkrumah (Ghana), Mwalimu (The Teacher) Julius Nyerere (Tanzania), le Grand Silly (Elephant) Sékou Touré (Guinea), Ngwazi (Great Lion) Kamuzu Banda (Malawi), and Mzee (Esteemed Elder) Jomo Kenyatta (Kenya)" (p. 472). These leaders' mythologies were established not necessarily by a yearning growing out of customary and traditional groups who believed their traditional way of life could be facilitated by such figures' political success, but rather by other members of a burgeoning political class — African activists and politicians emerging to fill a void in leadership at the governmental level as the era of colonization came to an end. Prempeh (2007) argues that "nationalist mythology and historiography had invested these leaders with messianic attributes for their role in wrestling sovereign statehood from the jaws of European colonialism" (p. 472). The result is a post-colonial and post-conflict African narrative that functions, in effect, as a form of political propaganda.

Historical Formal Institutions and the Nigerian Case Study

Nigeria is one nation in Africa that has benefited extensively from investment and development, and that has consequently seen its structural, dramaturgical, and institutional formal health care approach change and reflect modern universal trends (Shuaib et al., 2014). Nigeria has also demonstrated a formal capacity to stop the spread of pandemics — as recently as the Ebola pandemic of 2014. Ebola first appeared in Nigeria following the 2014 outbreak that began in West Africa and spread throughout the neighboring state of Guinea. From Guinea, Ebola spread to Liberia, and when a traveler from Liberia arrived at Lagos Airport, the pandemic reached Nigeria. The patient was immediately identified as ill, and death was recorded within five days of arrival. This case was quickly designated as "patient zero" by Nigerian authorities. Through contact tracing, Nigerian health authorities were able to show that this index patient had "potentially exposed 72 persons at the airport and the hospital" (Shuaib et al., 2014, p. 867). The pandemic was swiftly monitored and contained, primarily because of close oversight and decisive action by the Federal Ministry of Health, overseen by the Nigeria Centre for Disease Control — a formal institution modeled on the American CDC. An Ebola emergency was declared immediately; no time was lost in politicizing the matter or debating what to do. A protocol had been established by health authorities and was followed. Nineteen lab-confirmed cases confirmed that the virus was spreading from patient zero, and 1,000 contacts were identified by authorities. Before long the situation was under control, with no sign that the outbreak would cripple the country (Shuaib et al., 2014).

Because Nigeria had experience dealing with outbreaks in the past, its national public health institution was ready to respond to the Ebola outbreak: "six response teams were developed within the Emergency Operations Center (EOC). The EOC specific to an Ebola response, including: 1) Epidemiology Surveillance, 2) Case Management/Infection Control, 3) Social Mobilization, 4) Laboratory Services, 5) Point of Entry, and 6) Management/Coordination" (Shuaib et al., 2014, p. 868). This is but one example of how a formal health institution in Africa has emerged to combat major health crises. However, there are many informal health institutions in Africa that have developed as a result of economic disparities that prevent poorer and impoverished populations from seeking care at formal institutions like Nigeria's (Nelissen et al., 2020).

Community participation is expected in times of pandemics, as the 2014 Ebola crisis in Nigeria demonstrated. Community care provision is also expected and anticipated (Shuaib et al., 2014). Community cost-sharing is a different matter. Cost-sharing initiatives have been implemented in the past — particularly by the World Health Organization in sub-Saharan Africa — but they have not been particularly successful, and many are no longer continued (Burnham et al., 2004; Shaw & Griffin, 1996). The reasons for discontinuation range from political to economic instability (Burnham et al., 2004). Community food security in Africa is also variable and differs widely from state to state. Even before the outbreak of COVID-19, food insecurity was a major problem throughout sub-Saharan Africa (Ehui, 2020). One can find examples of community participation in nearly any African state that can serve as a representative illustration of the continent as a whole — for though Africa is extraordinarily diverse, there is a universality within that diversity.

Evolution of Informal Institutions: Community Level

The Zulu word Ubuntu refers to the capacity of Africans to demonstrate cooperation, humanity, dignity, reciprocity, and compassion without any formal system of government obliging them to do so (Khoza, 2006). Prior to the colonization of South Africa in the 17th century by Western Protestants, the region had already come into contact with the Catholic Portuguese. It consisted of diverse tribal communities in which dozens of languages could be found. To this day its diversity is pronounced, but its social identity has largely been shaped by the concerns of the modern West, including equality and democracy. African customary practices are rooted in age-old theories of collectivism. Claridge (2004) highlights a Western tendency to claim theoretical ownership of these practices by rebranding them under the term "Community Participation" — a new buzzword built upon old concepts of community self-sustainment (Buchy et al., 2000). Ubuntu, a Zulu word that roughly translates to the idea that a person is who they are because of others, has become a universal concept in discussions of Africa, illustrating the extent to which a communal sensibility prevails across the continent (Fraser-Moleketi, 2009, p. 243). The word is now widely regarded in the literature as referring to the African cultural capacity to demonstrate cooperation, humanity, dignity, reciprocity, and compassion (Khoza, 2006, p. 6). The Ubuntu spirit is widely applied across African societies, and its elements can easily be found in many aspects of daily life across East, West, Central, and South African communities (Louw, 2006). Applying the spirit of Ubuntu in the modern world would unlock the capacity of African peoples in particular to express mutuality, humanity, dignity, reciprocity, and compassion in their communities and nations (Poovan, Du Toit & Engelbrecht, 2006, pp. 23–25). In many African countries, love and respect are foundational ideals — both are central to Ubuntu because they are understood to sustain community life. Individual care through informal channels is therefore an accepted practice, as empathy and love inform many communities across the African continent.

Participation in communal life is regarded as an important dimension of Ubuntu. According to Brager et al. (1987), one of the many definitions of participation is a process by which citizens are empowered and their competence increased. By participating in the governance of their societies, citizens can gain political power and strongly influence how their societies are run. Citizen participation is a process through which citizens become responsible for their communities, voice their opinions on issues affecting them, and act for the public good (Poovan et al., 2006). What must be noted is that for citizen participation to work, citizens must act collectively. It is only collective effort that gives citizens the power to influence decisions and political outcomes (Brager et al., 1987).

Ghana is a typical example of African community. The history of Ghana is linked to the Atlantic slave trade, during which Western traders exchanged goods with coastal African communities for enslaved people (Dillard, Duncan & Johnson, 2017). Ghana was not an independent country at the time; in the 15th century the Portuguese established a presence there, only to lose their position to the Dutch (Ofosu-Mensah, 2017). Eventually the British took control of the area, but by the 19th and early 20th centuries African nations were pushing hard for independence from colonial powers. Ghana was formally constituted as a nation in the mid-20th century. Ghana is diverse tribally, with the majority of the population being Akan, followed by Mole-Dagbon, Ewe, Ga-Adangbe, Konkomba, and various other smaller groups (Nathan, 2016). Though English is the official language because of British rule, dozens of recognized languages are spoken in Ghana, from Bono to Wasa. It is a linguistically diverse nation, reflecting the many different tribes and kingdoms that historically existed there. Many African states share this characteristic, illustrating the complexity of generalizing about community life in any one African nation. Families in Ghana, as in much of Africa, are patriarchal and traditional rather than liberal. Families are intimately connected to communities, and ethnic identity is important within the diverse national population. Behaviors are learned by adolescents through observing their parents, who are responsible for passing down customs (Asiseh, Owusu & Quaicoe, 2017). Family values are traditional: homosexuality, for example, is not accepted and the vast majority of the population views it as immoral. Women are expected to fulfill defined social roles, and men are traditionally regarded as heads of households. However, the fertility rate does appear to have declined over the past few decades — from approximately 7 live births per woman in 1970 to just under 4 in 2017, according to the UN (2017). This indicates that modern attitudes towards sex and sexuality are spreading through African communities and that this, in turn, affects how communities share the health burden.