The brain drain of medical professionals from African countries to rich countries in Europe, North America, and the Middle East has been particularly pronounced since the 1980s. As Bibilola Oladeji and Oye Gureje have noted, as of 2011, there were more than 17,000 African physicians practicing in the US alone, over two-thirds of whom had been trained in African medical schools. Of this group, two-thirds were trained either in Nigeria or South Africa, the two countries with the most extensive medical training systems on the continent. Psychiatrists have also made up a significant piece of the larger medical migration, drawn by higher salaries, better facilities, opportunities for professional development, and prospects for long-term stability to seek jobs outside of the continent.
The brain drain has become a commonplace terminology to describe the emigration of highly skilled labor from developing countries to highly industrialized states in the post-colonial world. The concept has been particularly valuable for understanding persistent underdevelopment in sub-Saharan African countries as related not so much to deficiencies in African expertise as its redirection primarily for the benefit of wealthy countries. Similar to the “brawn drain” of the Atlantic slave trade or the natural resource depletion that characterized European colonialism in much of the continent, brain drain has had long-lasting impacts on African countries’ internal development and position in the global economy.
The impact of the brain drain on mental health care in Africa can be seen through the example of Nigeria, one of the few sub-Saharan African countries with university hospitals providing accredited medical training in psychiatry. Nigeria’s first trained psychiatrist of indigenous background was Thomas Adeoye Lambo, who studied at Birmingham and the Maudsley Hospital in the UK before returning to Nigeria to practice at the newly founded Aro Mental Hospital in 1954. Lambo and his acolyte, Tolani Asuni, developed much of the infrastructure of Nigerian psychiatry in the 1960s and 1970s, and several Nigerian universities began producing psychiatrists by the 1980s. The purpose of developing such programs was to produce a qualified mental health workforce for the country. Students from other countries in West Africa also trained in psychiatry at Nigerian institutions. Nigeria’s mental health care workforce grew slowly but surely from only three psychiatrists in 1955, to 25 by 1975, and 100 by 2001. But the brain drain has had a major impact on Nigerian psychiatry. Today, there are roughly 250 psychiatrists in Nigeria to serve a population of approximately 190 million. At the same time, a study from 2010 found that there were 384 Nigerian psychiatrists practicing in the US, UK, Australia, and New Zealand, a number 50% higher than the estimated total practicing in Nigeria.
The effects of this psychiatric brain drain have been significant. Beyond the worsening of the psychiatrist-to-population ratio, this phenomenon has the potential of severely weakening ongoing reproduction of this limited resource as more freshly qualified psychiatrists and senior residents are being enticed/encouraged to relocate on the guise of training opportunities abroad, from which they never return. In addition to psychiatrists, mental health nurses are also leaving the continent in droves, with packages designed to make emigration easy and more likely to be permanent. The rate of migration far outstrips the rate of production, leaving a huge deficit in human resources, one of the major pillars of a health system, according to the World Health Organization.
Several reasons have been proffered for the exodus of medical doctors from Africa to the economically developed world. Oberoi and Lin classified these reasons into endogenous and exogenous factors. Endogenous factors include poor working conditions, poor remuneration, and lack of job satisfaction and job security with little or no opportunities for career development. Exogenous factors include social pressures from relatives, preponderances of civil unrest, and armed conflicts with attendant high levels of insecurity. Ironically, the factors that push mental health care workers to relocate abroad are the same ones that likely contribute to rates of psychological distress in their communities of origin that, in turn, require more and better mental health care.
Since the late 2000s, the “global mental health” movement has sought to ameliorate this “treatment gap” in mental health services in developing countries, including Nigeria and others in sub-Saharan Africa. In most cases, reducing the treatment gap relies heavily on training lower-qualified workers to perform the duties of highly-skilled practitioners, a set of practices known as “task shifting.” Task shifting in international public health has existed for a long time, and has been employed extensively in the field of HIV/AIDS diagnosis and treatment in many environments. But it’s use in psychiatric care is somewhat more controversial. Most notably, global mental health has been critiqued as potentially socially and culturally insensitive, importing knowledge and practices from western industrialized countries that might not adequately reflect local cultural beliefs or social determinants of health, while simultaneously marginalizing indigenous health systems.
Task shifting has also been proposed as a strategy for alleviating the effects of the brain drain on the health care sector. In a review of policies to address brain drain in sub-Saharan African countries, Edward Zimbudzi has identified some areas of possible intervention. These include ethical recruitment, brain drain tax or compensation for source countries, increasing investment in training more professionals, improving remuneration of health workers and working conditions in general, importing more staff, ensuring political stability, and encouraging remittances. However, the review concluded “that there is considerable consensus on task shifting as the most appropriate and sustainable policy option for reducing the impact of health professional brain drain from Africa.” While some studies have concluded that task shifting has effectively filled the treatment gap, others have indicated that it is by no means a comparable substitute for professional mental health care due to lack of proper supervision and training of lower level workers, among other factors.
But we would like to offer a different critique of the task-shifting discourse: it’s tendency to normalize the brain drain of health care professionals. Global mental health has always emphasized practicality over ideology: anything that can be done to fill the “treatment gap” is presumably better than not doing it. The origins of the medical brain drain are not really global mental health’s concern, but its consequences are a large part of the foundation of the movement’s argument for “scaling up” the health care workforce to address the “treatment gap,” which is effectively the primary justification for the movement’s existence. However, in making the case for immediate action, the discourse on task-shifting in global mental health replicates the long history of ignoring the long-term exploitation of African resources in order to focus on short-term, externally funded, non-state interventions to provide what Africa supposedly “lacks.”
Promoting task shifting to lower cadre health care workers as the best way to scale up mental health services in low- and middle-income countries indirectly suggests that these countries cannot hope for better, even as billions of dollars are lost by African countries from investment in training highly qualified health workers who go on to treat patients in wealthy countries. Meanwhile wealthy countries acquiesce to helping train up less-qualified caregivers to fill the “treatment gap” created in part by this brain drain. It also implies that African countries can get by on less than wealthy countries. Indeed, severe mental illness continues to be neglected under the “task shifting” model that does little to increase specialist capacity to handle such cases. While this rather popular principle in global mental health appears practical, it inadvertently panders to the notion that some lives are more important than others, and calls to question the relative value placed on the health and lives of citizens of the developing countries of Africa compared to the developed world. It reinforces and normalizes global inequalities.
Mitigating the psychiatric brain drain must ultimately be about much more than filling “treatment gaps.” It must also be about addressing the geopolitical and macroeconomic conditions that have produced the gap in the first place. Developing equitable and sustainable mental health services for all Africans is a political, economic, moral, and ethical issue of contemporary urgency and historical significance.
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Africa: COVID-19 Is Deepening Africa’s Democratic Regression
As the recorded number of infections in Africa edges towards the six million mark, it has become clear that COVID-19 is not only a public health challenge.
Apart from the devastating economic impact of lockdowns and related regulations, the pandemic is undermining the well-being of democracy in Africa.
In prioritising public health, governments have drawn on emergency legislation to implement lockdown regulations. These measures narrow the gap between authoritarianism and democracy and can be used as a pretext for authoritarian regimes to hold on to power.
The pandemic struck at a critical time for some of Africa’s democracies and coincided with several elections scheduled for 2020 and 2021. Although some polls went ahead, others were postponed and rescheduled.
The health of democracy in Africa has been in question for some time and postponed elections can add to growing fears of democratic backsliding on the continent.
Postponed elections can threaten democracy in Africa for two reasons: moving an election is a controversial decision that can lead to instability, and uncertainty over whether elections will take place at all does not secure democracy.
Nowhere is this more evident than from Ethiopia’s June 21 parliamentary, regional state council and local elections. Rescheduled twice since August 2020, the postponements were not only a source of controversy, but are also linked to the conflict in the northern Tigray region after the Tigray People’s Liberation Front (TPLF) went ahead with elections in that region in 2020. Ethiopian Prime Minister Abiy Ahmed’s decision to postpone elections was interpreted by the TPLF as a move to extend his power, hiding behind COVID-19 public health concerns.
Further controversy arose after many opposition leaders were jailed, other opposition parties boycotted the polls, and constituencies in some regions were excluded from these elections based on security concerns and registration irregularities. Those regions will allegedly be voting in September 2021, but no elections are on the horizon for Tigray. This makes it hard to call these elections free and fair. Some experts believe that COVID-19 has “dramatically redirected Ethiopia’s political landscape deeper into authoritarianism”. Ethiopia is a key player in the Horn of Africa and the second most populous country on the continent. Its democratic trajectory is therefore of great importance.
Another case to consider is that of Senegal. Regional and local elections in Senegal have been postponed indefinitely from March 28, the third delay since 2019. Senegalese are already protesting the government crackdown on opposition leaders, corruption, and COVID-19-related economic decline. The Senegalese government responded with violence.
Postponing elections is not unheard of but the decision should not be taken lightly. Elections must take place within a specified period, usually five years. As a failsafe, an additional 90-days (usually) are factored in. If the time between elections exceeds this, a country can experience a constitutional crisis.
Delays can be interpreted by opposition parties as a move to consolidate power. Especially where elections have been postponed under states of disaster legislation during the pandemic, democracy has been rattled.
Many governments have abused their additional powers. Freedom House reports that since the start of the pandemic, respect for human rights and democracy has deteriorated in 80 countries across the globe.
Abuses of power include violent crackdowns on protestors, experienced in Nigeria; detention or arrest of government critics, experienced in Zimbabwe; and social media blackouts and media restriction as experienced in Uganda, and Tanzania. To this list can also be added the recent government-sanctioned internet blackout in eSwatini during pro-democracy protests in the country.
It is also possible that proceeding with elections in the name of upholding democracy could have the opposite effect. Higher voter turnout is desirable since it is more representative of the voting population. Despite COVID-19 precautions implemented by election management bodies, citizens may still decide that the risk of infection from venturing out to vote at polling stations is too great and abstain.
Amid a security crisis and the pandemic, Mali proceeded with two rounds of legislative elections in March and April 2020. This combination of security and health threats meant only 23.22 percent of eligible voters turned up to cast their votes. More concerning than the low turnout is the confirmation of these results by Mali’s Constitutional Court.
Regular elections are the hallmark of democracy and allow citizens to voice their views on governments. But due to the COVID-19 pandemic, elections have been postponed worldwide at a rate not experienced before. The International Institute for Democracy and Electoral Assistance reports that between February 21 last year and June 21, 78 countries and territories globally have postponed elections citing coronavirus concerns.
African countries make up 17.9 percent of this total. The pandemic has created many new challenges for governments, not the least of which has been upholding democracy in conditions which call for social distancing and limited numbers of people gathering in groups. Indeed, finding a “democracy-human security balance” is proving to be one of the more complicated tasks facing governments during the pandemic.
COVID-19 could spark a global reconsideration of the electoral process, with remote voting options, such as online voting, enjoying renewed interest. It is important to remember that elections are not the only measure of democracy. Factors such as a level playing field for opposition parties, citizen choice as to whether or note to vote, voter turnout and a free public space are important indicators of the quality of democracy.
Elections are important and should be allowed to go ahead where possible. But what the pandemic teaches is that timing and safety are everything.
This article was first published by the South African Institute of International Affairs (SAIIA).
BBI: Political Tool or State-Building Opportunity?
The Building Bridges Initiative has only opened up the more important discussion of Kenyans coming to terms with their social realities. It cannot be expected to be the silver bullet that will solve the country’s problems.
When the history of Uhuru Kenyatta’s second term at the helm of Kenya’s political leadership is written, it shall cast him in Machiavellian light as a wily fox—a scheming and unscrupulous prince. This history, shall perhaps, at the same time, be magnanimous and laudatory of Raila’s repeated efforts, over the long duration of his career, to demonstrate pragmatism and build bridges on more than three occasions. Indeed, these two politicians, perhaps, shall be looked upon by such an objective history quite kindly for being able, somewhat, to douse the intense fire and latent political violence before and after the 2017 elections. It is undeniable that the private talks, the subsequent highly public political and symbolic “handshake,” and the BBI consultation process was “created by people in the executive to stabilize the state.” However, as contemporary political commentators observed, this initiative has quite a few pitfalls, blindsides, and shortcomings, and this, history shall not forgive. As the constitutional lawyer, and political commentator, Kamotho Waiganjo noted, the BBI shall not “fundamentally solve our problems.” Moreover, the country’s fundamental problems do not lie in the law, but elsewhere.
When put in historical perspective, this political initiative, and the debate around it, only opens the more important discussion of Kenyans coming to terms with their social realities. As Waiganjo stated, citizens must have “an honest national conversation about what ails” Kenya— what takes away our ethos? Why do we celebrate unethical conduct by public servants and officials? Why do we elect people we know are thugs? Why is it that we are corrupt in every sector of our society? According to Waiganjo, that is the substantive conversation that Kenyans ought to have in every sector of society, be it private or public. As such, the BBI cannot be expected to be the be-all and end-all silver bullet that will solve all the country’s various problems (and especially not the two twin tyrannies of ethnic expectation and institutionalized corruption that feed off each other, and are inextricably connected).
As already noted above, while the initiative staved off violence and bloodshed, it largely remains an elite initiative as opposed to being people-led and driven as the protracted constitution-writing process of the 2000s was and, therefore, cannot be as radical, and revolutionary. And, if anything was revolutionary, it was the 2010 constitution, which was the result of a people-driven process. When the account of this process is written, it shall record that this process was, indeed, anything other than “a reform document,” and that, while the report may contain some strains of what could pass as reform, “it is inherently inconsistent with itself.”
As Wanjiru Gikonyo noted, the initiative failed the litmus test of elite accountability and answerability. In Gikonyo’s own words, the two political leaders, and the elite in general, ducked being accountable and answerable regarding the precipitous 2017 events by hiding behind BBI. Neither does the report mention the rampant economic or financial crimes perpetrated against the people of Kenya, and nor does it comprehensively address issues of economic marginalization. As such, the report did not only “fail spectacularly to be accountable to the people,” but it, for the most part, descended into “political theatre”. In the end, it is Kenyans who were had by the political class. “We have been snookered,” as Gikonyo put it. And, given the benefit of hindsight, honest and objective wananchi looking back would say, “No, we needed to get out of this charade. We were snookered. The report cherry-picked this or that carrot for women; another carrot for devolution; that carrot for youth; and put together all these various carrots in an unfathomable framework.”
In observing that BBI was akin to trying to fix fundamental and systemic governance weaknesses and failure using a Band-Aid approach, Gikonyo could not have been more apt: “It is a whitewash process, but this whitewash process is also trying to take us forward by taking us backwards. It is taking us forward from the chaos we have now, taking us back to the coalition government, because . . . without a vision, and failing to have a progressive mind-set, they [pro- BBI politicians] are saying things were a bit better when we had a coalition government. Let us put some . . . Band-Aid on our governance system and go back there.”
“BBI was akin to trying to fix fundamental and systemic governance weaknesses and failure using a Band-Aid approach.”
Lastly, it is also worth observing that, while widespread grassroots “consensus” was sought, the process was not necessarily greeted with enthusiasm. A survey conducted by Tifa, a polling firm, at the beginning of 2021 revealed that only a paltry 29 per cent of registered voters said they would vote for the BBI proposal or referendum to amend the 2010 constitution. Conversely, 32 per cent of Kenyans said that they would vote “No” to oppose constitutional changes suggested by the BBI. Another computer-aided telephone survey conducted at the end of January 2021 by Radio Africa Group revealed that the BBI referendum appeared to be on shaky ground. This poll found that 43 per cent of wananchi did not support the process compared to 21 per cent who were pro-the process. However, there was, according to this poll, “a potentially high swing vote as 25 percent say that they ‘do not know much about BBI,’ while 11 percent ‘don’t care either way.’” Furthermore, 40 per cent said they would not vote although 60 per cent said that they would. Without a doubt, the BBI process, like the electoral process historically, is quite divisive, which in Kenya, can only forebode trouble of a terrible kind.
The irony of the BBI process is that, while it was intended to stabilize the state, to build bridges between perceived rival ethnic groups, and to cohere the nation by healing past divisions, it appears to have succeeded in re-sowing seeds of old tribal hatreds across the country. As in the past, Kenya perches on delicate tenterhooks thanks to the “building bridges initiative.”
Obstacles on the way to Canaan: can Kenyans afford the democracy they crave?
This also is a key question. Indeed, it has enjoyed a lengthy history in Kenya, particularly regarding the issue of federalism or majimbo. A criticism raised against such schemes from the 1940s through the early 1960s was that federalism was too expensive for Kenya. The right-wing European politicians (e.g., the Federal Independence Party) who advocated devolution of powers to settler-controlled provincial or district councils sought an exclusionary political, economic, and social order that would keep political control and land in the White Highlands in the hands of the European minority while maintaining racially segregated schools and hospitals. Critics pointed out that such a system of government would be very expensive. For these federalists, exclusion had to be maintained no matter what the cost, especially in the case of schools.
Without a doubt, the BBI process, like the electoral process historically, is quite divisive, which in Kenya can only forebode trouble of a terrible kind.
KADU’s proposed majimbo scheme that emerged in 1961-62 also drew criticism as to potential cost from colonial officials and members of the public in addition to the leaders of KANU. This criticism focused on the creation of regional governments and duplication of functions. Peter Habenga Okondo, one of the architects of KADU’s federal proposals and a principal spokesperson for federalism, answered such criticisms bluntly. He wrote in November 1961, “If we want to preserve individual liberty what is the cost?” No cost was too high, he asserted, if Kenyans wanted to maintain a system of separation of powers and functions and “maintain the democratic process of government” that he claimed Kenyans longed for (East African Standard, 23 November 1961). The argument that no cost is too high to pay for civil liberties and representative government has since that time been reiterated during the debates surrounding the adoption of the 2010 constitution and by some of those supporting the constitutional changes called for in the BBI reports.
Yet these supporting arguments leave unmentioned issues that in the past have proved controversial and difficult to surmount. Two economic issues that raised concerns of cost during the transition to independence have yet to be confronted and put to rest. These are the issues of land ownership and labour mobility under a devolved system of government. At about the same time Okondo was advocating for regional governments with control over land and the government work force in their areas, civil servants at the British Colonial Office expressed concern that if regional assemblies were given the right to allocate land to owners and tenants, this would go against British proposals for a free market in land. The officials feared that KADU’s proposed system was “a reversion to the old tribal concepts from which we have been trying to get away in the new policy of regarding land as an economic asset” open to purchase or lease by any Kenyan. Jobs might be reserved only for individuals born in the devolved unit of government (British National Archives: CO 822/2242).
These concerns were allegedly laid to rest after the demise of KADU and the scrapping of majimbo, but the ethnic clashes of the 1990s and the 2007 post-election violence indicated that such was not the case. Do the BBI constitutional amendments promote a constitutional and legal environment that finally “solves” these issues? This is a key question yet to be definitively answered.
Not All Gloom and Doom: A Rebuttal to Mehari’s “Elections? What Elections? Abiy Is Counting on A Military Victory”
The plethora of political, judicial, economic and military reforms for the betterment of the People of Ethiopia and beyond that were introduced by PM Abiy since he came to power are still in place with an ever-increasing vitality and returns, to which the people of Ethiopia and other persons of common sense could attest to.
On 02 August 2021 your esteemed outlet The Elephant published an Op-Ed by Mehari Taddele Maru entitled “Elections? What elections? Abiy is Counting on a Military Victory”. In this regard, we would like to point out the fact that the piece was deliberately misleading, obviously biased and entirely fictitious. The distorted allegations against the leadership of Prime Minister Abiy Ahmed – that it has “failed to deliver on all three counts” i.e., political democratization, further economic liberalization, and what the author conveniently termed a ‘post-ethnic’ Ethiopian politics is not only misleading but also utterly misinformed. The plethora of political, judicial, economic and military reforms for the betterment of the People of Ethiopia and beyond that were introduced by PM Abiy since he came to power are still in place with an ever-increasing vitality and returns, to which the people of Ethiopia and other persons of common sense could attest to.
The author’s fallacious and twisted characterisation of Ethiopian politics as “bitterly polarised along ethnic lines”, against all odds, is a stale argument. First and foremost, conjuring up fictitious, non-existent “ethnic split” within the Ethiopian National Defense Forces (ENDF) could only serve the propagandist agenda of the Tigrayan Peoples’ Liberation Front (TPLF), let alone being a solid argument based on facts on the ground. Brazen declaration of Ethiopia as having “two armies” – the ENDF and Tigrayan Defense Forces (TDF) is not only utterly preposterous but a flat out attempt against the sovereignty and territorial integrity of the Federal Democratic Republic of Ethiopia. Equating a terrorist organization such as the TPLF with the
Government of Ethiopia, in the same token ENDF with TPLF, by itself constitutes the disinformation campaigns of the latter. As such, it is emblematic of complicity with the hypocritical junta that is hellbent on wreaking havoc not only in Ethiopia but also the entire of Horn of African region. On the other hand, interpreting the fight of the people of Ethiopia, in whom the sovereign power of the government lies, against a clique that threatens the national security, peace and calm of not only Ethiopia but also its neighbours, as a war against the people of Tigray is a morally flawed statement. The Government of Ethiopia, has made it time and again abundantly clear that the war being fought is against the terrorist cell that is TPLF, not the People of Tigray. The government firmly believes that the People of Tigray must be liberated from the tyranny of this insatiable cabal that on a daily basis rains brimstone on the People of Tigray and threatens peace of the country in their name. Hence, the Tigrayan people have been the perennial victims of the TPLF clique’s unorthodox, evil rule that deprived them of descent living, development and prosperity. Mutatis mutandis, Ethiopia only has one army and that is the Ethiopian National Defense Forces.
Speaking of economic liberalization, it is of grave importance to pay due emphasis to the myriad initiatives instituted by the leadership of PM Abiy under the rubric of A Homegrown Economic Reform Agenda: A Pathway to Prosperity and Ease of Doing Business since 2018. These pioneering tools of economic reform geared towards a prosperous Ethiopia, contrary to the author’s misreading, not only stimulated Foreign Direct Investment (FDI) but also heartened robust Kenyan companies such as Safaricom to venture into the untapped telecom industry of the Ethiopian economy.
On the political democratization front, discrediting the recently conducted historic General Elections in Ethiopia as lacking in participations and competitiveness in itself amounts to discrediting the collective will of the Ethiopian People. Deeming a historic election, the People of Ethiopia conducted in a peaceful, fair and democratic manner, while effecting a new political dispensation, as discriminatory as the author boldly claims, while accusing the Prime Minister of devising “ways to effectively exclude the real contenders with any chance of defeating the incumbent”, could more or less described as a total disregard for the will of the Ethiopian people. Technically speaking, putting a genuine critique of what really transpired during the 6th General Elections aside, the author is engaged in astroturfing in favor of the TPLF junta and character assassinations ad hominem against the Prime Minister. Professional journalism at least requires that the consent of the governed be logically analyzed and criticized based on distinct merits and that scapegoating of all sorts be put aside.
There is also no mention of the unconditional unilateral declaration of ceasefire by the Federal Government on 28 June 2021 aimed at enabling humanitarian assistance that is being hampered by the TPLF’s sabotage and continued harassment. The use of child soldiers by the TPLF is also nowhere to be found in the article. It is however surprising to witness the author’s meditative misinterpretation of the unilateral ceasefire as not only a scenario of capitulation- in the authors words, “defeat and withdrawal of the Ethiopian army from Tigray” but also of “Ethiopia…losing its army.” The withdrawal of the ENDF troops was not recognized by the author as a welcome gesture geared towards ensuring the wellbeing of our people in the Tigray Region, who are being held captive by the TPLF junta. It rather portrays the Government as an entity that capitalizes on what the author carelessly claims “legitimacy hanging on military victory.” To the contrary, the Government strongly believes that its legitimacy emanates from the collective will of the People and that there are not victories to be won in the efforts to save our People in Tigray from the mouth of a wolf pack in sheep’s clothing that is the TPLF.
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