Is weak governance and lack of accountability fuelling the cholera epidemic in Southern Africa?

By Dorothy Chisare
 
Southern Africa is facing a severe and preventable cholera epidemic affecting 13 countries. Originating in Malawi’s Machinga District in March 2022, it rapidly spread to South Africa, Zimbabwe, Zambia, and Mozambique by February 2023. While cholera is a waterborne disease that can strike any community, the severity and persistence of the epidemic raises concerns about deeper systemic issues. This blog presents insights on often overlooked factors – weak governance and inadequate accountability structures, as critical contributors to the recurring cholera crisis in Southern Africa.
 
What should be known about the cholera crisis in the southern region of Africa
Cholera is an infectious disease that causes severe diarrhoea, which can lead to dehydration and even death if untreated. Claiming  four million lives globally each year, the disease is spread through eating food or drinking water contaminated by faeces from an infected person. While treatable with oral rehydration solutions and preventable with a two-dose vaccine, cholera persists, highlighting issues of inequity and social development gaps. Communities facing poor living conditions, such as insufficient access to clean water, sanitation, hygiene services, and lacking healthcare infrastructure for treatment or prevention, are particularly vulnerable to infection.
Zimbabwe, previously scarred by one of the world’s deadliest cholera outbreaks in 2008 and another in 2018, reported its first case on February 12, 2023, and now has over 18,000 suspected cases and 71 confirmed deaths as of January 2024.
South Africa, facing its first cholera outbreak since 2003, battled cholera cases linked to travel from Malawi, facilitated by porous borders. The Malawi outbreak, intensified by the impact of Tropical Cyclone Freddy in 2023 which brought heavy rains, floods, mudslides and strong winds, led to displacement and limited access to clean water, and has resulted to 59,000 cases of cholera as of 2024.
In Zambia, the current cholera epidemic is the largest in recent years, with 11,947 infections. The country’s first case is linked to the Mozambique outbreak confirmed in January 2023. To highlight the urgency of the situation, the World Health Organization (WHO) classified the epidemic as a multi-country emergency, indicating the highest level of concern for a health crisis.
 
Corruption, unaccountability, and weak governance damage public health infrastructures in Southern Africa
A just public health system functions free from corruption, ensuring accountability for all actions and prioritizing the fair distribution of health resources and services among users. However, corruption and unaccountability have significantly worsened in many African health sectors, impeding efforts to contain diseases like cholera. While the cholera epidemic is multifaceted, its roots lie in core issues of poor governance, leading to inadequate sanitation services and limited access to clean water. Legacy issues such as infrastructure neglect, mismanagement, underinvestment, and misallocation of funds culminate a perfect storm of challenges.
The outbreak in Zimbabwe stems from the decay of water and sanitation systems that have surpassed their intended lifespans. Irregular and inadequate water supply, especially in cities like Harare, exacerbates the problem. The local government, responsible for water services, provides only a quarter of the required 1200 megalitres of potable water daily. During water purification shortages, the supply is entirely cut off, and the council blames the national government for a lack of investment. This is due to opposition councils being obliged to navigate through the Zimbabwe National Water Authority (ZINWA), an autonomous government-owned entity managing the country’s water resources.  The political obstruction, unclear roles and responsibilities, and ultimately the blame game between local and national authorities, turn clean water into a political pawn and leave citizens to the mercy of inadequate services.
South Africa faces dysfunctional municipalities and inadequate wastewater treatment, resulting in untreated sewage release into water resources. These challenges stem from a lack of accountability, mounting debt, and inadequate infrastructure spending spanning over two decades. The sewage dumping frequently surpasses government quotas. This is often linked to the failure of national and provincial authorities to adequately monitor municipalities. Left to self-report pollution events, municipalities have grossly under-reported them. This raises the question of who is overseeing the overseers.
The crisis is intensified by the increase in underserved households in illegal peri-urban settlements without water connections, leading to poor hygiene practices, as seen in Malawi. Urban informal settlers pay at least double the going rate for water from ‘water kiosks,’ managed by private individuals and ad hoc committees. In these settings, there is a risk of administrative or petty corruption, wherein service providers may be influenced through bribes for preferential treatment.
Similarly, for over two decades, Zimbabwean councils bypass urban planning regulations in allocating residential land, leaving residents with inadequate infrastructure, and relying on contaminated water sources. This negligence echoes the 2003 cholera outbreak in South Africa, triggered by the withdrawal of public services in expanding impoverished informal townships and resulting in 140,000 infections. These failures in urban planning and water policies are deeply rooted in mismanagement, corruption, and a lack of accountability within council systems.
 
Cholera thrives where corruption and unaccountability persist
Corrupt practices and accountability gaps in the region severely impact public health systems, contributing to infrastructure fragmentation and triggering the cholera crisis. Recognizing accountability as a cornerstone of good governance is particularly crucial. Whether at the state, healthcare provider, or individual levels, accountability serves as a critical tool and ensures that necessary actions are taken for effective responses.
The urgent nature of health emergencies creates opportunities for corruption and unaccountable behaviour, as seen in South Africa’s unmonitored sewage dumping beyond safety limits and insufficient infrastructure spending. This not only contaminates water resources or jeopardizes quality but also establishes conditions favourable for cholera to spread through communities already burdened with systemic failures.
In Malawi, vulnerable communities are exploited to pay exorbitant rates for water from unregulated sources. The lack of oversight and accountability enables individuals or entities to profit from this basic need, exposing marginalized communities to compromised hygiene practices and fostering cholera’s spread.
Urban planning negligence influenced by corrupt practices such as bribery or favouritism within Zimbabwean councils leads to misallocation of residential land and inadequate infrastructure that is not planned for, exposing residents to contaminated water and insufficient sanitation provisions – well known factors for cholera. There is a concerning increase in corrupt allocation of residential stands and lack of transparency from councils, with some houses developed on land above sewer tanks, causing sewage pipes to burst inside several houses. The lack of accountability allows these hazardous conditions to persist without corrective measures.
Addressing these governance gaps is not merely a matter of cholera containment; it is a necessary step toward building resilient health systems capable of withstanding future pandemics. Only through comprehensive reforms and strengthened governance mechanisms can the region hope to break free from the trail of cholera and safeguard the well-being of its communities.
 
A pathway forward
Cholera is a complex interplay of political and economic factors demanding a blend of vertical and horizontal solutions. Governments need to shift to proactive measures by establishing strong governance and accountability mechanisms before, during, and after any potential outbreaks. A collaborative regional cholera preparedness plan within and between countries, ensures a unified and efficient response. Preparedness plans must embrace the whole of society, from communities, local actors, health systems and government ministries. For instance, responses to the epidemic must extend beyond the health sector, integrating efforts across education, economy, trade, and water sectors.
Assigning clear responsibilities and holding national health authorities accountable for infrastructure maintenance, particularly water treatment and sewage systems creates a proactive environment. This requires monitoring mechanisms like public consultation and appeals for improvements from horizontal actors such as civil society organisations and citizens. To strengthen outbreak response efforts, governments can establish inclusive multi-stakeholder task forces and committees. These groups would provide diverse expertise and resources, contributing to the improvement of public engagement and shared accountability.
During an outbreak, streamlined governance enables rapid response activation and optimal resource allocation. A way to approach this could be an undertaking of a series of visits and consultations with actors at the grassroots to understand the challenges and to revise the approaches accordingly. This consultative policymaking, coupled with media advocacy, can instil confidence in the authorities, attract provisions from the private sector or donors, and lead to significant improvements. Concurrently, strict accountability measures ensure transparent communication and timely actions, pivotal in halting the outbreak’s progression.
In the aftermath of the outbreaks, it is crucial for governance to evaluate the effectiveness of the response, guiding updates to preparedness plans. Holding individuals and institutions accountable for outcomes encourages necessary reforms, breaking the cycle of repeated outbreaks, preventing future epidemics, and mitigating potential pandemics.
 
About the author
Dorothy Chisare is a Research Officer specializing in African Health Systems within the Department of Health Policy at the London School of Economics and Political Sciences. She is a part of the LSE team working on the African Health Observatory – Platform on Health Systems and Policies (AHOP) hosted by the WHO Regional Office for Africa. She can be contacted at d.chisare@lse.ac.uk X/Twitter: @dorothyct9

“Corruption in the health sector is stealing from the sick”: Policy Forum for insights and action on accountability and corruption in health

By Prince Agwu, Obinna Onwujekwe, Dina Balabanova and the Accountability in Action Research Team
 
Background
Despite anticorruption thrusts that have always been a part of the manifestos of successive governments in Nigeria, corruption has remained considerably high in the country. With corruption being common in many sectors of Nigeria, the country in the 2021 Corruption Perception Index (CPI), scored 24 of 100, making it the 154th most corrupt country out of 180 countries in the world, and among the 15 most corrupt countries in Africa. Disappointingly, the health sector continues to feature as among the top-5 corrupt sectors in the country.
 
Image 1: Nigeria’s CPI since 2012 (Source: Trading Economics)
 
Is corruption in health a lack of morals or a failure of systems?
Thomas Hobbes described life as nasty and brutish, constantly in a state of war, which explains how the nature of man is disapproving of principles and good behaviour. Hobbes further used this philosophy to buttress the importance of social control (rules and institutions that keep to the demands of the rule of law) against the deviant nature of people and make them more compliant with rules. Just as Hobbes, Sigmund Freud argued that societies get better when the superego (comprising ideals, principles, laws, etc.) is enforced to quell the irrational and socially unacceptable personalities of people (ego). In these, and in other traditional scholarship, the innate tendency to be corrupt appears to be part of human nature, but people can be less or not corrupt in systems that are built to be intolerant of corruption. This is why the Anti-corruption Evidence Consortium argues for the need to strengthen vertical (government offices) and horizontal forces (grassroots people), such that systems can become self-enforcing against corruption.
Therefore, corruption may not entirely be the moral failure of individuals, but even more, a failure of institutions that creates incentives for corrupt practices. At times, institutions may fail to the extent that corruption becomes the only way for people to survive and support their families. Thus, instead of just identifying and punishing individuals who break the rules, an anticorruption agenda must seek to make corruption unattractive and difficult to perpetuate, and at the same time, build a system that can be self-enforcing against corruption.

A reminder about Nigeria’s health sector corruption
A recent review on health sector corruption and a nominal group technique with frontline health workers and policymakers in Nigeria revealed the most common forms of health sector corruption, which were absenteeism, informal payments, health financing corruption, employment irregularities, diversion of patients from public to private facilities, theft of consumables, and illicit procurement practices. More focused research approaches using ethnography, interviews, and group discussions have also shown that the Nigerian health sector is truly challenged by corruption, devastatingly affecting Nigeria’s progress toward achieving global health goals and leading to inefficient use of the current low budgetary appropriations and donor funding to the health sector. The poorest and most disadvantaged groups are most at risk as they have few alternatives to obtain adequate quality care. Indeed, corrupt practices change the ethos of the health system and distort priorities and procedures.
 
Image 2: Corruption ranking in Nigeria (Source: Channels TV)
 
While the situation often seems helpless, there is hope in the fact that anticorruption can be successful when governance structures are set up and incentivized in ways to gradually curb it, and when grassroots actors finally say, “enough is enough”. Therefore, the question is – how do we stimulate and galvanize the interests and actions of macro governance structures and community actors toward anticorruption in the health sector? Also, how do we ensure that anticorruption approaches do not only work for a period of time but become an integral part of the system and sustainable?
 
Stakeholders in health sector anticorruption gathered to find solutions
The Health Policy Research Group (HPRG), University of Nigeria and the Bayero University, Kano (BUK), with partnership from the London School of Hygiene and Tropical Medicine (LSHTM) are vigorously pursuing an anticorruption agenda in the health sector of Nigeria through research and the use of evidence from research to inform policies and strategies that will eliminate corruption in the health system. To achieve this goal, the team convened a Policy Forum on Anticorruption in Nigeria tagged “Stop Health Sector Corruption”, attracting various key stakeholders in the Nigerian health system and anticorruption vanguards from several bodies in Nigeria.
Those that were represented included the Independent Corrupt Practices Commission (ICPC), Nigeria Academy of Science (NAS), Health Reform Foundation of Nigeria (HERFON), International Centre for Investigative Reporting (ICIR), Results for Development (R4D), National Health Insurance Scheme (NHIS), Budgit, UNODC, Nigeria Health Watch, Project Pink Blue, Anticorruption Academy of Nigeria, National Primary Health Care Development Agency (NPHCDA), SERVICOM, Nigeria Governors Forum, etc. The stakeholders narrated several personal experiences of health sector corruption and reinforced the urgent importance of addressing this failure.
With several presentations of documented evidence from the research team from UNN and BUK on the realities and dynamics of corruption in Nigeria’s health sector, particularly primary healthcare, the stakeholders confirmed that thoroughness of the research already done by the team, even though they pointed more areas to cover. Strong emphases were made on the managerial components of the health sector, as corruption, unaccountability, and sheer incompetence at that level have allowed for the thriving of corruption and accountability issues at the level of service delivery. The weakness of the Human Resource (HR) component of the public sector, as well as the lack of properly communicated context-specific rules and regulations for the health sector, were considered enablers of corruption.

Image 3: Cross-section of policy forum attendees
 
Where do we go from here?
The stakeholders who attended the Policy Forum were clear on where to begin to address health sector corruption. Unanimously, they emphasized the need to drive solutions using evidence from research. Implying that more conversations between researchers in corruption studies and policymakers should be encouraged. Also, based on the reported evidence, stakeholders opined that anticorruption will be unsustainable if strategies do not emanate and include actors at the frontline and those that are affected. It is more like tying the ends of macro politics (the big ‘P’) that comprise the managers at the authority level and their political networks in local government and beyond, with those of micro politics (the small ‘p’) comprising community actors and frontline health workers.
It was for instance suggested that a ‘Rule book’ on anti-corruption in health should be developed and deployed across the country, and civil society groups and community leaders should be encouraged and incentivized to play supportive supervision roles across health facilities. An important incentivization as mentioned by the policymakers is to ensure that the top-level managers act on reports tendered to them by community actors and civil groups. Such is needed for confidence building and developing trust across the “big” (P) and “small” (p) pees. Also mentioned included rapid digitalization of systems, educating service users on patients’ rights as enshrined in law using townhall meetings and media, establishing and optimizing human resource management across health facilities, and putting together reward mechanisms for committed health workers, to mention but a few.
 
Image 4: Cross-section of policy forum attendees
 
There is hope!
With the coming together of these powerful actors sourced from organisations and circles that are influential within Nigeria’s health system and policy space, a critical mass of people and systems that can drive a sustainable anticorruption agenda in the health sector is feasible. The policy forum attendees have made their commitments to this cause and are optimistic about improved situations within the health sector going forward. Therefore, more strategic and meaningful engagements will continuously hold until anticorruption in the health sector becomes an indispensable part of Nigeria’s health system, and the rule of law rises to becoming self-enforcing by the system.
 
Conclusion
With the amount of information asymmetry in the health system, where service users are barely aware of expectations, ensuring prominence of the rule of law remains a viable anticorruption strategy. We understand that this may be difficult to achieve in developing climes like Nigeria, where individuals and organisations can be even more powerful than the system. It is for this reason scaling-up and optimizing the awareness and voices of citizens at the grassroots is much needed and an achievable anticorruption agenda. And civil groups and researchers will continue to pursue avenues to hold government actors to account and draw their attention to the pathetic consequences of undermining the rule of law as applied to healthcare. More voices are needed in health sector anticorruption, and the Accountability in Action Research Team is excited at the rapidly growing institutionalization of health sector anticorruption, evidenced by:
  1. The Thematic Working Group on Action on Accountability and Anti-corruption for SDGs (TWG AAA) at Health Systems Global, where Prof Obinna Onwujekwe and Prof Dina Balabanova (are Co-Chairs)
  2. The proposed African Resource Center for Accountability and Anti-corruption in Health, to be based in Nigeria
  3. Forthcoming Global Network for Anti-Corruption, Transparency & Accountability in Health Systems (GNACTA) to be launched by WHO, UNDP and other major development agencies in December 2022. 
  4. The Nigerian Policy Forum on Accountability and Anti-corruption in the health system     
Acknowledgement
Associate Prof Eleanor Hutchinson
Dr Tochukwu Orjiakor
Dr Aloysius Odii
Dr Muktar Gadanya
Dr Maikano Madaki
Pamela Ogbozor
Divine Obodoechi
Accountability and Anti-corruption in Health Project Anti-corruption Evidence Consortium (ACE)

Mobilisation and deployment of resources for the COVID-19 response in Nigeria: a view with transparency, accountability and anti-corruption lenses

By Obinna Onwujekwe & Prince Agwu

In a previous article of ours, we raised concerns about weak accountability and corruption possibly getting in the way of Nigeria’s response to COVID-19. We cited the report of Transparency International on how corruption affected West Africa’s response to the Ebola epidemic, hoping that the lessons learnt will inform the responses to future pandemics in Nigeria.

There were predictions that the COVID-19 experience will surely not leave Nigeria’s health system in the manner it has always been. Even though the predictions were not clear on if the health system in Nigeria will head in the right or wrong direction. However, the evidence is that the health system is not getting strengthened due to a myriad of factors including poor coordination between the different levels of government, opaque accountability systems, and poorly responsive systems, amongst others.

The accountability mechanisms of these funds are not clear and citizens do not really feel the impact of the resources and there is a seemingly lack of trust in the public sector. This is pertinent because since the pandemic, we have heard on the streets of Nigeria how COVID-19 is a disease for the rich and/or a ploy by the political elites to siphon funds as it is considered customary to them. What we have seen is the outright discard of measures to stem the spread of coronavirus, as the average Nigerian seems to have rather given up on the government, but more concerned about their daily economic survival. We saw how this played out during lockdown, with Nigerians conniving with the Police to defy government directives to stay at home and even threatened to protest continued lockdown after an initial extension.

Now, easing the lockdown has seen a surge in coronavirus cases and deaths, difficulty to contact-trace, few citizens tested, and life seems to have returned to normal, yet Nigerians are largely unbothered. The question is, do we blame Nigerians for taking such position of survival and carelessness at the same time? Elizabeth Donelly of the Chatham House importantly and emphatically said that citizens’ trust is key if the Nigerian government must tackle COVID-19. But with emerging revelations of corruption and weak accountability, the question about trust is answered by the current defiant actions of citizens which seem to compromise responses to containing the virus, as well as the rage and piling of court cases spearheaded by Civil Society Organisations (CSOs) against the government within this time.

For a start, the primary healthcare (PHC) system seems to have been hardly involved in the fight against COVID-19. The scare of the virus has rather inspired low patronage, with concerns for Universal Health Coverage. This is in contrast to the active roles of the primary healthcare in Rwanda, Cuba and Thailand. What rather happened in Nigeria was a massive slash of the Basic Healthcare Provision Fund expected to revamp primary healthcare, which is direly needed during a pandemic as this one, as against a smaller cut in the appropriation meant to renovate the National Assembly Complex.

At a time when countries are making conscious efforts to spend in health, and particularly, human resources for health, health workers in Nigeria have severally indulged or threatened to indulge industrial actions within this time, protesting against neglect and failed promises. Yet at the same time, a single commission in the country shared over N3bn as COVID-19 relief funds among its staff, and federal-level legislators reportedly took delivery of 400 exotic cars at a price of over $20,000 for each.

Since the onset of the pandemic, the Federal and State governments of Nigeria have received cash and kind donations from both private and public donors, of which the cash component alone exceeds NGN230 billion[1]. At the same time, the FGoN’s 2020 health budget was increased by more than 13% from the previous year’s budget[2].  Additional resources that were mobilized include $12 million donated by the Global Alliance for Vaccines and Immunization (GAVI) for health worker training, commodities supplies, surveillance, communication and coordination, etc[3]; some of the over NGN 30 billion raised by the Coalition Against COVID-19 (CACOVID)[4]; and 100 million grant from the World Bank to each state.

Of keen interest to Nigerians, are donations made to the government in the fight against COVID-19. At some point, citizens were worried about making such donations to a government they do not trust, rather than channelling directly to the poor and less privileged who are littered all over the country. In later events after the country moved into a post-lockdown, citizens were seen breaking into warehouses to cart away donated palliatives (food items) mainly from the private sector. The citizens expressed shock and disappointment at the  much quantity of items that were allegedly hoarded by the leaders, even as they have been faced with harsh economic impacts from Covid-19 all the while.


[1] https://civichive.org/covidtracka/donations/

[2] https://yourbudgit.com/wp-content/uploads/2020/03/2020-Budget-Analysis.pdf

[3] https://www.gavi.org/sites/default/files/covid/Gavi-COVID-19-Situation-Report-15-20200811.pdf

[4] https://www.cacovid.org/pdf/list_of_contributors_to_the_cacovid_relief_fund_as_at_30_June_2020.pdf

The news of distrust, corruption and weak accountability have been rife in Nigeria within this time. From the distribution of N20,000 cash to some 2.6m poor Nigerians in 10 days, and the feeding of pupils in lockdown with N500m, all seem to have raised serious concerns about accountability, thus, seeming to confirm the fears of Nigerians. Heightened distrust about spending from the Humanitarian Ministry forced the National Assembly to call the Ministry to explain the figures they have in the public domain, including the steps they took to identify poor Nigerians who benefitted from the palliatives. Despite interventions from the National Assembly and public concerns, little or nothing is done to effectively open up activities of the Ministry to public scrutiny.

A cesspool of corruption in Nigeria is procurement. It reflects the saying by Patricia Garcia “with more money comes more corruption”. One might want to believe that Patricia made the statement with Nigeria in mind. COVID-19 brought about the need to procure certain items in bulk, particularly facemasks, hand sanitizers, disinfectants, among other personal protective equipment. At the onset of the pandemic, most of these items were in short supply, and the compulsory need for them led to increased spending in that direction. Expectedly, a hub for corruption seems to have emerged.

The Open Treasury Portal which government built to feed Nigerians information concerning COVID-19 funds appears to be a work-in-progress, as some important pages do not open. It as well does not give any detail concerning procurement, rather it provides information on bank transactions which amount to insufficient.  There is also the CovidFundTracka which only spells out what is donated to the country but not what is spent. Although there is a guideline for COVID-19 procurement as published by the Bureau of Public Procurement, the document seems more rhetoric than action.

Consequently, Civil Society Organisations (CSOs) try to ask questions and monitor government spending, of which the revelations of possible corruption have been quite revealing. The Ministry of Health is implicated in the purchase of facemasks for about N20,000 ($52) per one and awarding of supply contracts without evidence of competition and bidding. The Federal Road Safety Commission was equally said to have purchased a bottle of 500ml of hand sanitizer for N5,600 ($14) as against the most expensive cost price of N3,000 ($7). Many public agencies  in both within and outside the health sector have all been implicated in the possible poor procurement practices in the fight against COVID-19.

If there is a time Nigerians expect transparency and accountability from the various government Ministries, Departments and Agancies that are involved in the COVID-19 response, it is now. The pandemic places moral responsibilities on governments to get concerned with the affairs of citizens and not further create conditions that will escalate distrust. Nigerian government across all levels should see to it that they win back the trust of citizens by an application of the “rule of law”, and not “rule by law” which has largely been the case. A lot depends on the trust of citizens in their government during disease outbreaks, particularly concerning community engagement, resilience and effective response. These are areas where Nigeria keeps lacking. No doubt that trust is key to reviving these cardinal areas in disease response. It is hoped that Nigeria learns and at least puts forward a sincere, transparent and corruption-free approach in addressing the pandemic onward.

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Obinna Onwujekwe is a Professor of Health Economics, Systems and Policies in the University of Nigeria Enugu Campus. He is the Chief Editor of the African Journal of Health Economics, and the Coordinator of the Health Policy Research Group, University of Nigeria. He coordinates the African Health Observatory Platform (AHOP) for Health Systems, Nigerian Center.

Prince Agwu is an academic in the Department of Social Work, University of Nigeria and a research associate in the Health Policy Research Group, University of Nigeria.