Over the past few decades, African countries have been actively committed to reducing health inequalities by mobilizing development partners and stakeholders, in implementing health sector reforms [1]. But yet, the continent still faces persistent and pervasive health challenges, with vulnerable and fragile health systems, under the weight of an ever-increasing burden of disease [2]. This trend is even exacerbated in francophone African countries, where health systems are weakened by poverty and various types of conflicts [2]. Overcoming health inequalities in Africa thus requires systemic change, which is intrinsically dependant on substantial shifts in practices and public policies. This years’ extensive elections schedule in French-speaking Africa prompts further reflexion on this issue, for it is widely admitted that political engagement can directly or indirectly affects health outcomes, through its impact on policy choices or as a social determinant of health [3, 4, 5]. This paper will discuss the complex interplay between political participation and health, in the particular context of French-speaking countries in Africa.
Understanding Political Participation
Political participation refers to voluntary activities undertaken by the mass public to influence public policy, either directly or by affecting the selection of people who make policies [6]. It includes not only voting in elections, but also supporting a political campaign, contributing funds to a cause or candidate, interacting with decision-makers, organizing protests, petitions, and issue-based collaboration [6].
The Public health landscape in Francophone Africa
African francophone nations account for one-third of the World Bank’s list of low-income countries and thus are experiencing the epidemiological transition, with the double burden of disease typical of weak economies [2,7]. Across these 21 countries sharing French as official language, the epidemiological transition is materialized by a high persistent burden of communicable and neonatal diseases and the rising of non communicable diseases [8]. Communicable diseases such as malaria, lower respiratory infections, neonatal disorders, diarrhoeal diseases, and tuberculosis persist as major health challenges, while chronic diseases like heart disease and stroke are rapidly emerging as leading causes of death [8]. Healthcare systems in French-speaking African countries are under-developed, weak and fragile. Among the principal challenges limiting accessibility and availability of quality and appropriate healthcare, are insufficient workforce, inadequate budgetary allocations to health and poor leadership and management [9]. Moreover, health inequalities are fostered by poor quality services, inadequate and uneven distribution of healthcare infrastructure, coupled with an over-reliance on importing life-saving diagnostics, treatments, and medical technologies [9,10]. Nevertheless, demographic and economic growth and the digital revolution represent unprecedented opportunities for health system strengthening and progression towards Universal Health Coverage (UHC) in the region [11, 12].
The role of political participation in health system strengthening
Mobilizing political will
Political will has been identified as a major determinant of health policy advancement and effective health reforms [10]. To overcome the multiple and complex challenges facing francophone African health systems, it is thus critical to ensure careful selection and accountability of political leaders. There are supportive evidence that political engagement, when citizens select and sanction leaders based on their performance in delivering public goods can indirectly affects health, through its impact on policy choices [3,13]. For example, the increased engagement from political leaders has contributed to improved availability and affordability of some essential medicines in the region, particularly for tuberculosis, HIV, and malaria [10].
Promoting community participation to health policy planning, implementation and monitoring
Voting can directly impact people’s health at individual or community level. A case-study from Cameroon reveals that 82% of people in communities are willing to invest in local public health policies. Yet, participatory structures and frameworks are either nonexistent or under-exploited [14]. Political participation at local level may thus create incentive for local leaders to make optimal use of available ressources while supporting accountability and effective monitoring. Indeed, the rise of democracy and decentralization initiatives between 1990 and 2017 led to the establishment of directly elected local councils in francophone countries such as Cameroon, Senegal or Madagascar [15]. According to the US “Healthy people 2030” framework, increasing the proportion of the voting-age citizens who vote gives people an opportunity to influence decisions that may have an impact on their communities and impact their health and well-being [16].
Bridging the research-policy gap
Securing equitable access to affordable and quality healthcare products cannot rely entirely on imports, as it is the case in Africa today, where countries import between 70 and almost 100% of their medicines, vaccines, and other medical products [10]. It is essential for francophone African countries to follow the Research and Development (R&D) dynamic impelled by the African Union through Africa CDC initiatives for local manufacturing of health products. However, this can only be achieved if national governments fully undertake their stewardship role and commit to promoting R&D with a particular focus on health products [10]. Active participation in electoral processes represents a unique opportunity for citizens of francophone African countries to appoint and hold accountable, leaders who share such a vision and propose convincing programs integrating health policies and health reforms with a strong focus on R&D.
Barriers to political participation
To effectively mobilize political will for health in Francophone Africa, it is imperative to understand and address the significant barriers hindering political participation and undermining efforts to prioritize health in policy agendas. Population tend to be disconnected from political engagement in the region, as evidenced by the proportion of voter turnout during the 2020 legislative and municipal elections in Cameroon (45.98%), and during the recent presidential elections in Senegal (46.64%) [17,18]. According to a recent Afro-barometer survey, more than 40% of youth (age range 26-35 years) in Côte d’Ivoire, Mali, Gabon or Senegal tend to abstain from voting [15]. One of the major barriers hindering political participation in the region is reported to be the declining trust in democratic institutions, especially among youth. Indeed, popular support for democracy declined from 36 percentage points in Mali, -26% in Burkina Faso, -15% in Guinea [15]. Other serious challenges to political participation include unconstitutional changes of governments such as the recent military coups in Mali, Chad, Guinea, Burkina Faso, Niger, and Gabon; widespread corruption, official impunity, violations of individual and collective rights and freedoms [15].
Strategies for health systems strengthening through Political participation
The potential of electoral participation for the preservation of democracy, health systems strengthening and overall economic growth requires actions not only to break down barriers to engagement, but also to raise citizens’ awareness of this intricate relationship. This involves promoting civic education, health literacy and democratic culture.
Promoting civic education and a better democratic culture ensure that citizens are aware of their role in choosing leaders to represent them and defend their interests, as well as the power to hold elected representatives accountable and sanction them when necessary. Increasing health literacy is also essential if people are to understand pressing public health issues and be able to champion change through political participation and civic engagement. Specific areas of action include:
- Establishing systems for citizens to report on health service quality and gaps.
- Creating platforms for community members to discuss health issues, share experiences, and develop solutions.
- Conducting independent assessments of health programs and services with community participation.
- Empowering communities to advocate for increased health funding, improved service delivery, and equitable access to care.
- Training community leaders, health workers, and policymakers on health policy analysis, communication, and negotiation skills.
- Fostering collaborations between civil society organizations, government agencies, and healthcare providers.
Conclusion
Increasing political participation can have a positive impact on strengthening health systems. Therefore, the impending elections in a number of francophone African nations offer their citizens a rare chance to understand the importance of political engagement for the improvement of health outcomes at both individual and community levels.
Solange Dabou
Solange DABOU holds a Master of science in Clinical Biochemistry from the University of Dschang and have followed a distance learning training in epidemiology and health statistics from Aix Marseille University.
Regina Sinsai
Regina Sinsai holds a Bachelor of Arts Degree in Psychology from the United States International University – Africa, in Nairobi and an HND in General Nursing from the Humanity Health Professional Training Center (HHPTC) in Yaoundé.
Dr. Bruna Djeunang Dongho
Ghyslaine Bruna Djeunang Dongho, Ph. D., is the Senior Researcher in Global Health and Public Health at the Nkafu Policy Institute.
