Greater Accra (Ghana) in 2016



Some basic observations of, and hopefully substantive reflections on,

Greater Accra Region in 2016


Jean-Germain Gros


A Changing Landscape for the Nouveaux Riches

The Greater Accra Region in mid-2016 is a bustling metropolis of over 4 million people. What jumps at the visitor, even from the air, is the number of construction cranes pullulating the city. Accra is almost literally one huge construction site. The boom in commodity prices in recent years and direct foreign investment (DFI) by China have transformed urban Africa into a mishmash of office building mini-skyscrapers, luxury apartment blocs, new roads, and monstrous traffic jams. The most impressive display of this building renaissance in Accra is in Airport City, a strip of hitherto vacant and wildly vegetated land, public housing, and shacks tucked between Kotoka International Airport and Liberation Road, the main artery running on the North-South coordinate. Airport City currently hosts office buildings, some high-end restaurants and hotels (President Barack Obama stayed at the Holyday Inn when he visited in 2009), and the inaptly named Marina Mall. It will soon welcome its first redevelopment residents, for a significant portion of the land from the Big Six roundabout at the main airport exit to the Polo Ground is slated for what the artist rendering suggests will be scores of apartment blocs interconnected by courtyards, walkways, pedestrian bridges, etc. This is likely to be Accra’s new sleeping quarter and playpen for the upwardly mobile, sandwiched between two paragons of urban consumerism­­––Marina Mall (already mentioned) and Accra Mall––and opposite of a soon-to-be expanded international airport.


New luxury apartment buildings and townhouses are sprouting up elsewhere: e.g., in Labone, Cantonments, and Airport Residential. The architecture of these communities displays diversity, but there is a discernible preference for a variation on the Immeuble Villa style once championed by Le Corbusier: multi-storied square and rectangular structures with cell-like individual apartments stacked one on top of another, with plans that combine living and dining rooms, master bedrooms with separate bathrooms, kitchens with all of the amenities, and, in some cases, garden terraces and balconies. The picture below is typical of this style.


Here functions take precedence over forms, and practicality trumps esthetics. As shown in the next picture, all of the developments are walled and gated, thus off limit to non-residents, underscoring security concerns and perhaps subliminal guilt.



Because of Africa’s fungible class structure, one of the inescapable realities of urban life, from Cairo to Cape Town, Accra to Nairobi, is the intimate juxtaposition of wealth and poverty, which of course produces contrasting vistas. Ghana’s upper middle class resident must often share space with the more modest living quarters of the worker right next door or the kiosks of the street vendor in front; the opulent driver of the latest town car (sedan) must contain her anger at the squeegee man, who shows up unexpectedly during traffic stops to “clean” the windshield; the chauffeured entrepreneur must display similar magnanimity toward the hordes of hawkers, who peddle everything from plantain chips to puppies, impeding circulation in the process. These survival strategies on the major streets of Ghana’s capital, called débrouillardisme in Francophone Africa, are easy to explain. The train of “development” has yet to pick up most passengers in Ghana; it has only accommodated those who can afford to travel first-class. None the less, it may be a reflection of the basic decency of Ghanaians that the urban poor are seldom harassed on a sustained basis, in spite of the untidiness of their activities.


Accra is generally expensive. But housing and land prices are getting out of hand. Evidently, Greater Accra either suffers from a severe shortage of housing suitable for the well-to-do, to which real estate developers are correctly responding, or irrational exuberance has reached African shores, setting the housing market for an unwelcome correction (i.e., crash). Time will tell which one, but there is no question that the luxury housing stock is being increased in Greater Accra. The question is, for whom? The answer is almost certainly: not for ordinary Ghanaians. New housing units in Accra are often priced in the six-figure range in U.S. dollars­­––in most cases well above 100,000 in the American currency––while per capita GDP in 2014 was recorded at 775.36 U.S. dollars. The low purchasing power implied in per capita GDP means that most Ghanaians cannot afford the new housing units. This is exacerbated by the scarcity of credit. Ghanaian banks are notoriously risk averse when it comes to lending money, as reflected in high interest rates.


I visited an apartment complex in Labone in early June: a rather compact two-bedroom, two-bath unit on the first floor of a three-story building tagged at 290,000 USD. The “penthouse” on the top floor, which the real estate agent insisted (unconvincingly) offers a view of the Atlantic Ocean on a sunny day, had an equal number of bedrooms but they were even smaller than those at the bottom floor. Still, it was being sold for 315,000 USD. In the less affluent community of Dzorwulo, another two-bedroom apartment was available for 190,000 USD. On the day of my guided tour by a twenty-something Ghanaian fresh from his studies in Britain, Accra was being pounded by a torrential rain. Puddles of water had formed around the elevator of the building, with more sipping through the glass windows, raising questions about the quality of construction not only at this site but throughout Greater Accra. The Friday downpour was the capstone to a very wet week during which parts of the city had flooded (e.g., Kwame Nkrumah Circle), officially killing three people and stranding many more. Two common problems in Third World cities are the lack of adequate government oversight of construction projects and poor drainage. Accra definitely suffers from the latter; it is a fool’s errand to bet against the former. Accra also experienced at least one tremor in recent years. It is not clear its buildings, old and new, meet the seismic requirements for minimizing the loss of lives in the event of an earthquake. I speak from personal experience on this matter, to which Ghanaian authorities should pay urgent attention.



A discernible sign of progress in the Greater Accra Region in 2016 concerns infrastructure. New tarred roads have been built in many parts of the city, while existing ones have been enlarged. In peripheral areas, too, earth movers, tractors, bulldozers, and steamrollers are rumbling (at least some of the time). In Aboasa, the last town before crossing into the Eastern Region, there are visible signs that the hilly, rocky main road that wreaks havoc on shock absorbers will soon be more user-friendly. Central Accra is connected to Aburi by a multiple lane highway. (The pictured below was taken just south of the University of Ghana).



I remember distinctly when these two points were joined mostly by a single-lane road each way snaking through some of the most heavily populated parts of the Accra metropolitan area (Legon, Madina). The new interchange at Kwame Nkrumah Circle promises to rival any similar feat of transportation engineering in Los Angeles (drainage problems, and with them the threat of flood, notwithstanding). However, everything has a price. The wage of infrastructural improvement in Accra is an exponential increase in the number of vehicles on the city’s streets, which reduces traffic to a crawl seemingly during most hours of the day. To avoid this, some workers either leave home very early in the morning or depart their workplace well after working hours. Productivity loss due to traffic jam is probably considerable in Greater Accra, not to mention the health consequences of spending long hours in a car each day in an aggravated state. In rebuilding its road network, Accra has not corrected two longstanding deficiencies: the open gutter and lack of sidewalks, both of which make walking and jogging very difficult, if not to say, downright dangerous. In 1954 Richard Wright wrote about the visibility of Accra’s drainage in Black Power. More than 60 years later, the evacuation of “waste” water in Accra has yet to be granted some privacy. The streets are also unfriendly to the wheel-chair bound, as there are very few off-ramps for the physically challenged; government buildings and private housing units similarly overlook that in most countries at least 10 percent of the population need special accommodation of one type or another.




Work in Greater Accra remains overwhelmingly labor intensive, although there are some industries (construction) where heavy machineries are widely in use. The machete, the pickaxe, and the shovel are ubiquitous instruments of production in urban Ghana in 2016. Over a four-day period, I witnessed the befalling of about half a dozen coconut trees by machetes in the upscale neighborhood of Labone, a task that might have taken half that time with chainsaws. The work felt arduous, just by observing it. A worker repeatedly struck the bottom of the tree, while a rope is tied around the top with ends hanging on two sides. When the machete had cut sufficiently into the trunk, two workers pulled down the tree with the rope, producing a thunderous “thump” once it hit the ground (In the picture below, the rope can clearly be seen at the top of the tree, as can be the laceration of the machete nearly midway in the painted section at the bottom).




Parking in Accra often generates self-appointed parking “specialists” seemingly out of nowhere. Labor intensity is good and bad. Unemployment rates in Ghana averaged nearly 9 percent between 2001-2016, reaching its highest level in 2005 at nearly 13 percent and an all-time low of 5.2 percent in 2013 ( If it is assumed that the unemployment rate accounts for people who are unemployed but actively seeking work, as opposed to those who are unemployed but discouraged or ill, it can be conjectured that Ghana’s official unemployment rate is less than the real unemployment rate, upon which, it has to be conceded, the informal economy probably has a moderating influence. Whatever the case, in a country where many people may be unemployed, it makes sense for work to be labor intensive, as well as for it to be even “make shift” work. At least some people who might otherwise be unemployed are working. At the same time, much labor intensive work tends to involve low-skilled workers earning low wages, while capital intensive work, though requiring fewer workers, tends to generate higher wages (assuming of course that employers are willing to share productivity gains with workers, a fact that labor economics theory seldom acknowledges). Ideally, Ghana needs to reduce its unemployment rate while upgrading its human capital stock, so that the jobs generated are of the high-wage types, thereby increasing purchasing power and internally stimulating economic growth. This entails, as it does in most countries, investing in education. Office workers in Greater Accra (e.g., bank tellers, secretaries, etc.) and service workers in general (e.g., waiters and waitresses, security guards, etc.) are extremely lackadaisical. There is a creeping incompetence that permeates through all the nooks and crannies of the Ghanaian bureaucracy, public and private, challenging the patience of the most sympathetic visitor.


Waakye, “Rubber,” and the Environment

Ghanaian food is delicious, but heavy in starch (carbohydrate) and oil (fat). The restaurant scene in Greater Accra is also increasingly cosmopolitan. There are Thai, Chinese, Indian, Turkish, Jamaican, and continental restaurants. It is perhaps a testimony to the continued cultural subjugation of Africa that continental here means European! It is almost unimaginable that the same word could be used in a European capital in reference to African cuisine, if such could be found at all! Two traditional Ghanaian breakfast dishes are Hausa Koko, a porridge made from millet or maize, and waakye (pronounced waa-chay), a somewhat incongruous mixture of rice and beans, vermicelli, hard boiled egg, fried chicken or fish, and thick pepper sauce (shito). Originally from northern Ghana, waakye is delicious, nutritious, cheap, and, if generously consumed, can sustain the average person for an entire day (including this writer). But it is also mainly a takeout street food, which is served in small black plastic bags (“rubber”), many of which end up in the open gutters and canals of Greater Accra, along with plastic bottles and all manner of non-biodegradable materials. The picture below was taken just past Nkrumah Circle on June 30, 2016.




There is no large scale recycling initiative in Greater Accra, which needs to be urgently started and can conceivably be profitable (any entrepreneur reading this?). Nor is there any serious effort of which I am aware to replace synthetics with biodegradables, which are plentiful in Ghana. The lack of conservation efforts of significance has consequences for the environment. A good portion of the seaside of Accra, e.g., the area around the Artists Alliance Gallery, is not a sight to behold. Yet, this is prime real estate, a potential South Beach (Miami) on this side of the Atlantic.

Pedestrian life in Greater Accra requires pulmonary fortitude. There is really no mass transit system, which might have reduced air pollution and traffic congestion. Cars, trucks, and buses tend to use heavy fuel (foo-wal, as most Ghanaian seem hell-bent in pronouncing the word), which emit a strong odor and thick black smoke in the tailpipes of the less than road worthy vehicles (e.g., trotros). Less polluting and more rapid forms of private transportation should be encouraged. I have never noticed signs of bike lanes on the streets of Accra. The bicycle is a commons means of transportation in the Sahel and probably in northern Ghana. It is somewhat surprising it has not made its way south en masse. The taxi moto is perhaps more controversial, but it is ubiquitous in parts of urban Africa (e.g., Kigali). Properly regulated, with safety helmets required of both driver and passenger, it can be a viable means of transportation in Accra: i.e., faster, less polluting, and cheaper than the conventional taxi (but probably not the trotro). In the longer term, Greater Accra needs a public transportation system consisting of buses, light rails, which are being constructed in at least one African capital city (Addis Ababa), and, why not, subways.


People and Church

The most interesting aspects of any city are its people and the social institutions in which they interact. Accra residents are not gregariously friendly, but they are courteous toward and respectful of foreigners. In more than 20 years of regular, sometimes annual, visits to the city, I have not one experience of harassment, much less physical aggression. I have never been robbed, swindled, and “out-hustled.” It is possible to walk in parts of central Accra (e.g., the area around the U.S. embassy) during late evening without encountering a soul, until, that is, one reaches the traffic circle near the Togo embassy where members of the world’s oldest profession ply their trade. It is a curious choice of location, as it is not heavily travelled, but the ladies of the night must know something that most of us do not. (Politicians have been identified as the world’s second oldest professionals. If so, does that make political scientists pimps and madams?) Accra male residents generally prefer Western attire, although the traditional smock (fuugu or batakari), made famous by that picture of President Kwame Nkrumah and his closest aides on Ghana’s Independence Day, has not totally disappeared. Traditional clothing tends to reclaim its dominance during Sunday church services and funerals, and among women.


Religion is probably the most important social institution in Ghana, after the family. Ghanaians are among the most religious people on earth, and they are not bashful at expressing their faith. I had the privilege of attending church services on two occasions, as part of a nascent book project on magic, religion, democracy, and state making in Africa. One experience, was, to say the least, very interesting. When I arrived for the 11:00AM Sunday service in early June, the sprawling church on one of Accra’s busiest roads was only half full, as two services had been conducted in the hours prior. The architecture projected no particular style and seemed to be entirely the product of the imagination of the head pastor (formally he is called archbishop). Church service began with some announcements by what must have been the deacon. One congregant had sent news that he had been the victim of an armed robbery but his life had been spared, thanks to God, to which the deacon asked for and obtained: Amen! Another announcement informed that a member of the flock had passed away, but, not surprisingly, God was given no credit for this development, and there was no solemn agreement (Amen). Then came the church choir and band, both led by the church lead singer.


She was a rather gaunt woman, seemingly in her late 40s, but she had a powerful voice, which easily drowned out that of the choir. The songs were strongly reminiscent of African-American spirituals and R & Bs, but there was also a “classical” tune performed solo by the church organist, which seemed out of kilter with the cadence of the more animated African rhythms. Cheikh Anta Diop was correct: there is fundamental cultural unity among African peoples, and religion is its centerpiece. The mistake made by African Marxists, and the Left in general, in the 1970s was in not recognizing this reality. Religion is in Africa to stay. The challenge is to find points of convergence between religion and progressive secular projects, so mutual suspicions can be dissipated and coalitions built. One issue area might be social justice, another climate change.


Next came the pièce the résistance, the rhetorical crescendo: the pastoral sermon. By this time, the church was full and rocking! Clapping, dancing, and swaying, few people remained in their seats. The congregants seemed eager to hear the archbishop, in spite of the fact that they must have heard him countless times before, some probably that very morning. He was a stocky, sixty-something fellow with a thick gold chain that descended just above his protruding belly, the accoutrement recalling the profile of an ageing American rapper. He was exquisitely good at his craft. He delivered the homily with passion and conviction, but without the theatrical excesses that characterize the liturgy of many a Protestant denomination. There was no glossolalia (speaking in tongues), which I had secretly wished to witness (perhaps I had gone to the wrong church). He bent and closed his eyes when invoking a particularly weighty biblical passage; for emphasis, he kicked into the air with one fist clinched. Stepping away from the pew every once in while, with microphone in hand, the archbishop paced the stage with a gait that clearly suggests he knew he was basically an entertainer, but one with a serious message and specific goal: to collect as much contribution as possible. And collect he did!


At the beginning of the service each attendee was given a program and an envelope. The former was kind of a map to what would be said, the latter the vessel for the expression of generosity. To his credit, the archbishop, unlike some of his American counterparts, never asked for money directly, at least not on that day, but he did not have to. By the time he had finished his spiritual soliloquy, he had the congregants in the palms of his hands. With envelopes in ample supply, some made multiple donations, which were also increased by the constant passing of donation boxes. The music, singing and dancing were at their peak when the donations were proffered; they seemed designed to elicit the spiritual orgasm or ecstasy described by the German sociologist, Max Weber, thereby lowering the resistance of potential donors. Very interestingly, the service was broadcast live to other African countries and the rest of the world through the church’s 24-hour cable TV channel and the Internet. Religion, that most ancient of institutions, has made at least limited peace with that contemporary symbol of modernity: information and communication technology (ICT).


I left with a nagging feeling of what ifs. What if Africa in general and Ghana in particular had an ideology of development that could give religious ideology a strong run for its money? What if the donations of the congregants, many of whom seemed to be ordinary Ghanaians, were turned into a pooled savings fund, from which they could borrow at low or no interest rates to start new businesses (capital formation), build houses, invest in education (human capital), and purchase healthcare? What if the donations were earmarked for specific projects, with costs and dates of completion being part of the public record, to foster accountability? Instead of surreptitiously encouraging profligacy in contribution with no stated purpose, what if the archbishop had preached frugality in spending, which, though anathema to Church financial interest, strongly comports to Christian teaching? What if? What if? (In fairness, it is very possible that, in one form or another, the church does at least some of the things that are being suggested here. That they were not mentioned on the day of my visit makes the speculations more forgiving, but I concede a certain rush to judgment here.)



Funerals are important social events in Ghana. Greater Accra is no exception. I attended a funeral in late June 2016 in the Jamestown section of the city. This was a daylong event on one of the hottest days of the month. The male deceased had joined the ancestors at the relatively young age of 33. He had apparently fallen sick for a brief period before his demise. The prevailing conjecture seems to have been otherworldly foul play, which was not abetted by the inability of the family to order a full autopsy. The service took place on the street where the young man’s parents lived. Tents were erected in the middle of it and naturally vehicular traffic was not allowed. Ghanaian funerals may take months to prepare, as they can be expensive and faraway relatives must be accommodated. This particular funeral was relatively modest and the number of attendees “small” (probably around 75, if that). Relatives were dressed in black and (or) red. The father of the deceased wore a cloth. Service began in late morning with the body inside a casket lying “in state” on the sidewalk near the front door of the parental house. A Christian preacher pronounced the eulogy. At around 1:00PM the body was transported for burial at Awodome cemetery. The cortège drove past the infamous slum of Sodom and Gomorrah.


The burial ceremony was brief and simple, presided over by the same preacher who led the eulogy earlier, with the number of attendees, standing either atop of tombstones or in between, being much smaller. There was a theatricality to the event that took me back to my childhood years in the Caribbean. Just before the casket was interred and covered with dust, people started crying, with at least one women wailing and seemingly talking to the deceased, perhaps cursing whoever had (ostensibly) done him in. An older man stood right behind me, inconsolable, tears streaming like a river down his face. All of this came to an abrupt stop as soon as the signal was given that it was time to return to the house for the post-burial phase. In the trotro, not a single tear was shed; the attendees had displayed an uncanny ability to switch between mourning and normalcy. Are there “professional” mourners? Is there a certain amount of play acting–in other words, dramaturgy– to grieving, or is the line between sadness and its obverse a thin one, enabling people to switch effortlessly and honestly between the two? Ample food and drinks were provided at the post-funeral reception. And then it was time to do the tally. In the house backyard, a group of men, including the father of the deceased, sat around a table to calculate spending and donations. A spokesperson read out loud the figures. Evidently, spending had been higher than donations. Efforts were underway to align the two, when I decided it was time to hail a taxi back to the faculty guesthouse.


Why do Ghanaians spend so much resources on funerals? I am a trained political scientist, not an anthropologist. Hence, I must profess limited cognitive competence (“bounded rationality,” to borrow from Herbert Simon) on a matter that requires years of study. But, as a social scientist, I am also paid to provide at least educated guesses and plausible explanations (“theories”) of social phenomena that can be (in)validated. As an institution, the African funeral is inextricably linked, I believe, to African mythological cosmology, which ties together the dead, the living, and the unborn. In this outlook, the dead continues to live among the living, thus remaining a subject of enduring preoccupation (les morts ne sont pas morts, says the Cameroonian artist Petit Pays). The newly dead has to be sent back to the ancestors properly, lest (s)he and they come after the living with a vengeance. Africa is also experiencing an important demographic shift. According to the World Bank, a majority of Africans are about to become urbanites. The ties that bind are usually weaker among city dwellers. Could the Ghanaian funeral be performing a triple entendre, so to speak? Specifically, could it be a way to assuage the guilt of the upwardly mobile uprooted by urbanization and emigration, who are generally expected to do the heavy financial lifting at funerals? Could it also be a last ditch attempt by a besieged African institution (i.e., the extended family) to maintain its saliency? Finally, could the African funeral perform a function similar to the institution of the godfather and godmother in Latin America and southern Europe, that is to say, transmogrifying dying kinship ties into classic patronage? Of course, the conjectures are not mutually exclusive. All three could be true. Belief (cosmology) and practice (functionalism) may be the best partners of the dead in the African setting.


Closing Remarks

I have sketched out a picture of Greater Accra based on personal observations and reflections over the past seven weeks. Since I did not witness or experience everything, the tableau is necessarily limited. For example, Greater Accra faces very serious power outages, which have gone on for years (dumsor). Fortunately, I had electricity continuously during my stay, except at very brief intervals. The importance of electricity can be expressed in a simple aphorism: no light: no development (point de développement sans lumière). In the final analysis, Greater Accra is unlikely to reach its full potential without reliable and affordable energy, but there are other pressing challenges, as my musing tries to show. Ghana’s largest metropolitan area is changing. I am glad to have been a witness in mid-2016.








Assessing the impacts of Colonialism on African Healthcare

Colonialism had a major impact on all facets of healthcare in Africa: policy, systems, and outcomes. In regards to the latter, there were population declines in much of Africa, in no small part thanks to colonialism. In fact, healthcare policy in the early 1930s was partly an attempt to reverse this trend. As chapter 1 argues, there were many ways in which colonialism contributed to population decline in Africa. In the areas where large scale commercial plantations were established (southwest Cameroon  and Belgium Congo), Africans lived in fetid settlements, which became natural incubators for  contagious diseases. But perhaps the single most important way in which colonialism contributed to population decline was the disruption of family life and its consequences on biological reproduction. This was true almost everywhere, but especially in the mining economies of southern Africa and in the colonies where relatively large scale industrialization (e.g., Congo-Brazzaville), especially in transportation, was pursued. The high rate of industrial accidents, which were common even in Western countries at the turn of the 2oth century, combined with the fact that male workers in Africa had to be away from their homestead for weeks, if not months, adversely affected population growth. Still, the effects of colonialism on population growth, even during the first three decades of colonial rule, were not entirely negative. Vaccination campaigns were a major component of colonial public health policy. In Francophone Africa, in particular, the Pasteur institutes established at the turn of the turn of the 20th century did help some colonies to achieve community immunity (also known as herd immunity in veterinary medicine) that would not be matched in the post-colonial period, as African governments would prioritize hospital-based curative care provided on an individual basis over preventive care. Also, to acknowledge the negative impacts of colonialism on African healthcare is not the same as demonizing the medical missionaries, who played a very important role in colonial medicine. The facilities they built, in some cases at great personal cost to themselves ( e.g., Albert Schweitzer), helped to save countless African lives and lay the groundwork for the introduction of “modern” health systems where none existed before.

In sum,  colonialism had a “mixed” impact on  healthcare in Africa, but as chapter 1 argues, this is in no way to suggest that the “positives” and the “negatives” were proportional. There is no question that colonialism did far more damage to Africa than it did good; furthermore, the damage has been of longue durée, surviving colonialism itself. If healthcare systems in Africa are in shambles today (2015), the genesis can be traced directly to the colonial period. In this sense, colonial healthcare policy was path-dependent. This is a construct in institutionalism theory that has been misunderstood. Path dependence (or dependency) is not the latest buzzword for historical determinism. Path dependence merely asserts that once choices are made and become fully embedded in the body social, they are very difficult to uproot; consequently, they make choices related to the original choice (or choices) more likely than those that are unrelated.

On Institutionalism

Institutionalism is the theoretical approach of the book, but Foucauldian constructs, such as governmentality and biopower (discussed in the previous blog) inform the theoretical orientation of the book as well. Broadly speaking, institutions are the rules that govern human interaction; they are the building blocks of community and stem from the interdependence wrought by “bounded rationality” (limited competence). If human beings could do everything for themselves, and therefore did not need others with whom to trade, there would still be a need for institutions (to decide how to use natural resources, for example). However, institutions probably would not be as prolific as they are under current conditions. Institutions often give rise to organizations (a further evidence of human limitation, for what are organizations but collective action aimed at achieving common goals?), which are formal structures. Institutions can also remain informal understandings, or norms, which can be as powerful as those that are written down (rules, laws, etc.). Institutions are bounded by space, social, political, and geographic. There are micro-level institutions (e.g., the family), macro-level institutions (the state, a formal institution, the nation, an informal one), and meta-level (or geo-politically transcendent) institutions (the UN, WTO, Doctors Without Borders, etc.).

Basically, institutionalism asserts that institutions matter. To understand political and economic outcomes, such as, respectively, democracy or lack thereof, or prosperity or lack thereof, one has to examine the rules of the game, in other words, the rules that underwrite the way members of a community interact with one another. In some instances, institutions create incentives for people to innovate, that is to say, they unleash the creative “soma” juice of the people, even while they also occasion “creative destruction”(Schumpeter, 1956). In other instances, institutions are so constraining that they lead to stagnation.

There are many problems with institutionalism. Firstly, almost anything can be deemed an institution, and the utility of a good concept lies in its ability to exclude, which makes possible falsifiability.If the boundaries of institutionalism are so large that they encapsulate everything, then it becomes difficult to refute the assertions of institutionalists. Luckily, this problem can be resolved if researchers specify how they are using institutions in their work, in other words, on which point of the institutional continuum they are located. Another problem with institutionalism, which is related to the first problem, is that institutions are often used as independent and dependent variables, or as causes and effects, which is unacceptable. Here, too,  specificity can help. Researchers  must state explicitly how they are using institutions. A third problem with (mainstream) institutionalism is its almost religious commitment to incremental change, and consequent inability to predict, ex ante, revolutionary change.

In my view, perhaps the biggest weakness of institutionalism is its conception of institutions as external constraints. This has led theorists to engage, in my view, in a futile debate: i.e., whether structure (institution) or agency is responsible for human action. This dichotomy is rejected in the book on the ground that structure and agency cannot be separated; the two are different sides of the same (institutional coin).

Reflection on Foucault’s Governementalité and Biopower

Gouvernementalité (governmentality) and biopower are arguably two of Foucault’s most recognizable constructs, at least among political scientists who study Foucault. I scattered discussion of these constructs in various chapters in “Healthcare Policy in Africa…” In retrospect, I should have “centralized” their treatment in chapter 1, and then highlighted their relevance  in the remaining chapters, where appropriate.

Governmentality is obviously a clever synthesis of government and mentality. Through this concept Foucault probably meant to draw attention to the fact that governing in the public sphere requires not only the authority of the state (or what is conventionally called government), but also the passive acquiescence of the citizenry, if not their active support. It follows, therefore, that government has a significant interest in producing a particular kind of citizen: i.e., one whose compliance with the rules of the state, or its laws, will not require the use of force, since such rules will have been internalized by them as  “correct” or “just.” Governmentality also underscores transformation of the ethos of the state. Hence, it is not limited to the state producing a particular type of citizen more apt at following rules without coercion, it is also the state itself becoming more caring of its citizens, transforming its mentality as it were. In sum, governmentality is inwardly and outwardly oriented. It combines hard and soft power,  recalling  somewhat the “classic” political science binary: authority and legitimacy. For public administration specialists, governmentality is also reminiscent of development administration.

Biopower is considerably more difficult to explicate, since Foucault in its various lectures at the Collège de France seemed to ascribe it different meanings. However, it is safe to say that biopower relates to policies that have a direct impact on the body (literally). There seems to be “good” biopower and “bad” piower. Good biopower entails the state  improving the living standards of the population (in other words, biopower is a manifestation of governmentality). In concrete terms, good biopower has to do with public health measures, such as mass vaccination, the promotion of healthy habits including good nutrition, sanitation,  slum clearing, child rearing, the use of birth control,  etc. I refer to this type of biopower as faire vivre (allowing to live). Foucault does not necessarily regard these policies as nefarious in their intent; in fact, he thinks they are inherently good and does not question the motivation of the state in implementing them. Bad biopower may be seen as the obverse of all of these measures, but, just as importantly, as the direct application of pressure (in other words, pain ) on the bodies of citizens and, in the colonies, subjects. This type of biopower I refer to, somewhat awkwardly, as making die, or more elegantly, as allowing to die in chapter 2 (“In Conquest and in Health: Healthcare Policy in Africa, 1870-1960”).

The problem with bifurcating biopower is that, in the real world of colonialism, good biopower and bad biopower were often indivisible. In much of colonial Africa vaccination campaigns entailed colonial officials and local African authorities herding the populace like cattle and brusquely, and at times painfully, injecting medicines into their bodies. Mass vaccination itself was good, inasmuch as it helped to achieve community immunity against potentially deadly diseases, but the brutal methods used in vaccination campaigns left much to be desired. Furthermore, the reason why the colonial state wanted healthy African bodies was so that they could be pressed into the mines, the plantations, the new railways and roadside chain gangs for low wages, and sometimes no wages at all. In sum, in the colonies the motivation of the state was hardly anodyne, much less its strategies for implementing “good’ biopower. In this policy area (healthcare), as in many others, colonialism in Africa had a very mixed record. The public goods provided by colonialism often came with very high (and unnecessary) social costs. Still, they had their utility: i.e., they created a habitus or path dependence for post-colonial governments to follow. It is a rare African country that did not incorporate some type of publicly-funded healthcare system with universal access as its core principle in either its constitution or  economic plans.

Chapter I of Healthcare Policy in Africa: Analytical Schematics

This chapter lays out the analytical framework of the book: institutionalism. However, it is more than an exposé of this school of thought. It also explicates the key themes and constructs that are recurring throughout the book, even the most basic ones, such as public policy, healthcare, healthcare system, agency, and globalization. Some authors and readers may think this is unnecessary, given the expected audience for an academic book. I did not want to take any chances. Furthermore, I use some of these constructs differently from many people. For example, I do not accept that globalization is the spread of market relations; instead, I view it as a result of information, communication and transportation technology (ICTT). In other words, capitalism, liberal democracy, and Western, especially American, popular culture are being carried on the wings of ICTT. Hence globalization is the “thing” itself: ICTT. It is not to be confused with its results. Had I not made this clear in chapter 1, readers might have assumed that I accept the conventional definition of globalization, which tends to glorify free-market capitalism, liberal democracy, and “Westernization.”  This was not my aim.

I should take time to make one correction in chapter 1. In reviewing scholarship on Africa in the closing decades of the 20th century, I discussed Robert Kaplan’s “The Coming Anarchy” and Keith Richburg’s Out of America. In the second sentence of page 7  I wrote: “The two articles made for some depressing stuff.” I should have said the two works, for Richburg’s Out of America is a book. I believe it started out as an article for Newsweek, but in Healthcare Policy in Africa, it is clearly cited as a book, not as an article.

I discuss agency at some length in the chapter without tying it to the rest of the book. In fact, there are several constructs which needed to be put in “frames,” and there are at least two, which were left out entirely, but perhaps should have been brought in: Foucault’s governmentality and biopower. I discuss these in later chapters, but an argument could be made that they should have been at least introduced in a chapter that is called “analytical schematics.” I will correct the lacuna on agency today. A discussion of governmentality and biopwer requires more thoughtful musing, and will have to be postponed.

I remarked in chapter 1 that agency in the West was part of a larger process of individuation and “rationalization” rooted in the Enlightenment, the Renaissance and the great revolutions of the 18th century, especially the French revolution. This may explain why when the construct of agency is used, it is normally posited to mean individual agency.  Likewise, civil society tends to be viewed in opposition to the state. I should have tied these two concepts, and then argue that they need not be reproduced in these exact forms and play similar roles outside of the West. If I had to rewrite chapter 1, I might have written the following paragraph.

Because in the West agency was framed as a struggle for the emancipation of individuals from the strictures of religion and monarchic absolutism, among other oppressive institutions, civil society came to be viewed as the means by which this end was to be achieved as well as the end itself. Hence both agency and civil society came to be viewed as bulwarks against the state. This cannot be assumed to apply to (non-Western European) societies. Agency can take a collective form, and civil society can cooperate with the state. This can be readily observed in Africa in the healthcare field, where NGOs effectively implement healthcare policy, either on their own or under contract with the state. There are civil society institutions, of which NGOs are prototypes, whose relationships with the state are conflictual in healthcare, but there are scores of others where this is not the case. Chapter 5 builds a taxonomy of civil society institutions, based on their embeddedness in and with the state. Chapter 6 examines the role of elite, not strictly individual, agency in the making of healthcare policy in Botswana, Ghana, and Rwanda.

A paragraph like this might have helped readers. As I mention earlier, I will have more to say about governmentality and biopwer in a later post.

Healthcare Policy in Africa: Institutions and Politics from Colonialism to the Present

Tomorrow (10/15/15) is the Big Day: “Healthcare Policy in Africa” will be unofficially out. Naturally, there is nothing more exciting for an author than seeing his/her work coming to fruition, after hours, days, weeks, months, and years of hard work. The publication of this book is very timely, as Africa has just committed itself to a more ambitious version of  the UN’s  Millennium Development Goals, even as the threat of Ebola has not totally dissipated from the continent and the economies of Africa appear set to cool off in 2015, partly as a result of stagnating commodity prices and a slowdown in China.

With the publication of “Healthcare Policy in Africa,” I hope to engage in a permanent conversation about the topic. Thus, this book is more of a beginning than an end. I will point to what I might have done differently if I had to write the book over again. In the process, I will draw attention to areas of weaknesses. I  readily concede that there are some things I may not have got “right.” Where that is the case, I will be the first to do a mea culpa. Welcome aboard. Enjoy the ride.