PRINCETON, N.J.--Sub-Saharan Africans rate their own wellbeing, their health and their health-care systems among the lowest in the world, according to a new report published by Princeton University's Woodrow Wilson School of Public and International Affairs.
Despite these low ratings, health care is not a primary policy concern for people in these countries. Instead, sub-Saharan Africans cite jobs as a top priority, followed by improving agriculture and tackling corruption.
One influence behind such perceptions is the pervasiveness of HIV in certain countries within sub-Saharan Africa, which poses challenges for poorly funded health care systems. But the introduction of Western aid may have swayed certain perceptions: people living in regions with the highest rates of HIV report receiving better health care in the five years prior to 2012 - most likely due to spillovers from foreign funding, the researchers report.
The research - released by Health Affairs as a Web First - points to some of these difficulties of addressing health in general and HIV/AIDs in particular in African nations suffering from chronic poverty, unemployment, corruption and conflict. The confluence of these crises creates many dilemmas: Nations find it difficult to provide adequate health care, and countries with poor health care have so many other immediate problems that for people in those countries, health is often not one of their top concerns.
"Countries with high HIV prevalence have attracted a great deal of health-related aid, which may have helped improve their citizens' perceptions of their health-care systems," said co-author Angus Deaton, Dwight D. Eisenhower Professor of Economics and International Affairs at the Wilson School. "There may well have been positive spillovers from external funding for HIV into the more general health care system. Even so, we find that people in the region do not feel that improving health care should be the highest priority for their governments."
While Africa is the continent with the poorest health data, there is a dearth of information on how Africans perceive their own health. One survey collector is the Gallup Organization, which has been collecting information in sub-Saharan Africa since 2005 as part of its World Poll. Twenty-eight sub-Saharan African countries are included in this survey, which uses face-to-face interviews in local languages to ask residents how they feel about various aspects of their lives.
Deaton and co-author Robert Tortora (who worked at the Gallup Organization when this report was written) used data from the Gallup World Poll along with publically available data from the World Bank's World Development Indicators, UN-AIDS and the Demographic and Health Surveys, which is funded by the U.S. Agency for International Development. Altogether, these data allowed the researchers to examine health perceptions of sub-Saharan Africans at individual, local and global levels.
Perceptions of Health and Health Care in Africa
The Gallup World Poll uses the Cantril ladder, a measure of wellbeing developed half a century ago by Princeton social researcher Hadley Cantril. This measure asks participants to visualize a ladder with steps numbered from zero at the bottom (worst possible life) to 10 at the top (best possible life).
When calculating wellbeing in sub-Saharan Africa, the researchers find that it is lower than that of any other region in the world. As previous work has shown, the researchers find a strong correlation between average Cantril ladder scores and gross domestic product figures. Simply put, lower incomes translate to lower ratings of wellbeing.
"Sub-Saharan African countries are poor, and people in the region understand that their lives are much worse than they might be," Deaton said.
In terms of health care, only 42.4 percent of sub-Saharan Africans are satisfied with the availability of high-quality care near where they live. Still, 57 percent of people say their government has done well or fairly well at improving basic health services - a percentage that declined between 2002 and 2013. Overall, the researchers report a broadly negative picture of self-reported health in sub-Saharan Africa.
Perceptions of health in sub-Saharan Africa varied by country. The number of people who reported that they were in perfect health ranged from highs of more than 50 percent in Somaliland and Ethiopia to only 17 percent in Madagascar and Tanzania. In Ghana, Somaliland and Sudan, more than half of the population said that they had never had contact with a medical professional. But in Cameroon, Gabon and Senegal, the fractions were less than 10 percent.
Health care spending varied even more widely by country. South Africa and Botswana, both relatively wealthy and with high rates of HIV, spent $942 and $734 per person, respectively. But the median for all countries was $109 per capita. The Democratic Republic of the Congo, Ethiopia, Madagascar and Niger spent less than half of that amount.
Privately provided health care is important in sub-Saharan Africa. In 12 of the 28 countries included in the Gallup World Poll, at least half of all health care spending is in the private sector. Only in Malawi does the private sector account for less than a third of all health care spending.
"The private sector tends to be somewhat more important in places where little is spent overall," said Deaton. "Private providers can often deliver services as good as those the state delivers in places where the state has low capacity, especially for routine care."
When evaluating health and wellbeing perceptions on an individual level in sub-Saharan Africa, the researchers found both predictable and not-so-common results.
The effects of age on life evaluation provided the first surprise: life evaluation did not differ by age in sub-Saharan African countries. This is in sharp contrast to the famous U-shape age profile of life evaluation in richer countries like the United States where life evaluation dips in middle age but then increases with older age.
"One possible explanation is that the U-shape only occurs in countries where there are strong social security systems and programs that provide health care coverage for the elderly, which is certainly not the case for sub-Saharan Africa," Deaton said.
Still, the researchers found some similarities between sub-Saharan Africa and wealthier countries. In both cases, women evaluated their lives more highly than men, and income and education brought greater wellbeing. Likewise, those who were divorced, separated or widowed reported lower levels of wellbeing, and people with two or more kids in the house reported lower wellbeing than people with one or no children at home.
On an individual level, confidence in health-care systems varied sharply by country. Women, people with more education and those with higher incomes had more confidence in their country's system compared to men, those with less education and lower incomes.
"This is surprising because the groups with more confidence are also more likely to experience health care and - one might have thought - to understand its weaknesses," Deaton said. "Perhaps they simply have limited experience with which to judge the adequacy of health care available to them."
With regards to health care exposure, the probability of ever having contact with a health care provider in the system increased with age. It was also higher for women and people who were married, had children, were more educated and were more religious. The correlation between religion and medical exposure might reflect the role of religious institutions in providing health care to the region, the researchers said.
Perceptions of Health Care Needs in Sub-Saharan Africa
One of the controversial issues in the literature and the donor community is the effect of the HIV/AIDs epidemic on health care, both before and after 2004, which saw a large increase in aid, from the U.S. President's Emergency Plan for AIDS Relief (PEPFAR) and the Global Fund.
When asked whether health care has improved over the past five years, public perceptions did not vary according to the level of HIV prevalence in their country - except among the countries where prevalence is highest. In these countries, higher prevalence is associated with more people perceiving improvement.
"It is possible that the first phase of the HIV/AIDS epidemic ... and the subsequent expansion of antiretroviral therapy - which helps to suppress and stop HIV - has been complementary with improvement in some other categories of health provision," Deaton said.
But while health aid has increased to sub-Saharan Africa from high-income countries, residents there do not view health care as a top policy priority. Instead, 31 percent of people picked new jobs as their top concern, and 21 percent picked improving agriculture. Tackling corruption was next at 14.4 percent. Education and health care were chosen by 13.6 percent and 13.5 percent, respectively. Providing electricity was picked by only 6.3 percent.
When drawing comparisons between the groups, the researchers found that the people who prioritized agriculture also valued new jobs. These choices share an underlying factor: the importance of better livelihoods.
Still, when looking for a connection between prioritizing health care and HIV prevalence, the researchers find none. For sub-Saharan Africans, HIV/AIDS ranks third after poverty reduction and hunger reduction - and ahead of providing more jobs, reducing child mortality, among others. As noted, countries with the highest HIV rates also had the most advanced health care systems at the start of the epidemic. Therefore, people there may feel their governments are already paying enough attention to health care.
"Of course, just because people in sub-Saharan Africa do not see health care as the highest priority does not mean that aid agencies are incorrect to prioritize it," Deaton said. "People in the region may be poorly informed or after centuries of high morbidity, they may not believe the government or anyone else is capable of providing meaningful relief. But even if they are well informed, it might also be the case that aid agencies believe - correctly or not - that they are more effective at saving lives than at generating economic growth."
The paper, "People in Sub-Saharan Africa Rate Their Health and Health Care Among the Lowest in the World," will be published in the March 2 print issue of Health Affairs. It will appear on the Health Affairs website Feb. 25 at 4 p.m.
Deaton's work is supported by the Gallup Organization and by the National Institute on Aging through both the National Bureau of Economic Research (grant nos. 5R01AG040629-02 andPO1 AG05842-14) and Princeton University's Roybal Center for Translational Research on Aging (grant no. P30 AG024928). Deaton is a consultant to the Gallup Organization.