News of Ethiopian Prime Minister Meles Zenawi’s death on August 20, 2012 brings to four the number of African heads of state who have died so far this year. At times like this, it is often reported just how risky it is to be an African president: since 2010, Africa has lost ten heads of state due to natural causes (eleven if we include the President of Somaliland) plus Gaddaffi’s violent execution.

Until relatively recently, it was very rare for an African head of state to leave voluntarily. Today, this is somewhat different (although note that since 2000 there have been ten coups and eighteen attempted coups in Africa). Across much of Africa, the institutionalisation of behavioural norms and constitutional rules seem to be having an effect, replacing violence as the main source of constraint on presidential excesses.

Indeed, the public dispatching of Gaddaffi last year was actually something which is now a rarity on the continent, although the 2009 killing of  Guinea-Bissau’s Joao Bernardo Vieira by renegade soldiers did momentarily bring back memories of the bad old days.

This normative milieu is a quite different scenario from what Africa saw between the 1960s and 1980s, when the majority of African presidents involuntarily left office via assassination, a coup d’état or some other similarly violent downfall. Since the 1990s, however, the majority of African heads of state have vacated office largely through institutionalized measures. Today, this is often through the resignation of office once the constitutionally-defined term has finished—or by losing an election.

Indeed, elections are developing into important mechanisms for both choosing leaders in Africa, as well as changing them. Elections across the continent are numerous, increasing in number and also their general competitiveness. Of course, we cannot ignore the fact that incumbents still almost always emerge victorious, highlighting a major challenge to limiting presidential power in Africa.

Yet Africa has moved forward and if and when presidents do start trying to avoid adhering to constitutional limits on their terms of office, the people are likely to go out on the streets to prevent them. The Presidents-for-Life have disappeared.

Yet, the death of Zenawi brings to the fore something that hasn’t much changed.

As mentioned, since 2010 Africa has lost ten heads of state. Given that there are currently 54 African states, a presidential mortality rate of nearly 19% in ten years may make some of the continent’s presidents think about a quick medical check-up. This is where plus ça change, plus c'est la même chose. That Zenawi died in a hospital in Brussels, Belgium, is surely a damning indictment of the legacy of presidentialism and personal rule that has so disfigured the continent. Can it really be the case that Ethiopia does not have a single hospital fit to treat its own head of state?

Of the ten African heads of state that have died of natural causes in office since 2000, only two actually passed on in their own countries. And of these two, both had been receiving medical care abroad and effectively returned home to die. In other words, not a single African head of state who has died in the last ten years of natural causes had any confidence in his own country’s healthcare.

The phenomena of African presidents dying abroad is truly a disgrace and reflects the failure of Africa’s leadership to seriously invest in healthcare provision. Quite simply, in many African states the elites have not bothered to provide public health leadership and management, have not invested in sufficient health-related legislation and the enforcement of such laws, have proven inefficient in resource allocation and use, and have systematically undermined the provision of adequate national health information and research systems.

A failure to invest in national healthcare systems has then led to extreme shortages of health workers, exacerbated by inequities in workforce distribution (with a strong urban bias) and subsequent brain drain.

Rampant corruption in procurement systems and inefficient supply systems then combine with unaffordable international prices to produce shells of “hospitals” where one has a greater chance of contracting something extra than being cured of one’s existing ailment. Notably, a recent survey of global hospital rankings placed Africa’s best performer (South Africa’s Netcare Group) at 392.

Emblematically, Africa’s fifth best hospital, the Hopital Central de Yaounde in Cameroon, was ranked 1,404 in the world. Sadly, it is the lucky ones who can darken the door of such hospitals in Africa: 47% of the continent’s population have no access to such health services.

Whilst Structural Adjustment Policies have undoubtedly impacted upon healthcare in Africa, one should avoid the temptation to place all the blame on external factors. Health financing in Africa is often characterized by negligible investment, an absence of any comprehensive health financing policies and strategic plans, weak financial management and inefficient resource use. The reasons for this are political.

Unfortunately, the idea that resources should be channelled towards the nebulous concept of “national development”, which includes healthcare, is not on the agenda of many elites in Africa. For them, wealth generation and survival does not depend on productive development or investment in the people, but is dependent upon control over select areas of the country i.e. where the mines and plantations are, or by the manipulation of the market for personal reasons of power and profit.

Elite survival comes from access to rents to distribute to patronage networks and thus retain key support, not on investing in services. Investment in such national infrastructure and the advancement of policies that benefit broad swathes of the population is not required in many of Africa’s neo-patrimonial regimes.

This has a direct impact on policy formulation. Why bother spending money on building and maintaining hospitals (or schools or universities) when one can fly to European hospitals to be treated—or send one’s kin abroad for education? Within the logic of many extant African regimes, it makes no sense to invest in public ventures. That’s what the gullible donors are for!

Elites in such states dismiss any interest in a broader project of creating a state that serves the collective good.  For them, fostering institutions that may possess independent interests and act on behalf of interests separate from the elites’ exercise of power (such as functioning bureaucracies—including a functioning healthcare system) is out of the question.

Thus Africa’s big men continue to die abroad in foreign hospitals fifty-years or more after independence. By doing so, they not only demonstrate an implicit contempt for “African” standards—African hospitals are apparently fit only for the poor and unfortunates with no other options, but also continue to signal their disdain for broad-based national development where equity and decent life chances for all Africans exist.

Written by Ian Taylor

*  Chair Professor, Renmin University of China

*  Extraordinary Professor, University of Stellenbosch, South Africa

*  Honorary Professor, Zhejiang Normal University, China

• Place of death of Africa’s heads of state dying of natural causes, 2000-2012