Kenya: public health on a foreign drip, and the drip is running dry

According to France 24, Kenya is trying to preserve treatment for patients and prevention programmes, at a time when the funding of its health system has become uncertain since the withdrawal of American aid from USAID (the US Agency for International Development). The government is multiplying initiatives and new agreements, whose durability, the broadcaster stresses, raises questions. That is what we know. The sums, the partners, the conditions and the timetables do not appear in the summary we have: we will not invent them.

Then there is the question of structure, and it is our reading, not an established fact. A health system whose prevention programmes hang on the decision of a donor thousands of kilometres away is not really steered from Nairobi. It is steered from wherever the aid budget is voted. When that vote changes, it is Kenyan patients who find out, not American voters.

Dependency theorists have said so for a long time: poor countries are not simply "behind", their economies were shaped to serve the centre. Debt, debt servicing and conditional lending lock in that position. One could add conditional aid. A state that devotes a large share of its revenue to repaying its creditors has little room to fund hospitals itself. We do not have Kenyan figures on this point here, and the dispatch offers none; but the question deserves asking with every new "agreement".

That is where the shoe pinches. The new arrangements France 24 describes are presented as a response. Yet replacing one donor with another, or with a loan, does not end dependency: it changes the name on the counter. Kwame Nkrumah counted among the privileges of neocolonialism the "right" to provide "aid", and this is far from innocent: whoever gives also sets the agenda. What remains to be known is which counterparts will accompany these agreements, and that is precisely what we do not know at this stage.

The second risk is commercialisation. When public finances dry up, the temptation to bring the private sector into care, and to turn a common service into a source of profit, is strong. Nothing in the dispatch says Nairobi is heading that way; we merely note that it is the classic outcome for countries caught in a vice between debt and donor disengagement, and that the terms of future contracts will need watching.

Beware, too, the narrative of "resilience". It flatters governments, suits donors, and implies that the make-do spirit of health systems in the South is a virtue. It is above all a bill passed on to those who care and to those who are cared for.

Real health sovereignty would mean being able to fund one's dispensaries without asking permission. That means renegotiating debt, taxing more heavily the profits that leave the country, and demanding that aid not be a lever. This is what the USAID crisis makes visible: political independence is worth little if the health budget is decided elsewhere.