In sub-Saharan Africa, healthcare has been shifted from the realm of politics and democratic accountability to that of billionaires and so-called “experts” in a process that has resulted in what Egyptian economist, Samir Amin, has referred to as “low intensity democracy.” Bill Gates has a much greater say in public health issues concerning Africans than African citizens themselves. Similarly, it is perfectly uncontroversial for South African president Cyril Ramaphosa to publicize local billionaire pledges to the COVID-19 pandemic on national TV, perhaps reflecting that they form his real constituency. Where are the voices of the millions of ordinary citizens who vote in African elections? Have they been hollowed out by the rich and powerful?

Let’s consider Zimbabwe. The country’s Forbes-listed billionaire Strive Masiyiwa, who has invariably donated to the country’s health-care system through his Higherlife Foundation, has proposed the creation of a Special Purpose Trust to help Zimbabwe and Sudan’s response to the coronavirus pandemic. A few months before the outbreak of the coronavirus, a prolonged doctors’ strike, which had all but paralyzed the Zimbabwe’s healthcare sector, ended with doctors’ accepting a funding offer from Masiyiwa’s Higherlife Foundation. In sidelining the government and democratic accountability, Mr Masiyiwa advocates for the exclusion of the state and the promotion of “third parties” in the management of humanitarian responses.

Unsurprisingly, the UK based philanthropist exclaimed, “Don’t just wait for governments” after donating 45 ventilators to be used in Zimbabwe’s public hospitals. To be clear, this is by no means a reproach of good deeds except to point out that these acts illustrate how the government’s duty of service provision has been subordinated to private actors. Besides, a public health system that’s worth its salt cannot rely on the benevolence of private foundations. A closer look at Mr. Masiyiwa’s interventions reveals that they probably reinforce existing systemic failures which they intend to solve. By quelling a doctors strike with a cash payout, Zimbabwe’s healthcare system lost out on the opportunity for broad systemic change through labor struggle—especially given that the doctors were striking for broad issues beyond pay. Likewise, failing to advocate for the lifting of economic sanctions on Zimbabwe under the guise of entrepreneurial activism as opposed to political activism is hypocritical. No one can possibly sustain an argument that sanctions have not negatively affected Zimbabwe’s economy in general and healthcare system in particular.

In the case of South Africa, the statement by President Ramaphosa that the Oppenheimer and Ruppert families had pledged 1 billion Rands ($57 million USD) each for small enterprises to tap into during the COVID-19 pandemic was an unprecedented publicity stunt for private individuals by a state president. In addition, the president announced the set-up of a solidarity fund. According to Ramaphosa, the government would provide seed capital of R150 million into the fund to complement public sector efforts to combat corona virus. The Fund’s website states, “… individuals and organizations will be able to support these efforts through secure, tax-deductible donations.” Most significantly, he stressed that: “The Fund will be administered by a reputable team of people, drawn from financial institutions, accounting firms and government.” This provides irrefutable evidence of the growing role of accountants and managers in healthcare provision.

What the aforementioned actions belie is the transformation of African public health into a core site of accumulation. Moreover, health philanthropy as an alliance of national governments, charities, NGOs and Western capital allows elites to mask their real intentions as humanitarian actions. And yet, this has significantly undermined the resilience of global south national health systems. African ministries of health have increasingly shifted towards serving the needs of financiers by focusing on disease specific interventions instead of broadly strengthening national health care systems. NGOs and western capital have promoted this through vertical funding. Because of this, social justice, egalitarianism and community participation in health care have been displaced. It is thus important to shed more light on this transformation.

For decades, until the end of World War II, public health in the Global South had been under the purview of colonial rulers. Hence, health services extended to the “third world” peoples was strongly linked to capital accumulation. However, by 1978 at the height of the Cold War, third world peoples became conscious of the benefits of healthcare for all. This culminated in the Alma-Ata Declaration whose ethos was “health for all.” It declared that: “The people have the right and duty to participate individually and collectively in the planning and implementation of their health care.” Consequently, 134 members of the World Health Organization (WHO) signed the declaration in Alma-Ata, USSR on September 6, 1978. Indeed, the declaration reflected the popularity of socialist policies at the time. Most importantly, its proponents led by the Chinese delegation to the WHO viewed it as a tool for redressing injustice.

This effort, however, was undermined by the US which hindered the development of self-sustaining healthcare systems in the global south by starving them of funding. This culminated in the 1993 World Development Report which criticized Alma-Ata’s financing mechanisms. The final death knell was struck on socialist health programs by structural adjustment programs, which further deprived public healthcare programs of funding. Its place was filled by “global health governance” (GHG) as part of the “new world order.” This meant the supplanting of governments in the realm of public health by foundations, NGOs and Public-Private Partnerships (PPPs). Instead of supporting governments in the provision of holistic health-care, global financiers alienated health ministries through sophisticated financial schemes. As a result of this, the WHO was greatly weakened and reduced to servicing private foundations instead of the majority of the world’s population.

By far the most striking effect on the public health of the developing world by the GHG agenda is its focus on “health-care verticals.” This has been promoted by initiatives such as the Global Fund to Fight AIDS, Tuberculosis and Malaria and Gavi, the Vaccine Alliance, both initiatives heavily influenced by the Bill and Melinda Gates Foundation. A key feature of health verticals is their focus on specific diseases, as well as their pliability to hierarchical management by multiple stakeholders. Consequently, health ministries have been significantly weakened. Their focus has been diverted towards funded initiatives much to the detriment of other conditions, which are equally important but perhaps less profitable to the foundations. This is the state of the milieu in which COVID-19 finds a majority of African countries.

At present, sub-Saharan Africa is experiencing a low reported numbers of cases and deaths from COVID-19 relative to other parts of the world. Many governments on the continent have implemented social distancing measures and are now easing them. However, because of the virtual absence of both adequate public services and a social safety net, there has been a short shrift consideration of their effectiveness. This has been in part caused by years of neoliberal decimation of the resilience of Global South governments in the past four decades.

Take for instance South Africa—after almost three decades of “democracy,” informal settlements and rural areas still lack basic services like running water and adequate sanitation. Social distancing in the townships which are home to the majority of South Africans is almost impossible. Similarly, South Africa’s former colony, the Republic of Namibia, which grappled with Hepatitis E last year, instituted a lock-down. However, it faces immense sanitation challenges and has had to rely on tippy taps for hand washing water. In Zimbabwe, the death of a prominent journalist in the country’s main COVID-19 facility prompted elites to establish a private state of the art facility in a PPP with the government—once again reinforcing the divide between the haves and the have-nots.

To sum up, COVID-19 provides Africans with a prism for reflecting on what GHG might mean to them. Following the freeze on funding by the US president to the WHO, its apologists have come out guns blazing. As argued in this article, the WHO has long been unfit for purpose, after years of onslaught by private financiers—this might be an opportunity to restore the sovereignty of nations at the WHO and revert back to the principles of the Alma Ata Declaration. Surely a few billionaires cannot continue to speak on behalf of millions of Africans.