International Health Governance

Fostering Regional Health Governance in West Africa: The Role of the West African Health Organization (WAHO)

Regional integration in Africa has been regarded as a necessary step towards accelerated development on the continent. The belief is that greater gains would be made if states pooled their resources together rather than act individually. Despite elaborate regional goals and objectives, regional institutions in Africa have not been effective in facilitating development, for two major reasons. First, they have significant capacity deficits, especially considering the weakness of their members in this regard. Second, regional institutions have not been utilized as a legitimacy-enhancing mechanism to engage citizens and provide the motor for effective governance.

Alesino and Spolaore note that, “borders … are the outcome of choices and interactions by individuals and groups who pursue their goals under constraints”. Control over territory in Africa has been undermined by limited infrastructure, governance deficits, and low citizen loyalty; and the size of the States has, along with their historical, economic and political development, contributed to their lack of control. There are indeed domestic collective action problems because the central State is unable – sometimes unwilling – to supply public goods, and individual incentives to cooperate are greatly limited. Therefore, the capacity and legitimacy deficits of African states are inextricably linked.

Regional institutions can enhance State capacity by pooling resources together and legitimacy by deemphasizing borders and providing citizens with access to communities and resources across borders. Migration and trade policies as well as cross-border programs have the binary effect of facilitating regional trade while also bringing together societies and giving citizens greater freedom to develop their capacities.

Regionalism in West Africa

The Economic Community of West African States (ECOWAS) was established by treaty in 1975 as an intergovernmental organization with the primary purpose of promoting economic development in West Africa. Membership consists of 15 West African countries, most of which have experienced violent conflict, military coups, and authoritarian governments within the past five decades. Refugee flows, “spillover” effects of conflicts and violent groups, arms proliferation, as well as the spread of communicable diseases, reveal how vulnerable States in the region are to conditions in other Member states. Consequently, in a revised treaty in 1993, ECOWAS expanded its mandate and institutions to include non-economic principles such as the maintenance of peace and security and respect for human rights.

ECOWAS functions through political and administrative institutions with general functions and specialized agencies with particular functions. These Community institutions, which form the regional governance structure, rely on States for implementation of Community policies and decisions. It is a largely State-driven process, with limited collaboration with civil society and the private sector. This is the framework within which a regional response was crafted to address the Ebola crisis in 2014.

The Ebola Response

The two main institutions responsible for managing the response to the Ebola crisis were the ECOWAS Commission and the West African Health Organisation (WAHO). WAHO was established in 1987, came into operation in 1998 when its Headquarters was instituted in Bobo-Diolassou, Burkina Faso, and began active operations in 2000. The ECOWAS Commission, which was also responsible for providing a response to the Ebola outbreak, is described as “the main engine room for all ECOWAS programmes, projects and activities”, and its Commissioner for Social Affairs and Gender is responsible for regional health matters.

Given regional constraints, the intervention strategy of ECOWAS was sub-optimal. WAHO sent out fewer than 10 technical officials into the field after the outbreak began. It was not until December 2014, a year after the outbreak began and more than half a year after the diagnosis was made, that WAHO sent out its first robust team of 150 trained medical professionals from member states (Cote d’Ivoire, Ghana, Mali, Niger, Nigeria, and Togo) to assist with the medical response. Meanwhile, at this point Medicins Sans Frontiers (MSF) had already deployed more than 300 international medical professionals and more than 3000 locals to tackle the outbreak. Needless to say, WAHO did not provide a leadership role in the Ebola response.

Fostering Regional Governance

Capacity deficits make it difficult to set up the kind of ‘insurance scheme’ required at the regional level to “share the risk of an uncertain environment” resulting from State fragility. Therefore, in order to build effective regional institutions, it is important to look beyond the State for resources to strengthen the capacity of regional institutions. At least two challenges, in this regard, are likely to arise in addressing the costs of cooperation. Firstly, since States see themselves as sovereigns acting collectively to independently address their collective concerns, seeking external assistance for regional institutions might pose challenges to cooperation. This is unless the benefits arising from such a system outweigh the “sovereignty” concerns. Secondly, many African States rely on external assistance for national capacity. Given that external assistance – whether from intergovernmental organizations, partner countries, or the private sector – constitutes limited resources, this would create competition between national and regional institutions for scarce resources and States would naturally prioritize their individual interests over the collective interest.

States remain at the center of the West African integration process, so their capacity and legitimacy deficits undermine the effectiveness of regional institutions. The history and institutional design of regional integration in West Africa is such that the State has maintained a central role and maintained critical control of regional institutions, from determining legal and policy interventions to determining capacity issues such as funding and technical support. This means that regional institutions serve not just as a forum of States but as an extension of the State. While the capacity deficit of regional institutions affects their ability to pursue regional objectives and supply regional public goods, this can be overcome by reliance on external support to build the capacity of regional institutions. However, with States at its center, the regional process is clouded by the legitimacy challenge of the State as well, because regional institutions, if controlled by the State, would not provide an alternative community for citizens to cooperate.

The legitimacy of regional institutions is based on two realities: first, the citizen, marginalized by the State and without access to basic resources, is constantly in search of an alternative supplier of public goods, a parallel system, if you will; second, the trans-border realities of African societies whose social, cultural and political networks are not adequately represented within clear border territories are better represented within a ‘borderless’ regional framework. Thus, the regional system provides an alternative mechanism for the supply of public goods that can garner acceptance based on a legitimate exercise of power and provide decentralized institutions that would be recognized by citizens as legitimate.

This is yet to be addressed. In order to tackle the shortcomings of the current regional system, it is important to focus on enhancing the capacity and harnessing the legitimacy of regional governance structures so that they can form the basis for the valid exercise of power by political institutions, which is lacking in the current statist governance structure. To effectively harness its strengths as a viable political, legal and economic system, the regional institution must look outward for capacity and inward for legitimacy.

Edefe Ojomo is a lecturer in the Department of Jurisprudence and International Law, University of Lagos, Nigeria, and currently JSD student at NYU Law School.

ISSN 2510-2567
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