Why Justice is Good for Healthcare in Africa: Towards an Ethical framework

  • Samuel J. Ujewe


This chapter aims to establish the place of justice in the discourses on and outlooks of health and healthcare in Africa. It anticipates a specific African approach of justice in the distribution of and access to healthcare. African countries, south of the Sahara, are widely recognised to share a common cultural heritage in which communitarian ethical values are emphasised. Among other things, they also share a similar burden of disease. In the region, communicable diseases constitute approximately 50% of the leading causes of deaths. While Africa bears a relatively high proportion of the global burden of disease, financial commitment to healthcare amounts to less than 2% of the total global expenditure. This results in high rates of household out-of-pocket payments. Yet, over two-thirds of Africa’s populations live below the acceptable poverty benchmark. These facts raise questions of justice for healthcare in Africa, especially relating to ethical issues surrounding distribution and access. While questions of healthcare justice abound, much of the discourse in bioethics in Africa mostly focuses on research ethics (e.g. involving patients in clinical trials). Relevant debates are often limited to questions of autonomy and informed consent. Furthermore, global Bioethics has largely avoided questions of health inequalities in Africa. Various efforts in healthcare reform exclude ethical measures in reviewing the system and analysing health policies. The chapter envisions a framework of justice for healthcare that should more appropriately guide ethical reforms in African health systems.


  1. Abun-Nasr, J. M., Warmington, B. H., & Brett, M.. (2016). ‘North Africa’. Encyclopædia Britannica. Encyclopædia Britannica, inc.
  2. Adekunle. (2014). How Ebola disease got to Nigeria. Vanguard News (blog). 22 October 2014.
  3. Africa Check. (2017). FACTSHEET: Africa’s leading causes of death. Africa Check. 4 August 2017.
  4. Akuki, A. (2015). Salvaging Nigeria’s health care challenges. Independent Nigeria (blog). 20 January 2015.
  5. Arin, D., & Hongoro, C. (2013). Scaling up national health insurance in Nigeria: Learning from case studies of India, Colombia, and Thailand. Washington, DC: Futures Group Health Policy Project.Google Scholar
  6. Azetsop, J. (2011). New directions in African bioethics: Ways of including public health concerns in the bioethics agenda. Developing World Bioethics, 11(1), 4–15.CrossRefGoogle Scholar
  7. Bichell, R. E. (2017). How Madagascar took control of its plague outbreak. NPR.Org. 19 November 2017.
  8. Bonilla-Chacin, M. E., Okigbo, A., Malife, N., Sherburne-Benz, L., & Ruhl, O. (2010). Improving primary health care delivery in Nigeria: Evidence from four states. Washington, DC: World Bank.Google Scholar
  9. Callahan, D. (2000). Universalism & particularism: Fighting to a draw. Hastings Center Report, 30(1), 37–44.CrossRefGoogle Scholar
  10. Daniels, N. (1985). Just health care. Cambridge: Cambridge University Press.CrossRefGoogle Scholar
  11. Daniels. (2000). Accountability for reasonableness: Establishing a fair process for priority setting is easier than agreeing on principles. BMJ: British Medical Journal, 321(7272), 1300.CrossRefGoogle Scholar
  12. Daniels. (2006). Toward ethical review of health system transformations. American Journal of Public Health, 96(3), 447–451.CrossRefGoogle Scholar
  13. Daniels. (2007). Just health: Meeting health needs fairly. Cambridge: Cambridge University Press.CrossRefGoogle Scholar
  14. Daniels, N., Bryant, J., Castano, R. A., Dantes, O. G., Khan, K. S., & Pannarunothai, S. (2000). Benchmarks of fairness for health care reform: A policy tool for developing countries. Bulletin of the World Health Organization, 78(6), 740–750.PubMedPubMedCentralGoogle Scholar
  15. Daniels, N., Flores, W., Pannarunothai, S., Ndumbe, P. N., Bryant, J. H., Ngulube, T. J., & Wang, Y. (2005). An evidence-based approach to benchmarking the fairness of health-sector reform in developing countries. Bulletin of the World Health Organization, 83(7), 534–540.PubMedPubMedCentralGoogle Scholar
  16. Ezeome, E. R., & Marshall, P. A. (2009). Informed consent practices in Nigeria. Developing World Bioethics, 9(3), 138–148.CrossRefGoogle Scholar
  17. Ezeome, E. R., & Simon, C. (2010). Ethical problems in conducting research in acute epidemics: The Pfizer meningitis study in Nigeria as an illustration. Developing World Bioethics, 10(1), 1–10.CrossRefGoogle Scholar
  18. Feasey, N., Wansbrough-Jones, M., Mabey, D. C. W., & Solomon, A. W. (2009). Neglected tropical diseases. British Medical Bulletin, 93(1), 179–200.CrossRefGoogle Scholar
  19. Focus Economics. (2017). ‘Nigeria Economic Outlook’. Focus Economics: Economic Forecasts from the Wolrd’s Leading Economists, 14 November 2017.
  20. Fox, R. C., & Swazey, J. P. (2010). Guest editorial: Ignoring the social and cultural context of bioethics is unacceptable. Cambridge Quarterly of Healthcare Ethics, 19(3), 278–281.CrossRefGoogle Scholar
  21. Fullman, N., Barber, R. M., Abajobir, A. A., Abate, K. H., Abbafati, C., Abbas, K. M., Abd-Allah, F., Abdulkader, R. S., Abdulle, A. M., & Abera, S. F. (2017). Measuring progress and projecting attainment on the basis of past trends of the health-related sustainable development goals in 188 countries: An analysis from the global burden of disease study 2016. The Lancet, 390(10100), 1423–1459.CrossRefGoogle Scholar
  22. Inyang, I. (2017). Labour Kicks, Says Reps N30,000 Minimum Wage Not Good Enough. Daily Post Nigeria (blog). 15 October 2017.
  23. Kelland, K. (2015). Two new trials of Ebola vaccines begin in Europe and Africa. Reuters, 15 July 2015.
  24. Kerridge, I., & Gilbert, L.. (2014). Epidemic ethics: Four lessons from the current ebola outbreak. The Conversation, 24 August 2014.
  25. Kombe, F., Anunobi, E. N., Tshifugula, N. P., Wassenaar, D., Njadingwe, D., Mwalukore, S., Chinyama, J., Randrianasolo, B., Akindeh, P., & Dlamini, P. S. (2014). Promoting research integrity in Africa: An African voice of concern on research misconduct and the way forward. Developing World Bioethics, 14(3), 158–166.CrossRefGoogle Scholar
  26. Maluka, S. O. (2011). Strengthening fairness, transparency and accountability in health care priority setting at district level in Tanzania. Global Health Action, 4(1), 7829.CrossRefGoogle Scholar
  27. Maluka, S., Kamuzora, P., Sebastián, M. S., Byskov, J., Ndawi, B., & Hurtig, A.-K. (2010a). Improving district level health planning and priority setting in Tanzania through Implementing accountability for reasonableness framework: Perceptions of stakeholders. BMC Health Services Research, 10(1), 322.CrossRefGoogle Scholar
  28. Maluka, S., Kamuzora, P., Sebastiån, M. S., Byskov, J., Olsen, Ø. E., Shayo, E., Ndawi, B., & Hurtig, A.-K. (2010b). Decentralized health care priority-setting in Tanzania: Evaluating against the accountability for reasonableness framework. Social Science & Medicine, 71(4), 751–759.CrossRefGoogle Scholar
  29. Maluka, S., Kamuzora, P., Sebastián, M. S., Byskov, J., Ndawi, B., Olsen, Ø. E., & Hurtig, A.-K. (2011a). Implementing accountability for reasonableness framework at district level in Tanzania: A realist evaluation. Implementation Science, 6(1), 11.CrossRefGoogle Scholar
  30. Maluka, S. O., Hurtig, A.-K., Sebastián, M. S., Shayo, E., Byskov, J., & Kamuzora, P. (2011b). Decentralization and health care prioritization process in Tanzania: From national rhetoric to local reality. The International Journal of Health Planning and Management, 26(2), e102–e120.CrossRefGoogle Scholar
  31. McNeil, Jr., & Donald, G. (2016). Yellow fever epidemic in Africa shows gaps in vaccine pipeline. The New York Times, 5 December 2016, sec. Health.
  32. Moon, S., Sridhar, D., Pate, M. A., Jha, A. K., Clinton, C., Delaunay, S., Edwin, V., Fallah, M., Fidler, D. P., & Garrett, L. (2015). Will Ebola change the game? Ten essential reforms before the next pandemic. The report of the Harvard-LSHTM independent panel on the global response to Ebola. The Lancet, 386(10009), 2204–2221.CrossRefGoogle Scholar
  33., and (2017). Minimum Wage, Minimum Wages South Africa – Mywage.Co.Za. 2017.
  34. Segall, S. (2010). Is Health (Really) special? Health policy between rawlsian and luck egalitarian justice. Journal of Applied Philosophy, 27(4), 344–358.CrossRefGoogle Scholar
  35. Simon, C., & Mosavel, M. (2011). Getting personal: Ethics and identity in global health research. Developing World Bioethics, 11(2), 82–92.CrossRefGoogle Scholar
  36. Tangwa, G. B. (2010). Elements of African Bioethics in a Western Frame. African Books Collective.Google Scholar
  37. Tangwa, G. B. (2016). Leaders in ethics education: Godfrey B. Tangwa. International Journal of Ethics Education, 1(1), 91–105.CrossRefGoogle Scholar
  38. Ujewe, S. J. (2016). Just health care in Nigeria–The foundations for an African ethical framework. Preston: University of Central Lancashire. Scholar
  39. WHO. (2014). WHO declares end of Ebola outbreak in Nigeria. WHO. 20 October 2014.
  40. WHO. (2016a). Ebola Virus Disease: Situation Report.Google Scholar
  41. WHO. (2016b). WHO | Yellow fever situation report. WHO. 15 July 2016.
  42. WHO. (2017). WHO | Plague – Madagascar. WHO. 15 November 2017.
  43. WHO. (2018). Ebola virus disease – Democratic republic of the Congo. WHO. 23 May 2018.
  44. World Health Organisation. (2017). World health statistics 2017: Monitoring health for the SDGs. Geneva: World Health Organization.Google Scholar
  45. World Health Organization. (2004). Guidance on ethics and equitable access to HIV treatment and care. Geneva: WHO.Google Scholar
  46. Writer, S. (2017). South Africa’s cheapest Medical aid schemes and hospital plans in 2017. BusinessTech, 4 May 2017.
  47. Young, M. (2016). Private vs. Public Healthcare in South Africa. Western Michigan University. Honors thesis. Paper 2741. Accessed June 2019.Google Scholar

Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  • Samuel J. Ujewe
    • 1
    • 2
  1. 1.Canadian Institute for Genomics and SocietyTorontoCanada
  2. 2.Global Emerging Pathogens Treatment ConsortiumLagosNigeria

Personalised recommendations