Lankoanda and his two colleagues at TengaFootnote 1 health dispensary were deeply engaged in completing the monthly activity report, when I passed by one afternoon in December 2015. Tenga is a village located in the south-central part of Burkina Faso, around 225 kilometres from the capital of Ouagadougou. Lankoanda and his colleagues were sitting in one of the consultation rooms, vigorously discussing which data to put into the report's tables. The atmosphere in the room was one of concentrated activity. The monthly report was to be completed the following day and sent to the district health office. The report is preformatted and includes a number of tables that need to be completed. The dispensary staff report on completed mother and child services, including the number of deliveries, vaccinations and admissions, and they also fill out a table on ‘new consultations’. More than forty rows with different diagnoses are listed in this table, with sex and age groups in columns. The health officers at remote dispensaries, such as this one in Tenga, complete the form by hand. At the district level, all data from the incoming monthly dispensary reports are entered into a database for further analysis. The monthly report takes its points of departure from the World Health Organization's (WHO's) International Statistical Classification of Diseases and Related Health Problems (ICD).Footnote 2 Lankoanda and his colleagues must enter each new consultation, from the whole month, in the correct row and column. He explains that they have to be meticulous when completing the report, as he was assigned to this dispensary because the chief district medical officer had identified problems with the reports submitted by his predecessor. Following the reporting standards by filling out the rows and columns on a range of activities conducted during the previous four weeks is an important part of Lankoanda's work, and submitting the reports on time is an important performance measure here in Burkina Faso, just as it is in many other healthcare systems around the globe. Close reading of the monthly reports from Tenga and a neighbouring dispensary in the village of Keru shows that the diagnosis called ‘paludisme simple’ (uncomplicated malaria) accounts for a very large proportion of the total number of ‘new consultations’ and that the proportion has increased over the years.
At first glance, Lankoanda and his colleagues seem to be good citizens doing their duty to the state by making visible health conditions and needs. A closer look shows that these monthly reports, with their overwhelming focus on malaria, are in fact part of a technology of invisibility that contributes to accelerating fragility in citizen–state relations. For people living in rural Africa, health facilities, along with schools, constitute the most important point of encounter with state authorities and therefore a strategic location for exploring relationships between citizens and the state. Drawing on several periods of fieldwork in this area since 1996, I am particularly interested in examining ordinary citizens’ formal and informal encounters with the state and how the everyday grammars of the state are determined by both national and global processes as well as by local (dis)engagements with state authorities (Adebanwi and Obadare Reference Adebanwi and Obadare2010; MacLean Reference MacLean2011; Von Schnitzler Reference Von Schnitzler2008; Obadare and Adebanwi Reference Obadare, Adebanwi, Adebanwi and Obadare2010).Footnote 3 As formulated by Gupta:
If … we are to understand the paradoxical relation of different groups of poor people to the state, which simultaneously articulates inclusion and care with arbitrariness and structural violence, then we need to pay close attention to the routinized practices of different branches and levels of the state. (Gupta Reference Gupta2012: 41)
This article contributes to the debates about state–citizen relationships by connecting local health-seeking practices to global trends of datafication and a strong focus on the fight against malaria in this part of Africa. I show that the routinization of diagnostic procedures combined with a strong national and global political focus on the fight against malaria create a ‘supply–demand nexus’ in which citizens selectively ask for the health services that they know the system can supply. The monthly reporting from rural health facilities shows how a discernible focus on malaria, which is based on disputable data, reinforces the cumulative tendency to prioritize the fight against malaria as the most important health problem to be addressed in Burkina Faso. I argue here that the combination of limited health service capacity, political unrest and growing insecurity weakens the already fragile relationship between state and citizens in Burkina Faso. I use fragility here as a notion to characterize the state–citizen relationship. According to the Oxford English Dictionary, fragility refers to an object that is easily broken or damaged.Footnote 4 In what follows, I first briefly reflect on the socio-political situation in Burkina Faso in order to provide the context for my discussion of the state–citizen relationship as exemplified in the high number of malaria cases registered in the monthly reports.
Political commotion and paradoxes of the state
In 2014, the ruling president for twenty-seven years, Blaise Compaoré, was dismissed and sent into exile in Côte d'Ivoire after a very short and intense period of insurrection populaire (popular uprising) led by a grass-roots organization called Balai Citoyen (Citizens’ Broom) in collaboration with trade unions and a range of non-governmental organizations, including women's organizations. The popular protests were triggered by a proposed new electoral code whereby the ruling president would be eligible for re-election more than twice; this would have allowed Compaoré to stand for another term as president (Hagberg et al. Reference Hagberg, Kibora, Barry, Gnessi and Konkobo2018; Zeilig Reference Zeilig2017). After a short-lived military coup in September 2015, elections were held in November 2015; Roch Marc Kaboré, an ex-member of the old regime, won in the first round with 53.49 per cent of the vote (Zeilig Reference Zeilig2017: 159). During this period, the Sahel region, including Burkina Faso, was being challenged by an increasing number of attacks by various jihadist groups such as AQIM (al-Qaeda in the Islamic Maghreb) and Ansaroul Islam (Hagberg et al. Reference Hagberg, Kibora, Barry, Cissao, Gnessi, Kaboré, Koné and Zongo2019). These organizations moved their battle zones from the border areas of Mali, Burkina and Niger to launch violent and spectacular actions against military, government and civilian targets inside these countries. In January 2016, there were two bomb blasts at a hotel and a café in Ouagadougou. Both places were known as hubs for Western tourists, aid workers and well-off Burkinabe citizens, and kidnappings of both Western and national citizens have occurred in Mali and Burkina Faso in recent years. New attacks, including attacks on health facilities, schools and Christian congregations, followed, and 600,000 people had fled their homes and were living in refugee camps inside the country in 2019.Footnote 5 In parallel to the escalating insecurity caused by the many terrorist attacks, organized crime has also increased over the last few years (Hagberg et al. Reference Hagberg, Kibora, Barry, Gnessi and Konkobo2018). Most recently, the Covid-19 pandemic has reached Burkina Faso, presenting another huge challenge to the government, which is under pressure due to a weakened economy, increasing poverty and a growing critique of its capacity to fulfil the promises it made during the elections. In other words, the current political, economic, social and health situation is extraordinarily tough and the population's trust in the state is particularly challenged by serious security issues and a looming pandemic.
Looking at the Burkina state over recent decades, we see at least three types of paradoxes. First, Blaise Compaoré's presidency, which lasted twenty-seven years, was quite strong for a long period yet also weak. Second, the state is both absent and present at the same time (Masquelier Reference Masquelier2001; Law Reference Law2002; Street Reference Street2012), something that is particularly visible in rural areas. Third, governance is both stable and fragile. The first paradox relates to the fact that Compaoré's presidency was surprisingly strong until 2014. He was elected and re-elected several times, and, during his rule, he navigated many conflicts between various ethnic groups inside the country, he balanced the power of the government with that of the traditional chiefs, and he succeeded in negotiating ‘peace deals’ with the northern jihadist groups by offering them certain privileges. In addition, the economy grew at an average annual rate of more than 5 per cent between 1991 and 2016. However, the notion of ‘Africa rising’ (Zeilig Reference Zeilig2017; Mbembe Reference Mbembe2016), which has been used to characterize the impressive economic growth rates of many African countries, would not apply if we looked at living conditions in the rural areas of the country. The Compaoré government never managed to improve the living conditions of the poor and Burkina Faso is consistently ranked at the bottom end of the United Nations Development Programme's Human Development Index. In 2016, the country was ranked 185 out of 188 countries and 46 per cent of the population lived below the poverty line (Zeilig Reference Zeilig2017). The period after the insurrection in 2014, when Blaise Compaoré was forced to resign, and since Roch Marc Christian Kaboré won the elections in 2015 has seen a further weakening of the state (Hagberg et al. Reference Hagberg, Kibora, Ouattara and Konkobo2015; Hagberg Reference Hagberg2019; Samuelsen Reference Samuelsen and Adebanwiforthcoming n.d.). The second paradox, which relates to the absent–present state, is very visible in the rural parts of the country. Government institutions are visible (the school, the dispensary and the prefecture) with their distinct architecture, but they are remarkably empty, in terms of both people and equipment. I unravel this paradox in more detail below. The third paradox relates to governance and the country's health policy, which has been characterized by a long-standing focus on district-based primary healthcare as a fundamental element since the signing of the Alma-Ata Declaration in 1978. The government has steadily worked towards an increase in the number of dispensaries in rural areas and a reduction in the average distance to a public health facility in order to promote ‘health for all’. Despite the increased availability of health facilities, the healthcare system continues to face huge challenges in terms of quality of care (Melberg et al. Reference Melberg, Diallo, Ruano, Tylleskär and Moland2016), and, as we shall see below, the strong emphasis on malaria treatment may be taking the focus away from other important health problems.
Datafication and health policy
Before examining the rural residents’ encounters with local health facilities and the reporting system in more detail, it is important to note the increasing global demand for metrics and the modern state's need for systems of quantification. These trends have been widely discussed in political anthropology and beyond (Foucault Reference Foucault2012; Scott Reference Scott1998; Porter Reference Porter1996) and more recently within critical global health (Adams Reference Adams2016; Merry Reference Merry2011; Merry et al. Reference Merry, Wood, Baxi, Bhuta, Goodale, Hodgson, Jerven, Satterthwaite, Theidon and Urueña2015; Erikson Reference Erikson and Adams2016; Moats Reference Moats2016). As emphasized by Gupta: ‘Foucault's biopolitical order depends upon the normalizing power of statistics.’ He continues: ‘[I]f one does not critically analyze how those statistics are collected and employed, then the relationship between biopower and issues like sovereignty and violence is likely to be misunderstood’ (Gupta Reference Gupta2012: 42). Today, as pointed out by Vincanne Adams, the eagerness to quantify and categorize populations is not restricted to nation states; global health agencies and institutions are also committed to forms of (global) knowledge that are based on universals and that become visible only through forms of data production grouped together as ‘metrics’ (Adams Reference Adams2016: 6). With the increased use of metrics comes standardization, which makes it much easier to formulate comparable indicators and goals at national, international and global levels (Brunsson and Jacobsson Reference Brunsson and Jacobsson2000: 1; Timmermans and Epstein Reference Timmermans and Epstein2010). The disease classification system, ICD, is in itself a standardization of disease categories. WHO highlights the advantages of the ICD system as follows:
[I]t provides easy storage, retrieval and analysis of health information for evidence-based decision-making; it facilitates sharing and comparing of health information between hospitals, regions, settings and countries; and it facilitates data comparisons in the same location across different time periods.Footnote 6
Decisions about what to standardize and what to count are obviously political, yet somehow it is still assumed, both in national administrations and among global health stakeholders, that numbers are unbiased and apolitical and that they reveal the truth (Hacking and Hacking Reference Hacking and Hacking1990; Merry Reference Merry2011; Jerven Reference Jerven2013; Adams Reference Adams2016). Claire Wendland's analysis of maternal mortality metrics in Malawi provides an excellent example, demonstrating that the regression equation used to assess maternal mortality rates is based on six estimated numbers defined by WHO, not actual counts.Footnote 7 Wendland formulates her concern in the following way:
The product of an equation looks like a number and works like a fact, but it is more the moral of a story. In this case it is the story that bolsters the shaky foundations of a presidency. It is a story that hides uncertainty under layers of numbers, even when those numbers are estimates based on approximations based on intuitions. (Wendland Reference Wendland and Adams2016: 78)
In Botswana, as observed by Julie Livingston, a cancer surveillance system was not developed until cancer emerged as an epidemic, because cancer was never thought of as a problem (Livingston Reference Livingston2012). The government of Burkina Faso is following this trend of datafication with a Health Information System that includes a large number of quantifiable goals and indicators and a meticulous concern with the timely flow of data from rural dispensaries to the district level.
The diagnostic repertoire
The dispensary in Keru is staffed by two government-trained nurses: ‘le major’, who has overall responsibility, and ‘la matrone’, who is in charge of maternity and childcare activities, including vaccinations. The nurses have two years of training, while the third staff member, the assistant midwife (AIS), has only one year of training. A village volunteer is in charge of the medical depot. On most days, the atmosphere at the dispensary is quiet, with only a few patients waiting for consultation during the morning hours. The consultation rooms are sparsely furnished with an absolute minimum of equipment and instruments. A few fading educational posters hang on the walls and papers lie piled up on the desk and the examination bed. The dry and dusty weather conditions leave all surfaces covered with a fine layer of red dust. Without running water, it is difficult to keep the health facilities clean.
As in many other dispensaries in sub-Saharan Africa, clinical encounters at dispensaries in rural Burkina Faso follow a standard procedure: the patient (or mother with a sick child) enters the consultation room, where the nurse in charge is sitting behind the table. A few questions are asked about the condition and specific symptoms such as fever or coughing. In some cases, the nurse examines the patient, lifting the eyelids to look for anaemia or checking for fever. In cases of fever, a rapid diagnostic test (RDT) for malaria is often conducted. After a short conversation and examination, the nurse writes a prescription and asks the patient to go to the medical depot to get the medicines (including needles and syringes if injections are needed); when patients need injections they are asked to return to the nurse. The consultation process itself is routinized in the sense that the main component in the consultation is a short exchange between the patient or the mother of a sick child and the nurse, with the purpose of diagnosing the illness and deciding on the treatment. Front-line health workers have to depend on their clinical experience, the RDTFootnote 8 for malaria, a thermometer (if it is not broken) and a weighing scale.
As Table 1 illustrates, the proportion of malaria diagnoses among all new cases of sickness registered in the month of January increased from 28.4 per cent in 2001 to 46.4 per cent in 2013. At the neighbouring dispensary in Keru, the malaria diagnosis was applied in more than half of all ‘new consultations’ during a large part of the year. Although there are seasonal variations, the figures show that even in the month of January, which is not the peak season for malaria, more than 50 per cent of all diagnoses in the category ‘new consultations’ were categorized as ‘uncomplicated malaria’.
Table 1 Diagnosis of patients at CSPS Tenga and Keru in January 2001, 2010 and 2013
Note: CSPS = Centre de Santé et de Promotion Sociale (Centre for Health and Social Advancement).
Source: Monthly reports (2001, 2010 and 2013) collected from Keru and Tenga dispensaries.
Amadou, the nurse in charge at the dispensary in Keru, commented: ‘Our diagnostics are essentially based on the clinical signs, the physical signs, and simple examinations as for example the rapid diagnostic test. As we are not well equipped in terms of material and personnel, there are examinations that we cannot do.’ The limited availability of medico-scientific equipment clearly restricts health professionals’ diagnostic repertoire,Footnote 9 leaving staff at this level of the healthcare system to rely on their experience and their ‘clinical gaze’ (Foucault Reference Foucault2012).
The supply–demand nexus
Child fevers are extremely common in rural communities in Burkina Faso and the majority of visits to the local dispensaries in Keru and Tenga are translated into a malaria diagnosis, as the monthly reports show. Many other diagnostic categories listed in the form, such as anaemia and malnutrition, are hardly ever used, despite the fact that dispensaries in this area distribute food supplements to malnourished children between six months and five years of age. Other illnesses, such as sexually transmitted diseases, mental health problems and dental problems, are generally absent from the monthly reports. We do not know how frequent these other diseases are as they are never counted, and we do not know whether they are not counted because they are never raised in the consultation room at primary healthcare facilities or because health workers tend to translate diseases involving fever (with or without a positive RDT) into a malaria diagnosis. The brief, routinized consultations and the limited diagnostic repertoire result in malaria being the most frequently diagnosed disease.
The routine consultation process combined with standardized diagnostic procedures make the outcome of a visit to the dispensary rather predictable if we look at it from a patient's perspective. Rural citizens have a kind of certainty in knowing what is offered at the clinic, particularly in cases of fever: a quick conversation, a prick of the fingertip and a prescription, which is ‘cashed’ at the medical depot. Patients and the mothers of sick children do not complain if they do not get exact information about the diagnosis itself; they are more concerned about ‘doing’ away (Mol Reference Mol2002) with the symptoms by getting a prescription for medicines, which hopefully will improve the condition of the patient (Østergaard et al. Reference Østergaard, Bjertrup and Samuelsen2016). As Mogensen (Reference Mogensen2005) describes for rural clinics in Uganda, the little piece of paper with the written prescription becomes a token. The main aim is to take pragmatic action in response to the disease. As described above, often days will have passed before the mother of a child with symptoms decides to go to the dispensary, and often other methods will have been tried before contacting the public healthcare facilities (Olsen and Sargent Reference Olsen and Sargent2017). In Tenga and Keru, sick people, and particularly mothers of sick children, try to be hopeful and look for certainty. In one sense, they do find certainty at the dispensary: parents know that their child will be looked at and given some medicine, and their experiential knowledge tells them that this will happen in cases of fever. This is what I call the supply–demand nexus: sick people mainly go to public health services with afflictions for which they know treatment is supplied. The standardized diagnostic procedure and treatment of fever cases becomes an important means for both health professionals and patients in their joint efforts to take care of the sick. In this way, the ill child is taken care of rather than cured, if the fever is not due to malaria. I suggest that we can look at this supply–demand nexus as a form of ‘technology of invisibility’, similar to Joao Biehl's analysis of the non-registered AIDS deaths of marginal groups in Bahia, Brazil (Biehl Reference Biehl and Inda2005).Footnote 10 The three short cases below show how mothers of sick children pragmatically navigate the medical field and how strongly they associate the services at the public dispensary with fever/malaria treatment. The narrow focus on malaria and the incapacity to diagnose many other diseases exemplified here demonstrate the fragility of the state–citizen relationship.
Odette lives in Keru with her husband and their seven children. They subsist from tending their fields, like most other inhabitants in the village, and Michel, Odette's husband, also works for a latrine project, constructing pit latrines in households where owners are willing to invest in such a facility. Whereas most adult women in Keru have never attended school, Odette completed six years of schooling and uses her skills when she occasionally assists the Catholic mission in the village. In addition, Odette is also a dolotière, a producer of the local millet beer, and she runs a ‘cabaret’ (a millet beer tavern) every third day. Odette was one of fifty women interviewed about their therapeutic itineraries when their children fall ill. She invited my field assistant and me into her compound, finding small stools for us to sit on while she continued her millet beer preparation. Her youngest child, who was three years old, suffered from ying-wingre,Footnote 11 she told us. The sickness had started with a sudden fever and loss of appetite twelve days before our visit, but, after treatment, he was now slowly recovering. She emphasized to us that she took the decision herself to consult the dispensary located in the village and had asked a female neighbour if she could borrow her bike. Many women in this part of Burkina would have to ask their husband for money and permission before seeking treatment, but Odette has her own small income from her cabaret. The local dolotières are usually allowed to keep the profits for themselves (which they mainly use for their children's medicine and healthcare). At the dispensary, the child was prescribed some paracetamol and a course of malaria treatment, and he was given one injection at the consultation. Odette explained to us how the nurse instructed her to give the child the malaria medicine twice a day for three days and half a tablet of paracetamol three times a day for three days. She does not know what caused the disease, but said that ying-wingre is very common, adding that pug zabre (stomach problems/diarrhoea) and palu (malaria) are also common among small children. Odette did not use any herbal medicine for home treatment or consult any of the local specialists during this episode of sickness. She prefers to go straight to the dispensary in such cases, as ‘the local medicines do not cure this disease. Besides, visiting the traditional healers would take a lot of time and drag the sickness. It is better to go to the dispensary, it is quicker.’
Thirty-five-year-old Alimata, another of our interlocutors, lives alone with her three children, aged seven years, five years and ten months. Her husband, Idrissa, works at a plantation in Côte d'Ivoire, sending money home to her once a year. Her youngest child fell ill with the ‘palu’ (malaria) three days before our conversation. He had ‘corps chaud’ (a warm body) and was coughing. Alimata uses the local term ‘sobgo’ for malaria. She explained to us that she first bought some herbal plants at the market, which she boiled and gave the child to drink every morning for three days. On the second day, she also took him to the dispensary. Here they tested for malaria, which gave a negative result. Yet, he was prescribed treatment for malaria, artesunate/amodiaquine, as well as paracetamol and some medicine for the cough, and was given one injection at the consultation. Alimata's child is part of the malaria diagnosis statistics, although the test was negative. The child recovered after a couple of weeks following the herbal treatment and another visit to the dispensary. Many women told us about similar therapeutic pathways in cases of child fever, mixing home treatments with visits to local herbal experts and consultations at the dispensary.Footnote 12 As Alimata explained: ‘I only go to the dispensary if the disease does not finish [with home treatment], if it is grave, because I don't have money. My husband is in Côte d'Ivoire, he only rarely sends me 5,000 CFA [US$8.50].’ ‘Warm body’ or fever appeared as the most frequent symptom or sickness in our series of interviews on therapeutic trajectories.
Mariam, a young Mossi woman who had lived for many years both in Côte d'Ivoire and in Ouagadougou, said that the two most common diseases of her eight-month-old child are palu and ‘pugnondre’ (stomach problems). The palu is caused by mosquitoes, she says, while pugnondre is related to the ‘cycle of the moon’. She attends the dispensary for the palu while traditional medicine works better than going to the dispensary in cases of pugnondre. Like Odette, she highlighted the importance of consulting the dispensary in cases of child fever, saying: ‘Parce que le corps chaud se soigne à l'hôpital [Warm body/malaria is treated at the ‘hospital’/the clinic].’
The three cases above show that mothers consult the dispensary mainly in cases of fever (if they can afford it), knowing that treatment for malaria is provided there. In other cases of sickness – for example with stomach problems – they may rely on home treatments or consult other types of specialists. An examination of rural women's therapeutic trajectories shows that, despite the fact that public health facilities are available in rural areas, the link between citizens and the state is frail when the focus of the supply–demand nexus is limited to only a few symptoms and diagnoses.
In the rest of this article, I discuss some of the implications of the supply–demand nexus, with a particular focus on two aspects. First, I look at the local reporting system within the primary healthcare sector of Burkina Faso as part of a global trend in which current forms of governmentality are based to a large extent on processes of datafication. Second, I discuss how the supply–demand nexus affects the citizen–state relationship in the current political climate.
The labelling of all fever cases as ‘paludisme simple’ or uncomplicated malaria, whether as part of the government policy of treating undiagnosed cases of fever as malaria or as the habituated practice of health workers (or a combination of the two), confirms to both the public and policymakers that malaria is the main health problem in rural Burkina Faso. Whether all these patients really suffered from malaria is, of course, unknown. Nevertheless, we know from conversations with the inhabitants of Tenga and Keru that they also suffer from a range of illnesses other than fever. The knowledge produced on the basis of the monthly reports from Keru and Tenga dispensaries informs us of a significant and increasing burden of malaria in this particular area. This is the information that government healthcare policymakers are presented with and which continues to shape the overall healthcare priorities of the country. For decades, malaria has been singled out as a high-priority public health problem in Burkina Faso, if not the main problem (Ministère de la Santé 2011; 2012). This prioritization has been supported by global health organizations such as WHO and UNICEF in programmes including the Roll Back Malaria Partnership as well as the Millennium Development Goals Initiative (WHO and UNICEF 2005; WHO 2015; Owens Reference Owens2015). For decades malaria has been high on the global health political agenda as well as on the funding agenda (Pigott et al. Reference Pigott, Atun, Moyes, Hay and Gething2012; Cueto Reference Cueto, Biehl and Petryna2013). The supply–demand nexus thus feeds into a kind of self-fulfilling prophecy where the prioritization of malaria as the most important health problem to be addressed is confirmed – a prioritization that to a large extent is based on dubious and disputable data.
Accelerated fragility
In this last section of the article, I turn to a discussion of how the supply–demand nexus and the strong focus on malaria in the current political context further weaken the link between rural citizens and the state in Burkina. Apart from the public school, the local dispensary is the government institution with which rural residents have most contact. Yet, as described above, the residents of Keru and Tenga use the public health facilities in selective ways. Moreover, the capacity of the nurses at the local dispensary to fulfil their fundamental duties as representatives of the state by providing basic healthcare services to the public is limited. This is a challenge for the rural population, which is not ‘serviced’ in adequate ways, and, as pointed out by Street in her analysis of Madang hospital in Papua New Guinea, ‘institutional poverty weakens the efficacy of bureaucratic and biomedical technologies’ (Street Reference Street2014: 17). This also applies to the dispensaries (and the hospitals) in Burkina Faso. The capacity to perform medical sovereignty on biological bodies is limited. Government healthcare professionals are equipped with the technology and capacity for only a narrow focus on malaria. As pointed out by Foucault (Reference Foucault2012), Rose and Novas (Reference Rose, Novas, Ong and Collier2005) and a number of other scholars (Lock and Nguyen Reference Lock and Nguyen2010; Stapleton and Byers Reference Stapleton and Byers2015; Nguyen Reference Nguyen2010), in principle government institutions are a locus for biopower, but in Burkina these institutions are relatively weak and characterized by a number of absences. The state–citizen relationship is a two-way relationship. On the one hand, health staff (or other government employees) have the formal legitimacy to be in command of essential technologies to execute their power and manage the medical treatment of patients. On the other hand, health staff also need to be recognized by and visible to patients as professional experts with decisive capacities for action. This ‘rights and duties’ relationship is taken up by Vinh-Kim Nguyen in his discussion of therapeutic citizenship in relation to the AIDS epidemic in Burkina Faso and Côte d'Ivoire, where it became important to recruit HIV-positive patients for various treatment trials. Being part of a treatment trial also implied certain rights, such as the right to medicines and the right to food aid (Samuelsen Reference Samuelsen and Callan2016; Nguyen Reference Nguyen2010). In Niger, a country facing similar challenges to Burkina Faso in terms of high rates of poverty, political instability and weak public services, Masquelier explains how widespread resistance to a state-sponsored polio eradication programme was rooted in general perceptions of the state as a vehicle for generating political deceptions and fraudulent deals (Masquelier Reference Masquelier, Dilger, Kane and Langwick2012). She writes:
[P]eople may not agree as to what they should be entitled to, but they expect the state to do more for its citizens, especially when it comes to health care. These claims about entitlements are grounded in an expectation of free medical care inherited from the brief period of prosperity Niger experienced in 1970s and early 1980s. (Masquelier Reference Masquelier, Dilger, Kane and Langwick2012: 227)
Similarly, Warren et al.'s (Reference Warren, Beebe, Chase, Doumbia and Winch2015) study in Mali shows how a general mistrust in the state combined with health workers’ scolding and mistreatment of pregnant women may explain the low use of maternal healthcare services in rural areas. Rural citizens in Burkina Faso – in my experience – seldom openly criticize the health system when medicine is out of stock or when personnel are absent. They use the services offered in very pragmatic ways, but they do not claim their general entitlements as citizens with rights to the common goods of public healthcare as such; rather, they share an ontology of marginality (Das and Poole Reference Das and Poole2004). In the consultation room, patients present themselves in accordance with a legitimate order, to use Weber's (Reference Weber1978) terminology, where the health worker represents governmental authority and the patients are subordinates. They do not openly call for their rights to public healthcare; their healthcare-seeking practices are pragmatic, knowing that they have access to malaria treatment if they can afford it. The strong focus on malaria and the deployment of the RDT define and materialize the civil link to the state and, more importantly, participate in the construction of a narrative about a malaria-suffering nation with a government that works hard to control the disease.
After twenty-seven years with a ‘despotic’ president, many people in Burkina Faso had high hopes for real change, where basic needs such as security, healthcare and employment would be fulfilled. However, for the villagers in Keru and Tenga, nothing much has changed. In fact, as mentioned in the introduction, the basic security situation is gradually worsening, with terrorist actions spreading from the border regions to almost all the provinces of the country. Furthermore, armed gangs conducting raids against ordinary people to seize goods is a growing phenomenon in rural areas (Hagberg et al. Reference Hagberg, Kibora, Barry, Gnessi and Konkobo2018: 59). To mitigate these incidents, the local population has formed self-defence groups called koglweogo.Footnote 13 The members of these militia-like units are local volunteers. When I asked one of my friends in Keru, Thomas Kéré, what he thought about this development, he said that it was absolutely fine: ‘What else can we do?’ During a fieldtrip in 2017, we passed a group of koglweogo, including ten to fifteen males on their motorbikes with various types of weapons in their hands. Later, we passed a prisoner who was roped to a tree on public display. While these types of vigilance raise a series of ethical and legal questions, they also reveal a huge vacuum in the state's ability to fulfil its sovereign duties to protect its citizens. From the perspective of rural citizens, their experience is that they are left to themselves to take care of their security.
In terms of healthcare, the government of Roch Marc Christian Kaboré, elected in 2016 after the popular uprising, has granted free healthcare for children under five years of age (Hagberg et al. Reference Hagberg, Kibora, Barry, Gnessi and Konkobo2018: 67). However ‘free’ healthcare is not always free. Prescribed medicine may not always be available at the medical depot, in which case the patient or caregiver will have to buy the medicine somewhere else. As we saw in the cases above, patients and caregivers in this part of Burkina worry a lot about potential demands for money, both direct payments for medicines or under-the-counter payments (REN-LAC 2018)Footnote 14 and indirect payments in terms of transport costs or loss of income while spending time at the health facility. Thus, considerations about the potential cost of a visit to the dispensary continue to play an important role in the healthcare-seeking process. Direct criticisms of specific health services are seldom voiced by individual patients, but the recent history of Burkina Faso shows that in certain situations civil society can mobilize protests (Harsch Reference Harsch1998; Hagberg et al. Reference Hagberg, Kibora, Ouattara and Konkobo2015; Reference Hagberg, Kibora, Barry, Gnessi and Konkobo2018). During a series of strikes among health workers in 2012 and 2013, when people were prevented from accessing biomedical services, we saw incidents in which rural residents both criticized and attacked health facilities (Østergaard Reference Østergaard2016). And the insurrections in 2014 were not only an urban phenomenon; a large number of actions and demonstrations took place in the rural areas of Burkina as well. Moreover, the Covid-19 health crisis has also led to public protests against some of the restrictions enforced by the government, and the double layers of security and health crises led to public discussions about possibilities of postponing the scheduled government elections in November 2020.Footnote 15
When the state is not able to deliver basic healthcare and security to its population, ‘health for all’ is replaced by a ‘duty to be well’. The state and public authorities relinquish their obligations and responsibility for the provision of security and well-being, delegating to individuals and communities the responsibility for managing their own insecurities (Rose and Lentzos Reference Rose, Lentzos, Trnka and Trundle2017: 35–6). In the current situation, where political, economic and health crises are escalating, the everyday grammar of the state is under attack. We see this very concretely in the growing number of terrorist attacks, but also in more subtle ways when the state's capacity to care for its citizens is reduced (Trnka and Trundle Reference Trnka and Trundle2017). This, I argue, accelerates the risk of a further fragilization of the relationship between rural citizens and the state.
Conclusion
As I show in this article, the relationship between rural citizens and their local dispensaries is characterized by a supply–demand nexus, where citizens mainly demand those services that the system is able to provide. This may be logical and pragmatic from the viewpoint of the citizens. If, however, most fever cases are translated into a malaria diagnosis and many non-fever cases seek treatment with other local specialists or are treated at home, the government's (and the global health community's) policy of focusing on malaria as the most important disease to be addressed in Burkina Faso does not reflect the actual disease pattern of the country. The metrics produced through the system of monthly reporting and the routinized practices at the health facilities indicate that Burkina Faso, unlike many other countries in Africa (WHO 2015), is experiencing a heavy and increasing burden of malaria. However, as discussed here, the data substantiating this policy are fragile. As I suggest here, there is a risk that the routinized diagnostic practices that mainly focus on malaria serve as a ‘technology of invisibility’ by not capturing other important diseases among the rural population. Furthermore, by exploring diagnostic routines at the dispensaries and following individual cases of illness, we see the various ways in which the social contract between the government's healthcare services and rural citizens is played out in everyday life. The duties of the modern state to protect and care for the health of its citizens, as embedded in the term ‘public health’ (Prince and Marsland Reference Prince and Marsland2014), are not fulfilled. To a large extent, the rural citizens of Tenga and Keru are left to take care of their own health problems – or at least those ailments that are not directly translatable to a malaria diagnosis. The relationship between the government's health representatives at the village level and the rural citizens appears to be fragile in a number of ways. Lankoanda and his colleagues at the dispensary in Tenga are probably doing their best, but their reporting system and their lack of diagnostic capacity make them translate most fever cases into a malaria diagnosis. Finally, I ask whether the limited healthcare services provided at the rural health facilities in the current context of political insecurity, instability and a global pandemic spur a process of further fragilization of the social contract between rural citizens and the state.
Acknowledgements
Research for this article was funded by Danida through the Consultative Group for Development, Research Projects 11-04-KU and 17-06-KU. I appreciate collaboration with the Department of Sociology and GRIL at the Université Joseph Ki-Zerbo, Ouagadougou, and the Institut de Recherche en Sciences de la Santé (IRSS), Direction Régionale de l'Ouest, Burkina Faso. I am grateful to the citizens of Keru and the neighbouring villages who allowed me to follow their children's treatment-seeking practices and shared their worries with me. I would also like to thank Susan Reynolds Whyte and PhD research fellow Pia Juul Bjertrup for their valuable comments to an earlier version of the manuscript.
