The historical roots of institutionalized healthcare and education in Sub-Saharan Africa, the cases of Cameroon and Zambia

Jutta Bolt, Nicolai Baumert, Michael Chanda Chiseni, Jeanne Cilliers. Show Author details

Doctor British Africa healthcare education
Medical work in a British African context, Kikuyuland (Kenya)

Education and health are crucial parts of human development and broad wellbeing, since they greatly influence economic growth and gender inequality. Although this is widely recognized, access to education and healthcare continues to be far from equal between and within countries in Sub-Saharan Africa. Instead, regional differences in educational opportunities and access to healthcare exhibit strong persistence over time (Huillery, 2009). Therefore, understanding the historical roots of these inequalities becomes necessary to understand the current situation. With this aim in mind, our project uses newly collected colonial and missionary sources to study the introduction and long-term consequences of Western healthcare and education in Africa for two cases: Cameroon and Zambia. While missionaries provided most of the education to the African population throughout the colonial period (Frankema, 2012), healthcare provision was in the hands of both missionaries and colonial governments (Headrick and Headrick, 1994). To give a more complete account of education and healthcare provision throughout the colonial period, our studies of Cameroon and Zambia are the first to collect information about location, and legacy of both missionary and government schools and healthcare facilities.

Educational and healthcare establishments

Since missionary settlement decisions and schooling efforts influence each other (Jedwab et al., 2018), we first study what factors affect the choice of missionaries to settle certain locations. We do so by comparing the characteristics of geographical locations of all missionary and colonial government schooling and healthcare facilities established during the colonial period in both Cameroon and Zambia (see map below). For both countries we find that missionaries were more likely to settle along rivers, so they had access to fresh water. Further we find that they preferred to settle closer to the coast and along the railway both of which facilitated transport. Over time, we see that missionary societies followed other societies when they moved inland, and tended to settle in more densely populated areas. We do not find that the prevalence of diseases, such as malaria, played a role in settlement decisions. This might be the result of the availability of quinine as a cure for malaria, which was discovered already in 1840, and had reduced European mortality of malaria substantially.  


Health care schooling railways and Catholic Protestant Government hospitals


For both countries we find a strong positive effect of missionary schooling on short- and long-term school enrollment and on gender equality in education after the colonial period. In addition to the missionary effect, urbanized areas were found to be associated with higher school enrollment and lower gender inequality, both historically and today. Further, economic activity, indirectly measured by proximity to the railway in Zambia, and German plantations in Cameroon, are positively associated with higher enrolment rates historically and today. The railway played an extremely important role in colonial Zambia, by connecting the copper mines in the North to the market in the colonial capital Livingstone and in South Africa. This generated wider income earning opportunities raising the demand for education. In Cameroon, the railway did not noticeably stimulate the demand for education. Instead, the German plantations had a positive effect on enrollment in Cameroon prior to WW1. We argue that this is a combined effect of higher incomes stimulating the demand for education and the benefits of the Basel and Baptists teaching in German at the time. After Germany lost control over Cameroon, the economic success of plantations stalled and proximity to plantations is found to have been negatively associated with enrollment. The initial advantage of German missionary societies seems to have been lost after WW1. 

African gender norms and traditions also exert a strong lasting effect on educational outcomes. In Cameroon, we find that enrollment is lower for polygamous societies, potentially due to the incompatibility of polygamy with the Christian value system. In Zambia, we find that the practice of bride price payments, typically associated with increasing the value of female education, is associated with higher enrollments rates for both boys and girls. However, we only find a negative link between bride price payments and the gender gap in education for cohorts born after independence. 


While colonial governments invested relatively more in healthcare provision than education, missionaries remained important agents, especially for rural populations. In Zambia, the colonial government maintained 12 native hospitals primarily situated at their main administrative centers, mostly along the railway. Missionary societies, meanwhile, established 89 hospitals and clinics in the territory. 

Moreover, missionary presence affected the belief systems and behavior of African populations. This becomes clear when studying the long-term effects of missionary exposure on sexual behavior. We find that individuals who live close to a historical missionary site are more likely to be infected with HIV. In Zambia, faith-based organizations actively preached abstinence before marriage and lifetime commitment to one partner but have not encouraged condom use. We find that condom use is very low among individuals living in closer proximity to a church and that they were less likely to adhere to the Christian doctrines of pre-marital sexual abstinence and monogamy than those living further away. 

In Cameroon, we study the long-term persistence of medical infrastructure. We find that regions that already had medical facilities during the interwar period have a higher density of public health care facilities today. Further, whether the historical health care provider was government or missionary, influences the magnitude of this persistence. Historical government health provision is associated with a higher density of public hospitals today, while early missionary health provision is more predictive of non-hospital and private medical facilities today. This, we argue was driven by the development of a more favorable attitude towards Western medicine, a stronger political voice, and human capital accumulation of African in regions where historical healthcare was accessible. 


By collecting new detailed primary data on schooling and healthcare efforts during the colonial period for two case studies, our research sheds new light on how historical factors play a role in explaining deficient access to education and healthcare in Africa today. Especially exposure to missionary education and historical access to institutionalized healthcare are important factors, illustrating how strong and lasting specific local investments can be. Studying these patterns for other countries in order to understand why these early local investments did not diffuse towards broader national developments are key areas of future research.

Further information:

  • This article summarizes the PhD theses of Michael Chanda Chiseni: Here I am Send Me:  The Historical and Long-Term Impact of Christian Missionaries in Zambia 1924-2018, PhD Thesis Lund University; and Nicolai Baumert: For God’s sake: The work and Long-Term Impact of Christian Missionaries in Cameroon, 1844-2018, PhD Thesis Lund University
  • The picture associated with this article was taken from Flickr, and it is part of the project Africa Through a Lens of The National Archives.


Baumert, N. (2021). Health care under different colonial regimes: The historical roots of institutionalized heath care in colonial Cameroon. Unpublished manuscript.

Chiseni, M. C. (2021). Healing the Nation: Christian Missionaries and the Colonial Health Care System in Northern Rhodesia, Unpublished manuscript

Frankema, E. H. (2012). The origins of formal education in sub-Saharan Africa: was British rule more benign? European Review of Economic History, 16(4), 335-355.

Headrick R. & Headrick, D. R. (Ed.). (1994). Colonialism, health and illness in French Equatorial Africa, 1885-1935. African Studies Association Press. 

Huillery, E. (2009). History matters: The long-term impact of colonial public investments in French West Africa. American Economic Journal: Applied Economics, 1(2), 176-215.

Jedwab, R., Meier zu Selhausen, F., & Moradi, A. (2018). The economics of missionary expansion: evidence from Africa and implications for development. CSAE Working Paper WPS/2018-07.

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Professor (Lund University and University of Groningen)
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PhD Student (Lund University)

PhD Student (Lund University)

Postdoctoral researcher (Lund University)