In the face of the severe health
problems which have confronted the African continent in recent
years, a considerable amount of work has been generated designed
to promote a general understanding on the origins, nature,
dimensions and impact/consequences of the contemporary African
health crises. However, these studies, while offering some useful
insights, have also been marked by certain critical weaknesses,
among them a lack of historical depth and context, a dearth of
comparative insights, a general absence of multidisciplinarity of
approach, and an excessive, ill-informed cultural determinism
underpinned by narrow socio-anthropological perspectives. These
are weaknesses which require to be remedied if African health
studies are to advance in a problem-solving direction that also
contributes to the deepening of knowledge and promotes analytic
innovation. It is proposed to take a first step in that direction
through the organisation of a focused reflection on the governance
of the African health system as a whole.
It is now generally
established in the literature that health is, at all levels, a
public good. If, indeed, that is so, then it is equally important
that serious attention should be paid to the governance of the
health system. As an arena and a vector of power relations in
society, the health system both embodies and conveys questions of
access, equity, justice and sustainability that require to be
followed through for a proper understanding of the functioning and
functionality of the system. In the specific African context, the
questions of access, equity, justice and sustainability in the
health system are made more pressing today by the various cases of
systemic failure which have added up to produce a situation in
which the health status of Africans is in greater peril today than
at any other time since independence in the 1960s. Indeed, as has
been widely observed, including by agencies such as UNICEF, even
some of the historic gains in health status recorded after
independence in such areas as infant mortality have been rolled
back. Amidst the crises that has gripped the health sector, the
decline in the overall health status of many Africans, the
cut-back in the public health expenditure of the state, the
various health emergencies facing the continent, and the
challenges of reform that are posed, questions of access, equity
and sustainability clearly arise both as important issues in their
own right and as elements integral to the exercise of citizenship,
democratic rights and the social contract.
Furthermore, the
changes in health-seeking behaviour occurring across the
continent, side by side with the emergence and/or revival of new
private and popular forms of health provisioning come with new
governance challenges that deserve to be more closely studied
beyond the anecdotal. For instance, the growth of private health
insurance markets and private clinics are pointers to a growing
stratification of the health market in line with the intensified
income and social differentiation that has occurred over the last
two decades; it is, however, also a development which poses new
policy-making, managerial and regulatory challenges to which
governments and professional associations have to respond.
Similarly, the growth of the popular market for alternative
medicines and the rediscovery and popularisation of the
institution of the “traditional”/faith healer offer pointers to
the crises in the formal health sector and popular coping
strategies that are being adopted; they also open new terrains of
power, rights and standards which elicit regulatory responses of
their own. The increase in the illegal production and distribution
of fake and sub-standard drugs points to an opportunistic
entrepreneurial logic seeking to profit from the African health
crises and the problems of the health system; the opportunism may
only be the flip side of the operations of international
pharmaceutical cartels whose pricing strategies eat
disproportionately into developing country health budgets, take
the prospects of treatment beyond the reach of the working poor
and expose many to the ruthless dealers in fake and illicit
substitutes.
Additionally,
changes in the structure of care brought about by the explosion of
the HIV/AIDS pandemic, the persistence of malaria as a major
killer and the resurgence of diseases like tuberculosis which were
previously under control have implications for the governance of
health systems in so far as they are correlated with the
diminished/diminishing capacity of the public health facilities to
cope with a complex range of expanded needs. This diminished
capacity proliferates all spheres of the health system, ranging
from the drain of talents to the collapse of training and
personnel management structures designed to produce and reproduce
critical human resources. Government health budgets, already
diminished by years of economic crises and structural adjustment,
are under continuing strain and public health managers are
confronted with the difficult, even grim task of prioritising
expenditure among a range of equally important diseases and policy
measures. Governments are also called upon to strive to meet
various targets set out in a range of global/social development
health agreements, manage the activities of donors and
non-governmental organisations active in the health sector, and
overcome the difficulties associated with the quest for the
production/importation of generic drugs for which the major
multinational pharmaceutical companies hold patents.
Inescapably,
therefore, the role of the state as provider, facilitator and
regulator in the health sector is one with which we are constantly
required to grapple. This fact makes it equally important to
address questions about the nature and composition of the state -
capacity, legitimacy, etc. – and the ways in which these are
refracted into the functioning of the health system. The growth,
over the last few decades, of an international health coalition,
both inter-governmental and non-governmental as well as the
interface between this coalition and local civil society actors,
present additional dimensions of the governance of the health
system to which attention needs to be paid at a time of weakened
state capacity across the African continent. The range and variety
of issues associated with health sector reforms and the governance
of the health system is endless and various multidisciplinary
entry points are required for the achievement of a balanced and
holistic understanding. Prospective participants in the Institute
on Health, Politics and Society in Africa are invited to address
themselves to these different entry points and other aspects of
research on health system governance in Africa.
