The 2005
Session:
African countries
attained independence in the 1960s on the basis of a broad social
contract between the nationalists who inherited state power from
the colonial authorities and the general populace whose support
was instrumental to the success of the independence struggle. At
the centre of the contract was a commitment by the nationalists to
an across-the-board improvement in the lives and well-being of
the populace, with a promise to do so in ways which overcame the
discriminatory restrictions that underpinned colonial social
policy and opened new opportunities for social advancement. The
health and educational sectors occupied a pride of place in the
early investments which post-colonial governments made in the
social sectors and overall, these sectors witnessed an all-round
expansion in the period up to the end of the 1970s. To be sure,
even in the periods of expansion, there were numerous questions of
equity and access which were posed. Apart from income-based
differentials which conditioned and, in some cases, limited
equitable access to health services, there were also pent-up
demands which were not always met on account of various capacity
limitations. Furthermore, there were sharp differences between the
levels and quality of urban and rural health services, with the
former being generally better resourced than the latter.
Furthermore, public investments in the development of
“traditional” medicine patronised by a large proportion of the
populace was almost non-existent as all attention went to the
development of a “modern” medical sector structured along the
dominant institutional approach introduced during the colonial
period. The difficulties encountered in sustaining equitable
access were exacerbated by policy inconsistencies and
incoherencies, including the long-term neglect of primary health
care, preventive health education, and the creative interfacing of
“modern” and “traditional” health services. These policy
deficiencies spoke to the shortfalls and shortcomings in the
allocation of resources for healthcare; they also touched upon the
priorities set for the treatment of different diseases. Finally,
the issue of equitable access to healthcare is linked to the
broader strategies of social policy which are pursued, including
especially measures designed to eradicate poverty and promote
welfare. To the extent that poverty and inequality grew in
significance, it could be argued that this was an area in which
early post-independence policy recorded some shortcomings.
Still, the 1960s
and 1970s were a period of generalised expansion in the modern
African health sector, including major investments in the training
of health personnel. Furthermore, in spite of the weaknesses that
inhered in post-colonial African social policy in general and
health policies in particular, it was not until the 1980s that the
question of inequality in the health systems was brought to the
fore of public debate. The immediate context for this was the
economic crisis which gripped African countries at the beginning
of the 1980s and the structural adjustment programmes which were
introduced to manage the crisis. Both the austerity measures
introduced by African governments and the thrust of the adjustment
programmes that were adopted contained commitments to cost
recovery and the introduction of user charges; structural
adjustment went a step further to incarnate marketisation as
the directive principle of policy and practice. The
introduction of user charges, cost recovery and other
marketisation policies occurred at the same time as real incomes
for the working poor collapsed in the face of deep and repeated
currency devaluations; major losses of employment took place as
the public sector was first “downsized” and then “rightsized”; a
heavy inflationary spiral occurred which fuelled prices and ate
into incomes; the competitiveness of public sector wages and
salaries collapsed and a flight of talent from the health sector
in general and the public health system in particular was
experienced; there was a deterioration of the physical
infrastructure and equipment of public health facilities in the
face of a shortage of funds associated with the deflationary
public expenditure policies adopted by most governments and which
particularly targeted the social expenditures of the state; and a
proper public policy was lacking in relation to the traditional
medical system to which an increasing number turned as part of
their strategies for popular provisioning.
As the economic
crises and structural adjustment policies took their toll on the
public health system, the differences between public and private
health provisioning widened, with the new investments taking place
in the health sector mostly going into fee-paying private heath
institutions run on a purely commercial logic. What was left of
the public health system was itself increasingly exposed to an
internal commercial logic which, for the average patient, meant
payment for virtually every service rendered. And yet, in most
African countries, public health insurance systems are
non-existent and the culture of private health insurance remains
highly underdeveloped. Also, the “social safety net” programmes
put in place by most governments to alleviate the social
consequences of the various reform policies introduced failed to
make a positive impact as they were generally under-resourced,
came with very stiff qualification criteria that were meant to
dissuade as many people as possible from benefiting, produced
unacceptable social stigmas, and were generally after-thoughts
that were residual to the macro-economic strategy. In the
meantime, traditional health insurance institutions, such as the
burial societies of Southern Africa, were faced with serious
difficulties of survival arising from a variety of factors,
including increased levels of mortality. The new privately-owned
or commercially-oriented local health service providers that
emerged did not, as a consequence, serve a large proportion of the
populace but only the richest individuals who also had access to
private air ambulances for evacuation to the best-equipped
hospitals abroad. Arguably, the growth in the international
provision of health services offered on highly commercial terms
and serving a clientele that is drawn from the South is reflective
of the sharp social inequalities that have emerged over the last
two decades in the developing countries. The practice of
self-medication and treatment at home has become a prevalent
feature of health-seeking behaviour of those who have been
excluded from access to quality local health services at
affordable prices and the “globalised” services that are on offer
to the wealthy. The circulation of fake medicines and medical
quackery have also been on the rise. All of these developments
pose varying degrees of challenges to the well-being of the
working poor. Furthermore, home-base care, always a feature of the
health-seeking behaviour of the populace, has increased in
significance in the face of the increasing inability of
individuals and households to afford quality health services and
as public health institutions became reduced to shadows of
themselves and governments sought to displace the burden of care
to families.
The deterioration
of the public health system across Africa has had a host of
consequences which have already attracted scholarly and policy
attention, among them the reversal of many of the historic gains
that had been made in the post-independence period especially with
regard to the health and nutritional status of the populace, and
the diminished capacity of the public health system to prevent and
manage diseases. Most of these difficulties have been both symptom
and cause of the deepening inequalities in access to health
services in Africa, inequalities which have grown in tandem with
the widening gulf between the rich and the poor, the expansion of
the ranks of the working poor, the thinning out of the middle
class, and the increased segmentation of the category of the
working poor. At the same time as numerous questions of equity and
access have been posed domestically, the North-South divide in
health and well-being has also deepened, with Africa being the
continent with the worst indicators. The drain of talent from the
African health sector to the countries of the North has
exacerbated this North-South divide. 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. Participants in
the 2005 session of the CODESRIA Institute on Health, Politics and
Society will be encouraged to explore the various dimensions of
historic and contemporary inequity in the African health system,
the intellectual challenges of responding to them and policy
alternatives that could be pursued in the bid reform the health
system and at the same time make it inclusive and effective. The
range and variety of issues associated with the quest for
equitable access to health services is endless and various
multidisciplinary entry points are required for the achievement of
a balanced and holistic understanding. Prospective participants in
the Institute are invited to address themselves to these different
entry points and other related aspects of research on health
system governance in Africa.
