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Private Health
Provisioning in Africa |
The 2007 Session:
Private Health Provisioning in Africa
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 in ways
which also 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; overall,
those sectors witnessed an all-round expansion in the period up
to the end of the 1970s. As it pertains specifically to the
health sector, the primary accent was placed on developing the
infrastructure for the provision of “modern” medicine to the
bulk of the populace. From the primary health centres that were
created to the bigger, mostly urban-based general hospitals and
specialist medical centres, the expansion of the “modern” health
sector was treated as a tangible goal of independence to which
public investments were poured. At the same time, attention was
given to training of health personnel – nurses, midwives and
doctors – both locally and abroad to staff the medical
establishments which governments set up.
For the period up
to the middle of the 1980s, most of the public medical centres
that were established functioned relatively well: They were
well-provisioned in most senses, including the drugs and
personnel they needed to render services to the citizenry.
Governmental financial subventions to meet their operational
expenses were also regular even if not always sufficient. In
turn, public medical establishments generally enjoyed the
confidence of the public and were often the first choice of most
patients on account of the quality of their services and the
equipment at the disposal of their staff members. This picture
was, however, to begin to change rapidly from the mid-1980s
onwards when, in the wake of the economic crises which African
countries one after the other began to undergo, the health
sector suffered severe setbacks from which it still has not
recovered. Apart from the severe cut-backs in the budgetary
allocations by governments under severe pressure to balance
their budget, the sector was to witness a mass exodus of
qualified personnel on account of a variety of factors. The
brain drain from the public health sector was fuelled by the
sharp deterioration of the physical infrastructure and equipment
base of most health institutions; the severe shortages of drugs
and other supplies that became a way of life; the deterioration
in the remuneration of public heath staff; and overall
environment of work that discouraged professional excellence. As
if the exodus of staff was not enough, governments were also to
carry out retrenchment exercises as part of their public sector
reform programmes crafted within the framework of IMF/World Bank
structural adjustment. The adjustment framework also became the
platform through which so-called cost-sharing/cost recovery
policies were introduced from the 1980s onwards, policies which,
taken with the deterioration in the public health system, acted
as a disincentive for continued popular access to and use of the
services of the public health institutions.
The crises of public health provisioning acted as a spur for
the emergence and/or expansion of private health services underpinned by a
market logic. Private health provisioning has undergone a significant growth and
expansion not just in terms of numbers but also with regard to the levels and
complexity of services offered. In addition to local private providers – many of
them former or serving employees of the public health system who have not joined
the brain drain (yet) – there is also a steady stream of private
international providers entering into the local health sector to offer general
and specialist services. In many cases, the private providers depend on
moonlighting public heath sector personnel in order to sustain some of their
services. Alongside the development of private health provisioning has been a
growth in the private health insurance market. The emergence and expansion of
the private health system also signalled the formal arrival of a highly
stratified health structure in most African countries whereby the working poor
either had to make do with the public heath system such as it exists or seek
other popular alternatives through “traditional” medicine while the richer
members of society shifted their patronage to private providers. Available
evidence suggests that this stratification is reflective of broader processes of
deepening social inequality in Africa associated with the marketisation drive
that has underpinned much of public policy over the last two and half decades.
Objectives
Participants
in the 2007 session of the CODESRIA Institute on Health,
Politics and Society will be encouraged to explore the
various dimensions of contemporary private health
provisioning in Africa. What are its origins and what is the
nature of the private health sector? Who are the private
health providers? What patterns of locally-driven private
health provisioning are emerging? How is the growing
international trade in health services that is being
promoted by the World Trade Organisation (WTO) refracted
into the development of the local private health market in
Africa? What kinds of public policy frames exist for the
functioning of private health centres, how are the centres
regulated and to what effect? Who are the takers of private
health services with particular reference to social class
and gender? Are there correlations between income and/or
gender, for example, in the consumption of health services
in an increasingly stratified social context? In addition to
the social geography of private health provisioning, what
does the physical distribution of the private health
institutions tell us about its physical geography? What
connections exist between private health providers and
private suppliers of health insurance? On what foundations
(ideological and/or otherwise) are the claims of quality in
private health provisioning based and is there any merit to
them? How have the private health institutions, by their
sheer existence, affected what is left of the public health
system? In the health-seeking behaviour of the populace, how
are the available private, public and “traditional” health
services negotiated? The range and variety of research and
policy issues associated with the on-going expansion of
private health provisioning 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.
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