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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.
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