by Dr. David Sanders
Professor and Director School of Public Health
University of the Western Cape
Health is in a state of crisis in Sub-Saharan Africa (SSA). While at an aggregate level health status has improved in SSA over the last fifty years, these improvements have been slower in SSA than in other regions of the world. For example, between 1981 and 1999 IMR has decreased in SSA from 126 to 107 as compared with 78 to 57 for the world as a whole. The respective percentages of decline for this period are 15.1% and 26.9%. Furthermore, in 1999, seven of the 48 SSA countries had a lower life expectancy (LE) than in 1970, while eight countries have seen an increase in infant mortality rate (IMR) between 1981 and 1999. Life expectancy in 17 of 48 countries has declined between 1981 and 1999 (1) (2) (3). In addition, young child malnutrition has worsened significantly over the past decade in SSA (4).
In the past two decades there has been an alarming resurgence and spread of "old" communicable diseases once thought to be well controlled- for example cholera, tuberculosis, malaria, yellow fever and trypanosomiasis. while "new" epidemics, notably HIV/AIDS, threaten last century's health gains (5).
To aggravate matters, a number of African countries are experiencing an "epidemiological transition", with cardiovascular diseases, cancer, diabetes, other chronic conditions and trauma, replacing communicable diseases in some social groups, but in others, co-existing with them (6).
Access to health services improved considerably during the period 1980-1990. but has worsened since then as shown by Expanded Programme on Immunisation (EPI) coverage data. EPI coverage data for SSA in 1999 show declines in coverage of all routinely administered antigens (7). This occurred despite the intensive polio vaccination campaigns and the regular measles vaccination campaigns.
The above declines in health status and health sector performance are0 the result of the combined impact of economic decline and adjustment the HIV/AIDS epidemic which now affects 28 million Africans, approximately 70% of the total of HIV infected people globally (8), and conflict and violence which involves 13 of 48 SSA countries.
The serious economic situation is summed up by the startling statistic that 28 of 48 countries had an average per capita income of less than $1 per day in 1999 compared to 19 of 36 countries in 1981 (9). Furthermore, there is evidence that the income gap between rich and poor within countries has increased dramatically over the past decade. In addition, most SSA countries still spend less than an average of US$ 10 per person per year on health care, an amount that is 20-40% below even that required to cover the basic package of health services advocated by the World Bank (10).
The above situation is the result of a number of factors, some historical and others contemporary, the latter being ultimately linked to various aspects and instruments of globalisation.
In Africa, amongst the most important components of the recent phase of globalisation have been Structural Adjustment Programmes (SAPs). which have had the effect of further integrating countries into the global economy Ihrough the imposition of stringent debt repayments and liberalization of trade. SAPs have also resulted in significant macro-economic policy changes and pubbc sector restructuring and reduced social provisioning, with negative effects on education. health and social services for the poor. A recent review of available studies on structural adjustment and health for a WHO commission states: 'The majority of studies in Africa, whether theoretical or empirical, are negative towards structural adjustment and its effects on health outcomes' (11).
More recently, other instruments of globalisation have further undermined the ability of developing country governments to provide health care for their populations. For example, the development of agreements under the World Trade Organisation (WTO), notably Trade-related Intellectual Property Rights (TRIPS) and its interpretation by powerful corporate interests and governments, have already threatened to circumscribe countries' health policy options. The best known case relates to the recent legal battle around the attempt by South Africa to secure pharmaceuticals, especially for HIV/AIDS, at a reduced cost. In 1997 Nelson Mandela signed into legislation a law aimed at lowering drug prices through "parallel importing" - that is importing drugs from countries where they are sold at lower prices - and "compulsory licensing", which would allow local companies to manufacture certain drugs, in exchange for royalties. Both provisions are legal under the TRIPS agreement as all sides agreed that HIV/ AIDS is an emergency. This was confirmed during the WTO meeting in Doha in 2001. The USA administration did not bring its case to the WTO but instead, acting in concert with the multinational pharmaceutical corporations, brought a number of pressures (e.g. threats of trade sanctions and legal action) to bear on the South African Government to rescind the legislation. This followed similar successful threats against Thailand and Bangladesh (12). However, an uncompromising South African Government, together with a vigorous campaign mounted by local and international AIDS activists and progressive health NGOs, forced a climb-down by both the US Government and the multinational pharmaceutical companies (13).
Notwithstanding this important victory, the provisions of the WTO, particularly TRIPS and the General Agreement on Trade in Services (GATS) hold many threats for the health and health services of developing countries (14)14.
Accompanying neoliberal reforms of the macro-economy have been health sector reforms (H.S.R.). Key components of HSR include decentralisation of management responsibility and/or provision of health care to local level, improvement of national ministry of health's functioning, broadening health financing options through, for example, user fees, insurance schemes and introduction of managed competition; and rationing of health care through the identification of public health and clinical "packages", comprising a set of (often limited) interventions.
The combined effect of the above interventions together with the impact of HIV/ AIDS on the health workforce has resulted in a significant reduction in public provision of social (including health) services in SSA, and there is mounting evidence of a general decline in access to health services, affecting particularly the poor. This is starkly illustrated by immunization coverage, a sensitive marker of health service coverage, which has fallen during the 1990s (15).
In recognition of the growing global health divide between North and South, the crisis imposed by HIV/AIDS and the resurgence of TB and malaria, as well as the inability of both for governments and increasingly cash-strapped multilateral (UN) agencies to invest in health services, a number of Joint Public - Private Initiatives (JPPIs) have been recently launched. The best-known of these in health are GAVI (Global Alliance for Vaccines and Immunisation) and the GFATM (Global Fund Against Aids, Tuberculosis and Malaria).
The first disbursements of the GFATM have still to be made, but those for GAVI, made for 2000/2001, totaled USD 150 million from initial commitments totaling USD 1.03 billion. Of this initial disbursement 90% was allocated for the introduction of new vaccines and single use injection materials, while only 10% went to strengthen immunization services. Anita Hardon has commented: "The emphasis on the introduction of new and under-used vaccines in GAVI reflects a more general shift away from equity towards technological innovation and disease eradication in global health programmes. This appears to indicate a fundamental move in vaccine policy from the values of the Post-Alma Ata (PHC) era." (16).
Further, it is emblematic of the current emphasis of health policy and the influence of the private sector partners, that, notwithstanding the clear inability of health systems - particularly in Africa - to sustain "delivery" of robust, effective and tested technologies, such as the standard six vaccines, that the focus is on the pursuit of new technologies, rather than the resuscitation of delivery systems. Without a shift in currently dominant neoliberal thinking and a consequent change in macroeconomic policy and its reflection within the health sector, the future forAfrica's health is bleak.
References
(1) UNICEF. The State of the World's Children 1984. Oxford: Oxford University Press, 1983.
(2) UNICEF. The State of the World's Children 1994. Oxford: Oxford University Press, 1993.
(3) UNICEF. The State of the World's Children 2001. Oxford: Oxford University Press, 2000.
(4) ACC/SCN, Nutrition Throughout the Life Cycle, 4th Report on the World Nutrition Situation, Geneva, 2000.
(5) Sanders D, Primary Health Care 21: "Everybody's Business", Commissioned Directional Paper for an International Meeting to celebrate 20 years after Alma-Ata, Almaty, Kazakhstan, 27-28 November 1998, Jointly organised by WHO Headquarters, Geneva. Switzerland and the WHO Regional Office for Europe, Copenhagen, Denmark, WHO EIP/OSD/00.7,
(6) Frenk J, Bobadilla JL, Sepulveda J, Lopez Cervantes M. Health Transition in Middle-income Countries: New Challenges for Health Care. Health Pol Planning 1989; 4: 29-39.
(7) UNICEF. State of the World's Children, Reports 1984, 1994, 2001 op.cit
(8) Collins J, Rau B. AIDS in the Context of Development. Programme on Social Policy and Development. Paper number 4. Geneva: UNRISD, 2000.
(9) UNICEF. The State of the World's Children 2001. Oxford: Oxford University Press, 2000.
(10) Simms C, Rowson M, Peattie S. The Bitterest Pill of All. The collapse of Africa's health systems. London: Medact/Save the Children Briefing report, 2001.
(11) Breman A, Shelton C. Structural adjustment and health: A literature review of the debate, its role players and the presented empirical evidence. WHO Commission on Macroeconomics and Health Working Paper WG 6:6. Geneva: WHO, 2001.
(12) Bond P. Globalisation, pharmaceutical pricing, and South African health policy: Managing confrontation with U.S. firms and politicians. Int J Health Services 1999; 29: 765-92.
(13) Hong E. Globalisation and the impact on health: A third world view. Third World Network, 2000.
(14) See http://www.preamble.org.
(15) UNICEF. State of the World's Children, Reports 1984, 1994, 2001 op.cit
(16) Harden A. 2001 Immunisation for All? HAI Europe, 2001: 6(1).
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