African health care systems: what went wrong?

Editorial by Dr Ebrahim Malick Samba*

The last century witnessed unparalleled improvements in the health indicators of many countries in the African Region, particularly reductions in child mortality.

Available evidence indicates that the lowest child mortality rates occurred in the 1970s. However, since the mid 1980s, the rate of decline slowed significantly, with some countries even experiencing reversals in child mortality rates. Overall, there was an alarming deterioration in the effectiveness of health systems. Immunization coverage rates and the proportion of women receiving skilled attendance at birth, two key indicators of effectiveness, have been declining in many countries in sub-Saharan Africa. Although the impact of HIV/AIDS has been blamed for the reversals in health gains witnessed in many African countries, the truth is that the genesis of the decline predates the emergence of the HIV/AIDS crisis. This raises the question: “What went wrong with African health care systems?” Arguably, the economic crisis in the African Region and the responses to that crisis severely undermined social sector spending. This paper offers some answers to the question.

The Onset of Structural Adjustment Programmes in Africa

In the 1980s, a combination of natural and manmade factors as well as general worldwide economic depression left many African countries reeling towards decline. The increasing burden of debts prevented countries from allocating national budgets to health, education and other public services. Many countries resorted to external borrowing to finance debt repayments as well as government services.

Countries in crisis turned to the World Bank and the International Monetary Fund (IMF). These two institutions demanded reforms in return for loans which could be used to deal with the crisis. However, curtailing government expenditure even further only reinforced the negative impact of the economic crisis. These reforms, referred to as structural adjustment programmes (SAPs), attached a number of stringent conditions to funding, and these gave the World Bank and the IMF stronger influence over the economies of debt-strapped governments in the South, with devastating consequences on the economies of sub-Saharan Africa. New loans and aid were given only if the debtor nation implemented the reforms. In order to continue receiving funds, countries already devastated by debt obligations had virtually no choice but to follow these mandates. In addition, most donor countries and bilateral agencies gave assistance based on developing nations’ compliance with the World Bank and IMF structural adjustment programmes.

Conditionalities of Structural Adjustment Programmes

Structural adjustment programmes were designed to improve a country’s foreign investment by eliminating restrictive trade and investment regulations, boosting foreign exchange earnings and reducing government deficits. Although SAPs differed from country to country, they forced indebted countries to adopt a series of harsh economic measures. These included:

• a shift from growing diverse food crops for domestic consumption to producing cash crops or other commodities for export;
• abolishing food and agricultural subsidies to reduce government expenditures;
• severe cuts to health, education and housing programmes as well as massive layoffs in the civil service;
• currency devaluation to make exports cheaper but imports more expensive;
• liberalization of trade and investment, and increases in real interest rates to attract foreign investment;
• privatization of government-held enterprises.

Consequences

The reforms were originally designed to stabilize developing country economies. In reality, they imposed harsh measures which deepened poverty, undermined food security and self-reliance, and led to resource exploitation, environmental destruction and population displacement. The health sector was particularly adversely affected, and few proactive steps were taken to protect vulnerable populations and basic services.

Prior to the 1980s, the district hospitals, community health centres and other outreach health posts provided medical services and essential drugs free of charge. With reforms, user fees and cost recovery were introduced, and the sale of drugs was liberalized. Consumption of essential drugs (through the public distribution system) declined. With complete deregulation of the pharmaceutical industry and the liberalization of drug prices, imported branded drugs were sold in the free market at enormous costs and soon displaced domestic drugs. By 1990, domestic production of pharmaceuticals had virtually ceased. A large number of drug companies closed, and the local pharmaceutical and medical supply industry was pushed into bankruptcy.

Many governments discontinued budget support to the health sector which paralysed the public health system. There was no money for medical equipment and maintenance; salaries and working conditions declined. In one African country, a medical officer in the public sector was earning US$ 49 per month. With the emergence of private practice, tens of thousands of doctors and health workers fled the public health sector, in some cases emigrating.

By the end of the 1990s, the health systems in most sub-Saharan countries had virtually collapsed. Few people could afford annual check-ups, medicines or user fees at hospitals. One result was the resurgence of infectious diseases such as malaria, tuberculosis and cholera. A WHO study revealed that in some developing countries, malaria deaths tripled in the first four years of the reform partially due to the collapse of curative health services and the soaring prices of antimalarial drugs. Such was the impact of structural adjustment programmes on the health systems of most African countries.

Corroborative Evidence

Various World Bank reports describe the impact of the SAPs. These include Public Expenditure Reviews, Participatory Poverty Assessments and Social Sector Strategy Reviews. Following expenditure cuts during the 1980s, health care centres in Zambia lost qualified personnel and basic health materials (World Bank, Zambia PER, 1992). In 1985, the government budget for drugs and supplies in Madagascar decreased to 20% of the 1977 level, and only 10% of programmed medical imports were realized. The low level of government expenditure allowed the primary health care centres to cover only 25% of patient drug costs (World Bank, Madagascar PER, 1996). In Nigeria, capital investments were suspended, and the drastically reduced recurrent expenditures could not support such routine functions as payment of salaries, supply of essential consumables (drugs and instructional materials) or maintenance of facilities. All of this resulted in a significant decline in the quality of services (World Bank, PPA 1996). In Tanzania, health system performance suffered because of lack of training and poor motivation of doctors and health workers, shortage of supplies, breakdown of transportation and inadequate management. The quality of hospital care declined dramatically, and clinics became increasingly crowded (World Bank, Tanzania PER, 1991). In Senegal, medical consultations and hospitalizations declined against a background of increasing population (World Bank, Senegal PER, 1993). The collapse of the health system in Cameroon was probably the most painful suffered by any country in that it came after two decades of growth. As a result, structural poverty, rapid impoverishment and economic decline caused serious problems in the period 1985 to 1993 (World Bank, Cameroon PER, 1995). In Burkina Faso, only 14% of patients with severe diseases made use of the health services.

The Initial Response

The reduced resource allocations to health, education and other areas which resulted from the SAPs saw many affected countries sliding back into poverty. Many families in sub-Saharan Africa were unable to meet their most basic needs. By the end of the 1980s, such conditions were blamed on the debt burden imposed by the World Bank policies.

In response, the World Bank World Development Report 1993 concentrated on health. The report suggested World Bank complicity when it said that adjustment programmes often require reduced government spending, including health sector spending: “In many countries early cuts were indiscriminate and failed to preserve those elements of the health system with the strongest long term benefits for health” (World Bank, WDR 1993, p. 45). Having accepted that its adjustment policies resulted in negative consequences for many countries, the World Bank found it necessary to suggest certain remedial measures. These measures did not hinder the adjustment policies but initiated some sort of “disaster management”. The WDR 1993 was essentially a prescription for erecting a “safety net” to protect “the poorest of the poor”, those who most acutely bore the brunt of the adjustment policies.

The safety net was not created from any altruistic concern for the victims of SAPs in developing countries. Rather, it was an extension of earlier concerns. In the 1970s, the capitalist world was going through its own crisis of imperialist contradictions, global markets and trade agreements. By initiating SAPs, the World Bank hoped to make Third World markets accessible and stable for long-term exploitation.

More recently, a number of initiatives and health sector reforms have appeared, including World Bank suggestions for integration, decentralization and re-organizing external and internal financing. Some of these initiatives, especially the Global Fund to Fight AIDS, Tuberculosis and Malaria, are pouring large sums of money into low-income countries. The World Bank has proposed that health system problems be addressed through national poverty reduction strategy papers (PRSPs) which could turn back the trend as powerful tools for improving the health of populations.

The Way Ahead

The deficiencies of health systems in Africa are not wholly the result of Bretton Woods policies. Africans must share the blame. They did not make proper use (through sound investment) of the monies borrowed, although they started on more or less the same footing as other countries, e.g. Korea, India, which have performed significantly well. They failed to argue the case for supporting social services on the continent. They are now paying dearly for the trends of the 1970s and 1980s.

There is hope in such collaboration as the New Partnership for Africa’s Development (NEPAD). Through mutual support, African nations can become the drivers of their own destiny, rather than continuing to blame others for their ills. Policy-makers in African countries should implement evidence-based health care reforms. There is now plenty of evidence demonstrating how health status in low-income countries can be raised. The WHO Commission on Macroeconomics and Health Report published in 2001 documented this.

Lessons learnt by others who have achieved a high level of health outcomes despite being poor could be useful when African policy-makers are constructing their PRSPs. China, Sri Lanka, Barbados, Malaysia, Costa Rica and the Indian state of Kerala are ideologically, geographically and demographically diverse, yet they have low incomes and are high health status achievers. These countries were implementing the vision of comprehensive primary health care long before the Alma-Ata Declaration, paying particular attention to system building and intersectoral action for health. The role of public action in demanding health services and better living conditions was also crucial for their success. WHO suggests that countries in the African Region do more than paying lip service to the implementation of the Alma-Ata principles. Development partners in health have a duty to assist in this endeavour.

* Dr Samba is the World Health Organization Regional Director for Africa