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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 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.
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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