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In the face of the severe health problems which have confronted the African continent in recent years, a considerable amount of work has been generated designed to promote a general understanding on the origins, nature, dimensions and impact/consequences of the contemporary African health crises. However, these studies, while offering some useful insights, have also been marked by certain critical weaknesses, among them a lack of historical depth and context, a dearth of comparative insights, a general absence of multidisciplinarity of approach, and an excessive, ill-informed cultural determinism underpinned by narrow socio-anthropological perspectives. These are weaknesses which require to be remedied if African health studies are to advance in a problem-solving direction that also contributes to the deepening of knowledge and promotes analytic innovation. It is proposed to take a first step in that direction through the organisation of a focused reflection on the governance of the African health system as a whole.
It is now generally established in the literature that health is, at all levels, a public good. If, indeed, that is so, then it is equally important that serious attention should be paid to the governance of the health system. 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. In the specific African context, the questions of access, equity, justice and sustainability in the health system are made more pressing today by the various cases of systemic failure which have added up to produce a situation in which the health status of Africans is in greater peril today than at any other time since independence in the 1960s. Indeed, as has been widely observed, including by agencies such as UNICEF, even some of the historic gains in health status recorded after independence in such areas as infant mortality have been rolled back. Amidst the crises that has gripped the health sector, the decline in the overall health status of many Africans, the cut-back in the public health expenditure of the state, the various health emergencies facing the continent, and the challenges of reform that are posed, questions of access, equity and sustainability clearly arise both as important issues in their own right and as elements integral to the exercise of citizenship, democratic rights and the social contract.
Furthermore, the changes in health-seeking behaviour occurring across the continent, side by side with the emergence and/or revival of new private and popular forms of health provisioning come with new governance challenges that deserve to be more closely studied beyond the anecdotal. For instance, the growth of private health insurance markets and private clinics are pointers to a growing stratification of the health market in line with the intensified income and social differentiation that has occurred over the last two decades; it is, however, also a development which poses new policy-making, managerial and regulatory challenges to which governments and professional associations have to respond. Similarly, the growth of the popular market for alternative medicines and the rediscovery and popularisation of the institution of the “traditional”/faith healer offer pointers to the crises in the formal health sector and popular coping strategies that are being adopted; they also open new terrains of power, rights and standards which elicit regulatory responses of their own. The increase in the illegal production and distribution of fake and sub-standard drugs points to an opportunistic entrepreneurial logic seeking to profit from the African health crises and the problems of the health system; the opportunism may only be the flip side of the operations of international pharmaceutical cartels whose pricing strategies eat disproportionately into developing country health budgets, take the prospects of treatment beyond the reach of the working poor and expose many to the ruthless dealers in fake and illicit substitutes.
Additionally, changes in the structure of care brought about by the explosion of the HIV/AIDS pandemic, the persistence of malaria as a major killer and the resurgence of diseases like tuberculosis which were previously under control have implications for the governance of health systems in so far as they are correlated with the diminished/diminishing capacity of the public health facilities to cope with a complex range of expanded needs. This diminished capacity proliferates all spheres of the health system, ranging from the drain of talents to the collapse of training and personnel management structures designed to produce and reproduce critical human resources. Government health budgets, already diminished by years of economic crises and structural adjustment, are under continuing strain and public health managers are confronted with the difficult, even grim task of prioritising expenditure among a range of equally important diseases and policy measures. Governments are also called upon to strive to meet various targets set out in a range of global/social development health agreements, manage the activities of donors and non-governmental organisations active in the health sector, and overcome the difficulties associated with the quest for the production/importation of generic drugs for which the major multinational pharmaceutical companies hold patents.
Inescapably, therefore, the role of the state as provider, facilitator and regulator in the health sector is one with which we are constantly required to grapple. This fact makes it equally important to address questions about the nature and composition of the state - capacity, legitimacy, etc. – and the ways in which these are refracted into the functioning of the health system. The growth, over the last few decades, of an international health coalition, both inter-governmental and non-governmental as well as the interface between this coalition and local civil society actors, present additional dimensions of the governance of the health system to which attention needs to be paid at a time of weakened state capacity across the African continent. The range and variety of issues associated with health sector reforms and the governance of the health system is endless and various multidisciplinary entry points are required for the achievement of a balanced and holistic understanding. Prospective participants in the Institute on Health, Politics and Society in Africa are invited to address themselves to these different entry points and other aspects of research on health system governance in Africa.