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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 the training of health personnel – nurses, midwives and doctors – both locally and abroad to staff the medical establishments which governments set up. Efforts were also made to promote local medical research – mainly through university-based medical schools – and support the development of a domestic industry – initially of an import-substituting nature - in the medical sector.
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. In several countries, investments were also made in the local production of basic provisions and equipment. 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 fully 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. Furthermore, the adjustment context contributed to the demise of local medical laboratories and factories as part of a generalised experience of de-industrialisation witnessed on the continent.
The full depth of the crises of public health provisioning experienced in Africa has been brought out in sharp relief by the activities and interventions of the global pharmaceutical companies that seat atop the international production and supply chain for medicines and related health services. Indeed, through the global and local strategies of the companies, it is possible to develop a political economy of the crises of the African health system in all its dimensions and inter-connectedness. During the course of the last two and half decades, both as a result of new possibilities opened by contemporary processes of globalisation and as a defensive mechanism that has, itself, become part and parcel of the globalisation of corporate activities, the international industry in the production, distribution and consumption of medicines underwent a structural recomposition that is evidenced, in part, by major acquisitions and mergers. This process of recomposition has resulted in the emergence of a group of major international pharmaceutical companies such as GlaxoSmithKline, Bristol-Meyers-Squib, Pfizer, Hoffmann-LaRoche, Johnson & Johnson, Merck & Co., AstraZaneca, Abbott Laboratory, Novartis, and Sanofi-Aventis, among others, exercising an undisputed global dominance. Their dominance spans the area of pharmaceutical research and experimentation, product development and innovation, production systems, product packaging, distribution and marketing, and the shaping of patterns of consumption. They mobilise local and external support to protect their advantages through the intellectual property rights and patents that they obtain and guard jealously. Their enhanced global and sectoral reach is reckoned to be as significant as their connections to local and international policy and political institutions, including inter-governmental agencies and organisations like the World Health Organisation, the World Bank and the World Trade Organisation. Indeed, radical critics suggest that the firms collectively constitute a cartel that drives global and local health policies. In the face of the power projected by the pharmaceutical majors and the influence which they are able to mobilise, most African health systems are, perhaps unsurprisingly given their crises, easily vulnerable to the pressures which they exert in order to secure their interests.
Participants in the 2008 session of the CODESRIA Institute on Health, Politics and Society will be encouraged to explore the various dimensions of contemporary global pharmaceutical industry and the way in which it impacts on the African health system in general and its capacity to respond to the health needs of the peoples of the continent in particular. Experience registered in different African countries and anecdotal evidence available points to various dimensions of the impact of the activities and practices of the pharmaceutical majors on African health systems. At one level, there are legitimate questions which have arisen about the making of public health policy in contemporary Africa and the power/influence exerted over the relevant policy processes and structures by the global pharmaceutical industry. At issue is the question of who the dominant forces are behind the public health policy choices made in Africa and what the interests they represent are. At another level, the dumping of pharmaceutical products on African markets, sometimes packaged as aid or humanitarian assistance, has had detrimental effects on the local pharmaceutical industry in some countries. Furthermore, the major pharmaceutical players have engaged in pricing policies which have contributed in no small measure to straining the health budgets of African countries and diminished the affordability of drugs by patients and other consumers of medical products. This has, in turn, pushed many African’s into a search for alternative methods for meeting their health needs, including faith healing and the revival of indigenous medicine. It has also opened a window for a flourishing market in fake medical products that take a daily toll in lives lost.
The strain placed on the health budgets of African countries by the pricing policies of the leading pharmaceutical conglomerates has not been mitigated by the transfer-pricing techniques employed by the companies through the intra-firm trade that goes on between them and their subsidiaries established in key African countries. Additionally, various ethical questions have emerged from the pilot experiments undertaken by some of the firms, with the basic approaches which they employ when they try out drugs for the treatment of diseases such as tuberculosis, HIV/AIDS, and malaria being questionable. Also, under the guise of the huge outlays they make on research and the protections that are offered to them by internationally-agreed rules on intellectual property rights and patents, they spare no effort to discourage the production of local generic drugs. The experience of South Africa in its quest to procure generic drugs for treating HIV/AIDS is salutary in this regard. As part of the effort they have deployed to discourage generics in Africa, the pharmaceutical majors have supported campaigns aimed as discrediting the drugs – which are much cheaper in price terms – as fakes that are both ineffective and damaging. Amidst orchestrated publicity and fanfare, the big firms have also occasionally offered price reductions on essential drugs in order to reduce the pressure mounted on them over the huge costs involved in procuring their products. South Africa has also been a leading example of African countries where the global pharmaceutical majors have attempted to build and project corporate social responsibility and participants in the Institute will be encouraged to weigh the significance of the corporate responsibility measures they have pursued on the continent.
The drug regulatory agencies in many African countries are largely under-staffed, inadequately financed and poorly equipped. In consequence, they are mostly not very well-placed to perform their duties of establishing and enforcing standards of behaviour among the firms operating in their jurisdiction. Indeed, in some cases, the pharmaceutical majors offer them equipment, funding and other forms of support to carry out their statutory functions, calling their independence into question. Links are also forged by the pharmaceutical majors with African health professionals as much for the purpose of securing a competitive edge over their rivals as for anything else. Such is the power of the firms and the extent of their reach that they have also joined not only in the pillage of Africa’s indigenous medicines but also taken out patents on local herbal remedies used in the treatment of common diseases. Furthermore, they have established a strong foothold in the growing global industry in wellness and well-being. Indeed, it has been suggested that the big pharmaceutical firms have taken a frontline role in the “invention” of diseases and of treatments for them, doing so by feeding into a momentum that characterises as illness, conditions which may not in fact require elaborate medical diagnosis and treatment. The range and variety of research and policy issues associated with the role of the global pharmaceutical industry in the functioning – and dysfunctionalities – of African health systems, and the consequences of their activities for the health and well-being of the peoples of the continent are numerous, and various multidisciplinary entry points are required for the achievement of a 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.