Elsevier

Health Policy

Volume 71, Issue 3, March 2005, Pages 375-382
Health Policy

Public health care under pressure in sub-Saharan Africa

https://doi.org/10.1016/j.healthpol.2004.06.002Get rights and content

Abstract

Taking as point of departure the need for a strong public health care sector in developing countries the article firstly outlines how in sub-Saharan Africa enhanced scarcity has characterized the content and quality of health care in the public sector. This has eroded the trust among the public in the government as provider of health care and guardian of public health. Secondly, it describes how workers in the public health domain have dealt with the implications of scarcity by etching out a “puvate” zone in health care provision and how these informal activities need to be interpreted as “muddling through”. It also points out what are reactions of clients to a decline in public health care provision. Thirdly, it discusses the changing relation between the state as provider of health care and private sector health care provision at a time of emerging public–private partnerships. The article emphasizes the need for strong health services at basic health centre level. It is at that level that the state has to address problems of scarcity and regain public trust. It also is at that level where major long-term health policies like the imminent large-scale delivery of antiretrovirals (3by5) have to be accomplished.

Introduction

The Report of the Commission on Macroeconomics and Health (CMH, Chair Jeffrey Sachs, commissioned by the World Health Organization) concludes that investing in health is an effective strategy for poverty reduction in developing countries [1]. One road towards health improvement is by way of better health care, and as a variable but considerable part of health care provision is situated in the public sector it appears crucial that this remains strong and viable. The CMH points out that public health systems of poor countries face a host of problems, including procurement systems that work inadequately, public service delivery that is not accountable, and supervision that is not effective.

Recently, in a series of articles in The Lancet on child survival in developing countries, a group of public health experts concludes that strong public health systems are important in order to address the problem that while efficacious interventions are available still many children are dying: “Although private initiatives can and should contribute, the longer-term goal must be systems of public health that are capable of defining needs, generating resources, managing programmes and people, delivering cost-effective services, and gathering and using data to improve the effect of their efforts” [2, p. 325].

One important way to better understand prevailing problems in the public health sector in developing countries is by lowering the level of analysis in order to investigate how such issues take shape at the level of district health centres, small rural hospitals and the daily practice of health workers. It is there that public health service delivery and its clients interact most often and intensely, and where the stress on implementation of the new broad long term delivery policies of antiretroviral drugs against AIDS will be experienced continuously [3]. This paper focuses on conditions and changes at that level of public health care in sub-Saharan Africa.

The paper outlines, firstly, the general setting of scarcity in which health care in the public sector in sub-Saharan Africa operates. Secondly, it describes and discusses how workers in public health care at health centre level deal with the implications of scarcity, how their activities need to be interpreted when their behaviour deviates from the formal duties of a public role [4], and how their clients perceive problems in health care delivery. Thirdly, it describes some changes in the position of the state as provider of health care and maker of health policy that may affect availability of resources and operational culture in the public sector. Arguments are illustrated by referring to developments in Uganda, which have been well studied and documented. The Uganda case is relevant because processes that have been observed in Uganda, both before and during the introduction of the Health Reforms of the 1990s, also occur or have occurred in other countries in the region, although their specific shape and effects may differ. Moreover, more recently the Ugandan public health sector has shown signs of vibrancy, which imply that there are ways out of the serious problems discussed below.

Section snippets

Scarcity in public health care

In most countries in sub-Saharan Africa independence marked the beginning of a period of extension of curative public health care to the rural areas. Health centres were built and health care staff was trained. For a long time after independence the utilization of public health care was free of charge. Apart from vaccination campaigns when epidemics occurred and other efforts to control infectious diseases, public health care provision was largely a static phenomenon: people with health

Informal economic activities of health workers in Uganda

In Uganda downward changes in government health care already began with the onset of a period of dictatorial government and civil war in 1971 that would last well into the 1980s. Before it began to deteriorate public health care in Uganda was among the best in Africa, whence its breakdown showed sharply [17], [18], [19], [20], [21]. Descriptions of the deterioration process mention shortage of drugs, highly qualified staff members (doctors, nurses) leaving the services and migrating to another

Reactions of health workers and their clients to scarcity

The sick person who attends a government clinic has expectations about the quality of care he or she feels entitled to. Munene et al. [23] have studied the possible effects of the new Health Reform policy of the Ugandan government and observed these perceptions and expectations of users of public health care. They mention that getting medicines, being examined and getting an explanation about diagnosis and treatment are important among these expectations, with getting curative medicines clearly

Trust in the state as the provider of health care

According to Garrett [27] the provision of health care by the state is based on trust between that state and its citizens. The state is entrusted to further and protect the public good of health; the citizens agree to follow the rules and give payment. Consequently, the deterioration of public health care in many sub-Saharan countries can be interpreted as “a betrayal of trust”, the title of her book on the collapse of global public health. According to Garrett this breakdown can have dire

In conclusion: public health care under pressure and beyond

Using the example of developments in Uganda, this paper argues that public health care in sub-Saharan Africa has gone through a long period of enhanced scarcity. At the level of the health centre scarcity of resources may result in an erosion of trust in the state as provider of health care. It also may lead to an intertwining of public and private activities and roles of health workers that create a hazy “puvate” sphere where public servants provide private services. Moreover, a reaction by

References (33)

  • C. Anyinam

    The social costs of International Monetary Fund’s adjustment programs for poverty: the case of health care development in Ghana

    International Journal of Health Services

    (1989)
  • Cornia GA, Jolly R, Stewart F. Adjustment with a human face. London: Clarendon Press;...
  • World Bank. Sub-Saharan Africa: from crisis to sustainable growth. Washington: The World Bank;...
  • Streefland P, Harnmeijer JW, Chabot J. Implications of economic crisis and structural adjustment policies for PHC in...
  • Chabot HTJ. Health and structural adjustment. In: Proceedings of the Maastricht Seminar on sub-Saharan Africa: Beyond...
  • Agyepong IA. Implementing PHC under severe economic constraints: the Dangme West District of the Greater Accra Region...
  • Cited by (33)

    • Metabolic Syndromes and Public Health Policies in Africa

      2017, Medicinal Spices and Vegetables from Africa: Therapeutic Potential Against Metabolic, Inflammatory, Infectious and Systemic Diseases
    • Reasons for non-adherence to vaccination at mother and child care clinics (MCCs) in Lambaréné, Gabon

      2009, Vaccine
      Citation Excerpt :

      There was a contraction of the primary health care sector during the early 1990s in many Sub-Saharan African countries and this was partly due to a waning interest in community health care, the introduction of fees for health care services, and a shift of focus to the district level. At the same time, decision-making was decentralised to the district level, which may have lead to a loss of interest on behalf of higher level politicians and thus to a lack of money for the primary health care sector [16]. At the same time that government health care provision deteriorated, diseases like HIV, tuberculosis and malaria led to a sharp increase in demands on the curative services [17].

    View all citing articles on Scopus
    View full text