Ukunda Declaration on Economic Policy and Health

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Adopted by the first African Regional Conference of Social Science and Medicine, 13th  September 1990.

1. Africa's recent colonial history, experience of capitalist underdevelopment, and more recently recession, debt and the impact of structural adjustment policies (SAPs) have severely affected the health status and survival chances of the overwhelming majority of the population. There is accumulating evidence that the current economic crisis and attendant responses (including SAPs) have severely hampered the ability of Africa's people, especially "vulnerable groups," to maintain their already inadequate living standards and minimal access to effective health and social services. In addition, the gains of independence have alreadybeen largely eroded.
    

2. It is well organized that health (and disease) experience is the outcome of social, economic, political and cultural influences. Much historical evidence exists to show that without sustained improvements in socioeconomic conditions and consequent standards of living. Advances in health are unlikely to be achieved and maintained.
    

3. Both as a result of the economic crisis and as a consequence of the SAPs, there are growing sections of the population who have become marginalized, disempowered, and are increasingly unable to meet their basic needs. These are primarily low paid workers in the formal and informal sectors, a growing stratum of rural producers. Within these groups, it is women and their dependents who have been most adversely affected. In short, the greatest burden of these economic policies is being borne by those least capable of shouldering it.
    

4. In response to this crisis, there has been increasingly widespread popular opposition in the form of food riots, strikes, and other forms of protest. Advocacy initiatives such as UNICEF's Adjustment with a Human Face and the World Bank's Social Dimensions of Adjustment, have manifestly failed to address the underlying structural causes and have not even succeeded in their objective of mitigating the effects of SAPs. Worse still, these initiatives may have contributed to obscuring the fundamental bases of this crisis, and thus further disempowered the most vulnerable.
    

5. The core of these "recovery" programmes posits export-led growth as a strategy not only for resolving the short term economic crisis but also for creating the basis for future sustained development. The experiences of the last decades demonstrate – even during the long post war boom – the hollowness of this model. Indeed the pursuance of this approach even in the rich countries, is leading to increasing stratification and the impoverishment of significant strata within societies. Moreover, the unprecedented accumulated debt, particularly of the USA, underscores the bankruptcy of this approach and furthermore, cynically shifts the real burden of this debt to the underdeveloped world through the agency of the IMF and the World Bank, to maintain the value of the dollar and the high standard of living of the American middle class.
    

6. These policies have been implemented through the (sometimes unwilling) agency of African governments. While these policies have had disastrous effects on the majority of Africans, a few have benefited inter-alia, from trade liberalization, currency devaluation, and reduction in the value of real wages. Moreover, these groups have been relatively unaffected by sharp reductions in social sector spending because of the existence of alternatives – e.g., private sector health, education and welfare services.
    

7. Within the health sector itself, important and promising initiatives such as primary health care (PHC) have not escaped the influence of "adjustment" to the present reality. Programmes such as the child survival initiative have been interpreted in a narrow and overly technical way, and in many countries have been reduced to limited, vertical and often externally funded immunization and rehydration programmes. Even such limited interventions have been hampered in their implementation by the effect of the economic crisis – lack of transport, spare parts, equipment, vaccines, drugs and not even salaries. This situation has led to the devising and promotion of such initiatives as "cost sharing" and the "Bamako Initiative" which putatively seek to generate income to "improve the quality of services" and foster "community participation" in PHC. It is already becoming apparent that such programmes are further aggravating inequity, particularly since the distinction between willingness and ability to pay has not been addressed in policy formulation. Although the implementation of such programmes will save costs in the public sector, it is clear that the economic crisis and SAPs have resulted in the rapid expansion of the private sector where foreign exchange consumption for often irrational importations (unnecessary, expensive patent drugs for the last needy) dwarfs the income generated through cost sharing initiatives in the public sector.
     

8. These limited technocratic and piecemeal approaches in the context of the crisis have led to unprecedented and disturbing demographic changes. While reductions in infant mortality (probably temporary) have been achieved in some countries, morbidity and malnutrition rates have increased in most sub-saharan African countries and in some where the recession has been most severe, even mortality rates have started to rise. Additionally, the crucial social mobilizing content of the PHC initiative which holds the solution to some of these problems, appears to have been lost.
   

9. Clearly the long term solution to this crisis will require fundamental structural changes at national and international levels. It is suggested that inter-alia, the following policy options be seriously considered:

• diversification of the productive base away from the legacy of the colonial past
  

• development of indigenous technologies
  

• emphasis on regional self-sufficiency in food
  

• expenditure switching towards agriculture
  

• and social sectors
  

• environmental protection
  

• establishment of a debtor's club that could in a united way argue from a position of relative strength for debt repudiation

The adoption of the above policies will require political will on the part of African governments. The best guarantee of such bold initiatives is the sustained pressure from the majority who have been so adversely affected in this crisis. For this process to be initiated and maintained, fundamental democratization of the political and social structures in a prerequisite.

10. A minimum responsibility of health and social scientists is to facilitate the above enterprise. While there are a number of areas where research is necessary, it is our firm belief that for any research to have any operational or political outcome, the objects of research must become the subjects. Thus the definition of the research agenda and its implementation and utilization must result from a democratic dialogue between researchers and those most affected by the current crisis. Research areas should include a focus on the evolving impact of the economic crisis and SAPs on:

• living conditions of those most affected
  

• the development of cost recovery programmes and their effects on equity in health services access, utilization and quality
  

• social stratification, integrity and social violence
  

• social organizations and community responses in health and development related areas