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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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:
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diversification of the productive
base away from the legacy of the colonial past
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development of indigenous technologies
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emphasis on regional self-sufficiency in food
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expenditure switching towards agriculture
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and social sectors
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environmental protection
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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.
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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:
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living conditions of those most
affected
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the development of cost recovery programmes and their effects on
equity in health services access, utilization and quality
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social stratification, integrity and
social violence
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social organizations and community
responses in health and development related areas
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