Health Policy Development in Sub-Saharan Africa: National and International Perspectives
An HIV-positive mother cares for her child at the Tygerberg Hospital in the Cape Town, South Africa. (Photo: Guido Bergmann / AFP-Getty Images)
Worldwide, there is a growing realization that health is an integral part of sustainable development efforts. The critical importance of health among populations is also being recognized in foreign policy circles, in economic development discussions and within the context of socio-cultural issues of all countries—low, middle, and high income. The sea of change regarding the clout of health as an integral part of development is more noticeable in the developing world. Over the last 25 years, the face of the developing world has changed dramatically for the four billion people, living in developing countries outside of sub-Saharan Africa, who have experienced an advanced epidemiological transition. These populations can expect a better life for themselves, or at least for their children (1).
In sub-Saharan Africa, the role of health in development has also grown rapidly. Sub-Saharan Africa has witnessed increased resources for health, even in the poorest countries. Various national, continental and international initiatives have focused on healthcare delivery issues in sub-Saharan Africa. While this is a welcome development, these resources have induced huge stresses on a small health workforce and limited organizational capabilities due to the paucity of capacities for planning and managing these resources.
In the same region, the "bottom billion" living in 58 countries continue to be "trapped" in poverty, conflict, poor governance and poorly performing health systems. The situation is complicated by the skewed resource flow for HIV and AIDS to the neglect of other priority health problems in many countries. Countries are attempting to develop integrated approaches that allow them to tap into the available resources for HIV and AIDS, but this is yet to be fully realized. Despite additional flow of national and international resources to health in Africa, sub-Saharan Africa continues to bear the brunt of a double, possibly triple, burden of disease.
In this paper, I briefly review national and international health policy perspectives on sub-Saharan Africa over the last three decades. I end by proposing a way forward for improved health in Africa.
Domestic and international health policies in sub-Saharan Africa have being shaped by multiple international agreements and policies. Some of these international agreements and declarations include: Alma Ata Declaration of 1978; World Bank/IMF Structural Adjustment Program in the health sector of 1987; World Health Organization's Bamako Initiative in 1987; United Nations Millennium Declaration/Development Goals in 2000; Paris Declaration of 2005; and the second primary health care revolution of 2006. These agreements and policies heavily influenced the development of national health policies in low-income countries.
One of the most influential international declarations on health is the Alma Ata—the Birth of Primary Health Care: The Declaration of Alma-Ata, formally adopted primary health care (PHC) as the means for providing a comprehensive, universal, equitable and affordable healthcare service for all countries. It was unanimously adopted by all WHO member countries at Alma-Ata in the former Kazak Soviet Republic in September 1978 (2).
PHC is essential health care based on practical, scientifically sound, and socially acceptable methods and technology that is universally accessible to individuals and families in the community. PHC must be affordable to the community and the country in order to maintain continued development in the spirit of self-reliance and self-determination. It forms an integral part of a country's health system, of which it is the central function and main focus, and of the overall social and economic development of the community. It is the first level of contact for individuals, the family, and community with the national health system. It brings health care as close as possible to where people live and work, and constitutes the first component in a continuing health care process. Where western-trained doctors and nurses were not available, village health workers were to be trained and used as a formal part of the health care system (3).
Governments, WHO, UNICEF, and other international organizations, multilateral and bilateral agencies, NGOs, funding agencies, all health workers and the entire world community were expected to protect and promote the health of all people; support national and international commitment to PHC; and channel increased technical and financial support to it, particularly in developing countries. Several steps were taken to restructure the government through a process of decentralization in order to bring health closer to the people. The central government transferred responsibilities, authority, functions, as well as power and some resources, to provincial, district and sub-district levels. Adequate supervision to ensure service quality, essential drugs, vaccines and equipment, especially at the most peripheral levels, was envisaged.
Despite the support of local, national, regional, and international stakeholders, PHC did not achieve Health-for-All by the Year 2000 (4). The reasons are many and they include the following:
- Many people felt that PHC was a cheap form of health care. If possible, they bypassed this level and visited secondary and tertiary centers because of a lack of staff and essential medicines at the PHC level;
- Civil war, natural disasters and, more recently, HIV, affected the ability of PHC to maintain quality comprehensive services, especially in many sub-Saharan countries;
- Political commitment was not sustained after the initial euphoria of Alma-Ata. Most health care resources continue to be directed to the large urban-based hospitals;
- Issues of governance and corruption in the use of resources resulted in donors becoming very wary of funding comprehensive, broad-based programs. Vertical, definable, time-limited programs that could be changed every few years suited both donor agencies and governments.
The "World Health Report 2000—Health Systems: Improving Performance" marked the end of WHO's use of PHC as the means for the delivery of health care services in resource-poor countries. This report indicates that the failure of PHC to achieve its goal is due to inadequate funding combined with insufficient training and equipment for health care workers at all levels. The result was either a total lack of services at the community level, or services of such poor quality that people had no option but to bypass primary-level providers, resulting in the failure of the referral system within the PHC hierarchy (5).
Another influential international policy that impacted on healthcare delivery in sub-Saharan Africa is the Structural Adjustment Program (SAP). The World Bank's strong ideological framework based on privatization, cost recovery, and big loans in the health sector was launched in 1987 with a major emphasis on financial and macroeconomic goals rather than social sector issues. SAP was adopted in over 40 countries in Africa. The outcome of SAP is generally believed to have been less positive for healthcare delivery in resource-challenged environments. Loewenson, in his review of SAP, concluded that its impact had been negative in terms of state of health, food security, and access to care (6). He also stated that SAP had a major impact on the "brain-drain" of Africa's health workforce, both to the West and to other more affluent African countries. This brain drain severely hampered the capacity of national governments to adequately fight HIV and AIDS or significantly address other Millennium Development Goals (MDGs). The International Monetary Fund's (IMF) Independent Evaluation Office report titled, "The IMF in Sub-Saharan Africa," suggested that IMF conditions required substantial diversion of foreign aid away from its intended use in areas that directly address poverty alleviation (e.g., health, HIV/AIDS, and education) in favor of deficit reduction and the accumulation of currency reserves (7).
To meet the growing crisis of scarcity of drugs and reduced access to quality healthcare, and, counter the negative impact of SAP, the Bamako Initiative was launched in 1987 (8).
The Bamako Initiative was built on eight principles:
- Improving PHC services for all: equity;
- Decentralizing management of PHC services to district level;
- Decentralizing management of locally collected patient fees to community level;
- Ensuring consistent fees are charged at all levels for health services—whether in hospitals, clinics or health centers;
- High commitment from governments to maintain and expand PHC services;
- National policy on essential drugs should be complementary to PHC;
- Ensuring the poorest have access to PHC: pro-poor policy;
- Monitoring clear objectives for curative health services.
Following the adoption and implementation of the Bamako Initiative by many countries, especially in West Africa, community pharmacies were established and innovative financing mechanisms were adopted in some countries e.g., community empowerment through local cost recovery and equity implications. Improved health indicators were recorded in many countries and there was a positive impact on service cost efficiency. Quality of care improved and services were more efficient. Community health resources were managed locally through joint micro planning and monitoring, involving health personnel and village committees (9).
However, the Bamako Initiative gave rise to multi-drug prescribing, some of which was irrational (10). The initiative was highly donor driven with limited coverage. There were logistical, financial and quality control issues at operational community levels. In addition, governments and donors got involved in implementation rather than focusing on policy matters (11).
The Influential 1993 World Bank Development Report
The inability of the PHC and Bamako Initiative and other international initiatives to improve access and quality of healthcare in sub-Saharan Africa and other development regions in the late 1980s and early 1990s led to search for alternatives to health policy making. It was against this background that the World Bank's World Development Report of 1993, "Investing in Health," was undertaken (12). It reflected a marked change in the orientation of how healthcare services in resource-poor countries would be delivered. The report makes little use of the term "Primary Health Care." It considers the delivery of health care services in terms of the economic benefit that improved health could deliver, and sees health improvement mainly in terms of improvement of human capital for development, rather than as a consequence and fruit of development. The report focused primarily on health care sector activities to improve health and gave scant recognition to the role of other sectors, which contrasts with the original PHC's multi-sectoral approach (13).
This World Bank approach became known as Health Sector Reform. It heralded an emphasis on using the private sector to deliver health care services while reducing or removing government services. User pays, cost recovery, private health insurance, and public–private partnerships became the focus for delivery of health care services.
To inject political support, establish verifiable benchmarks, and engender an international solidarity of all nations, the United Nations Millennium Development Declaration became a rallying call to improve health in all parts of the world. The millennium declaration focuses on broad, multi-sectoral approach to development, including health. The eight millennium development goals (MDGs) are:
- Eradicate extreme poverty and hunger
- Achieve universal primary education
- Promote gender equality and empower women
- Reduce child mortality
- Improve maternal health
- Combat HIV/AIDS, malaria and other diseases
- Ensure environmental sustainability
- Develop a global partnership for development
Following this commitment by the international community and governments, the then United Nations General Secretary Kofi Annan became a strong proponent and champion of the millennium declaration as a vehicle for global development (14). At the midway point between their adoption in 2000 and the 2015 target date for achieving the MDGs, sub-Saharan Africa is not on track to achieve any of the goals. Although there have been major gains in several areas and the MDGs remain achievable in some African nations, even the best-governed countries on the continent have not been able to make sufficient progress in reducing extreme poverty (15). Maternal health remains a regional and global scandal, with the odds that a sub-Saharan African woman will die from complications of pregnancy and childbirth during her life at 1 in 16, compared to 1 in 3,800 in the developed world (16).
In response to the call for increased development assistance and action, the following funds and initiatives were created:
- Global Fund against AIDS, TB and Malaria (GFATM)
- US President's Malaria Initiative (PMI)
- US President's Emergency Fund for AIDS Relief (PEPFAR)
- Road map for accelerating the attainment of the MDGs related to Maternal and Newborn Health in Africa
- African Union framework for Child Survival
- African Union Maputo Plan of Action
- African Union Health Strategy
- African Union Implementation Framework for Achieving Universal Access to HIV/AIDS, TB and Malaria services
- International Health partnership (for the health MDGs)
These funds and initiatives have brought much needed injection of resources into the health sector in sub-Saharan Africa, resulting in new rounds of national health policies and strategic plans in the health sector or revision of existing ones. However, dearth of health workforce has reduced the capacity of African nations to take full advantage of these new sources of funds for the health sector. Conditions attached to new round of funds created tensions with recipient nations. In addition, the injection of new or promised sources of funds for the health sector opened up a long term simmering debate between donor and recipient nations: the issue of aid effectiveness.
Paris Declaration on Aid Effectiveness
The 2005 Paris High Level Forum convened to address the problem of aid or development assistance effectiveness. The Forum culminated with the endorsement of the Paris Declaration on Aid Effectiveness by over 100 signatories from partner governments, bilateral and multilateral donor agencies, regional development banks, and international agencies. The Principles of Paris Declaration on Aid Effectiveness include:
- Developing countries will exercise effective leadership over their development policies, strategies, and are to coordinate development actions;
- Donor countries will base their overall support on receiving countries' national development strategies, institutions, and procedures;
- Donor countries will work so that their actions are more harmonized, transparent, and collectively effective;
- Countries will manage resources and improve decision-making for results;
- Donor and developing countries pledge that they will be mutually accountable for development results.
The Declaration lays down 12 indicators to provide a measurable and evidence-based way to track progress against aid effectiveness objectives and sets targets for 11 of the indicators for the year 2010.
Proposed Way Forward for Sub-Sahara Africa
As briefly shown in this article, there is no dearth of international agreements, national policies, and strategies in sub-Saharan Africa. Many countries are off track for the attainment of the MDGs while some will not attain them until 2050 or beyond due to
- poor performing health systems,
- growing health workforce crisis, and
- pervasive challenge of scaling up to achieve universal access to health care.
The critical challenge for countries in sub-Saharan Africa is to move from policy to action in the health sector. This move from policy to action should be grounded on each country addressing its priority health needs and mobilizing its people to improve the state of health at personal and community levels. Sub-Saharan Africa countries, in translating existing policies into national plans of action, should also ensure that health programs receive adequate funding, health services are implemented at scale, and health systems are monitored and evaluated in a transparent manner.
To translate national health policies into measurable national action plans, it is important to take cognizance of the following issues:
- National plans should be developed to respond to the following key questions:
What? Essential interventions
How? Through an integrated service delivery strategy
Who? Skills required and which cadre can do what with a focus on the correct skills-mix
Where? Home or at a health care facility
With what? Supplies, commodities, and medicines
- Strengthening health systems should include:
- Health workforce: innovative approaches to train, retain and sustain qualified workforce,
- Make available essential medicines, equipment and supplies,
- Measure progress: what is measured gets done.
- Health workforce: innovative approaches to train, retain and sustain qualified workforce,
- Empowering individuals, families, and communities to own their health and demand quality services.
- Scaling up rapidly: bring essential services to most or all the population quickly, equitably, and lastingly. This requires additional investment in health.
For sub-Saharan Africa to overcome its health problems, policymakers in the continent must regain control over the identification of national health priorities and the elucidation of national health policies. Governments, the private sector and the civil society should work together to develop and implement equitable health systems that serve the needs of all citizens, including those living in extreme poverty. As economic development improves the incomes and standards of living in many developing countries, an increasing gap is opening up between the rich and the poor. Families living in poverty are increasingly shut out of health care services. It is very important to give "voice" to the poor in the planning and implementation of health services.
1. Collier, Paul. The Bottom Billion: Why the Poorest Countries Are Failing and What Can Be Done About It. (New York: Oxford University Press, 2007), p.21.
2. Declaration of Alma-Ata. International Conference on Primary Health Care, Alma-Ata, USSR, 6-12 September 1978.
3. World Health Organization. Global strategy for health for all by the year 2000. (Geneva: WHO, 1981).
4. Tarimo, E., and E. G. Webster. "Primary health care concepts and challenges in a changing world. Alma-Ata revisited," ARA Paper Number 7 (WHO/ARA/CC/97.1). (Geneva: WHO, 1997).
5. The World Health Report 2000 - Health systems: improving performance.
6. Loewenson, R. "Structural Adjustment and Health Policy in Africa," Int. J. Health Serv. 23 (1993): 717-30.
7. International Monetary Fund's Independent Evaluation Report: IMF in sub-Saharan Africa. P.9; Figs.2.2 & 2.3.
8. Jolly, R., F. Stewart, and G. A. Cornia. Adjustment with a human face: protecting the vulnerable and promoting growth. (New York: Clarendon Print, 1992).
9. Knippenberg, R., E. Alihonou, A. Soucat, K. Oyegbite, M. Calivis, I. Hopwood, R. Niimi, M. P. Diallo, M. Conde, S. Ofosu-Amaah. Implementation of the Bamako Initiative: Strategies in Benin and Guinea. MID: 15185584 [PubMed - indexed for MEDLINE].
10. Uzochukwu, B. S. C., O. E. Onwujekwe, and C. O. Akpala. Effect of the Bamako-Initiative drug revolving fund on availability and rational use of essential drugs in primary health care facilities in south-east Nigeria. Medicus Mundi Schweiz, Murbacherstrasse 34, 4013 Basel, Schweiz.
11. Economical solidity a precondition for equity—Manageable Bamako Initiative schemes. Von Felix Küchler (Schweizerisches Tropeninstitut STI) Bulletin von Medicus Mundi Schweiz Nr. 84, April 2002.
13. Hall, John J., and Richard Taylor. Health for All by 2000: the demise of the Alma-Ata Declaration and primary health care in developing countries… Medical Journal of Australia 2003; 178:17-20.
16. World Health Report 2005. Making every mother and child count.