World TB Day on March 24 has passed with much fanfare about drug regimes and increases in treatment. But little has been said about the broader health issues that continue to go unaddressed. The symptoms of the health crisis that faces the continent are only partially dealt with.

Health status is influenced by socioeconomic factors as well as health delivery services. In Africa, declining economies and growing poverty levels have led to a drop in the health status of the population. The HIV pandemic, as well as the persistent ravages of diseases such as malaria, has been exacerbated by poverty-associated malnutrition and unhealthy life-styles.

Experiences in Africa thus far continue to manifest the impact of structural adjustment programmes of the past, which failed and were largely discarded, but whose rationale continues to underpin policy-making.

The economic decline, occasioned by these programmes and other systemic factors, has also reduced the resources available for public spending. Along with social services and education, health care has born the brunt of the cut-backs instituted by governments Shrinking budgets, coupled with increased demand for health services and the rising cost of health care have plunged African health care regimes into chaos, necessitating urgent reforms. Sekwat (2003) adds that the inadequate resource mobilization is further complicated by the inefficient use of the existent resources.

The process of privatisation as a means of cutting public spending has an exclusionary effect that runs counter to the drive for equity and social justice. By privatising health services, elements thereof in effect exclude those who are not able to pay for it, and in most instances need it most. Public-private partnerships have met with limited success because of structural incompatibilities between the sectors.

A feature of health care reform in Africa has been the introduction of user fees for services. In this scenario, the cost of health care is shared between the state and the public. The reality is that whereas this has succeeded in raising revenue for the sector, it has placed an even greater burden on the meagre resources of the poor, and completely excluded those without the resources. The fallacy of the approach is evident in studies that have shown an increase in efficiency in health care delivery by measuring the level of waiting lists at health facilities. The reality is that those who cannot afford health care are simply not getting it.

There has been a recent move away from cost-sharing in the form of user fees, which have tended to prevent the poor from accessing health services. Sekwat (2003) points out that user fees have a particularly negative effect on adherence to mid and long-term treatment regimes. This is especially dangerous when dealing with diseases like tuberculosis.

Although a study of health policies in Africa reveals an emphasis on social justice and equity, the realities of implementation have tended to militate against this. Budgetary efficiency has often meant doing only what is possible within budgetary allocations. Health care has frequently received allocations well below the requirements, although countries like South Africa are making positive steps towards improving this. The drive for efficiency in resource utilization has met with limited success because most of the inefficiencies tend to be systemic rather than unique to the health sector.

One noble effort has been to shift more resources to broader basic health-care, with the view to early detection and treatment of health problems before they become more dangerous and costly to treat. However, the problem has been that doing this has necessitated redeploying resources from the secondary and tertiary systems. This problem has recently come up in South Africa where the Western Cape finance department has proposed cutting allocations to two major referral hospitals in order to increase capacity in secondary facilities. Whereas the secondary facilities are better able to serve the community, it substantially strains the tertiary system.

Examples such as the foregoing tend to call into question the ideological underpinnings of health policy. Whereas the provision of basic health care to benefit the poor is beyond reproach as a policy, should it mean that the poor only have access to primary health care? Rather the system should be designed to accommodate all people at all levels. Stierle et al point out the provision of health care to the poor is further hampered by lack of clear definitions of who is 'poor' or 'indigent' and therefore eligible for free health care. These are issues that need urgent attention if the health system is to serve in an equitable manner.

The lack of skilled personnel continues to be a problem in reforming the health sector. Furthermore the ability of the public health sector to retain these personnel is still a major challenge, which can only be overcome through better remuneration and working conditions. Needless to say, this is not achievable unless there is more budgetary allocation to health services.

The process of health care reform requires a multi-sectoral approach and a firm grounding in the broader principles of social justice and equity. Any process of reform needs to be sensitive to the most vulnerable, without creating structural imbalances that negatively impact sustainability.

Futher Reading:

Africa Action position paper: Hazardous to Health

Ambrose,S. 2006. Preserving disorder: IMF policies and Kenya's health care crisis http://www.wpro.who.int/NR/rdonlyres/B2E65CFE-C098-4281-9FF4-967DFEB22069/0/RC53_INFDoc1.pdf