The bitterest pill of all: the collapse of Africa's health system

The bitterest pill of all: the collapse of Africa's health system

The Global Fund - a cure for Africa’s failing health systems?

World leaders are discussing a multi-billion dollar package of initiatives aimed at tackling major diseases in poor countries. However, economic crisis and unsuccessful reforms in the past two decades have left many nations with failing health systems. What groundwork is needed before such vast resources are committed? Do previous initiatives offer lessons for today’s policy-makers?

A report written by Save The Children (UK), following consultation with key actors in African health reform processes, examines health systems in many of the nations targeted by the proposed Global Fund. The study argues that efforts to tackle major diseases will be unsustainable in the long-term unless action is first taken to establish effective health systems.

The economic crisis and large debt interest payments of the 1980s forced many governments to reduce spending on health, education and other public services. The World Bank and International Monetary Fund did little to clarify the likely impact of structural adjustment programmes provided in return for loans. So vulnerable groups were left unprotected. The report also finds that:

  • The changes demanded by donors such as decentralisation and increases in user charges were often badly conceived and poorly implemented.
  • Decentralisation can worsen existing inequalities by reducing the ability of governments to transfer resources between richer and poorer regions.
  • Essential child immunisation programmes are threatened by the possible transmission of HIV and hepatitis B infection. Non-sterile syringes and needles are used and many staff are poorly trained and unmotivated, increasing the risk of transmitting these viruses.
  • User fees have led to a decline in the use of maternity and other health services in the poorest communities, contributing to a rise in infant and maternal deaths. In addition, administration and running costs may soak up around half of the revenue generated by user fees.

Low-income countries need large injections of money simply to provide a minimal level of healthcare. However, finance should first be used to strengthen national health systems, develop policy-making capacity and establish administrative structures able to manage large increases in donor support. Health sector reforms should reflect local needs and initiatives such as the abolition of user fees and more adequate provision of support to health workers in the form of training and higher salaries. The report also calls for:

  • a move away from donor-led, vertical interventions that focus too narrowly on specific diseases
  • long-term support for recurrent costs as well as capital expenditure on health
  • greater emphasis on improving the conditions and training of health workers
  • a switch from charging patients at the point of delivery towards greater risk-pooling in the financing of healthcare
  • integrated donor support through the Poverty Reduction Strategy Paper process in order to avoid duplication of activities, help establish local participation and control over health sector priorities, and encourage greater intersectoral action for health.

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