Uneven Health Outcomes and Political Resistance under Residual Neoliberalism in Africa

Presented to the seminar on

Life After Capitalism: Health

ZNet at the World Social Forum

Porto Alegre, Brazil – 25 January 2003






In the wake of the devastation wrought in Africa by two decades of ‘neoliberalism’–i.e., state policies that are market-oriented, export-led, subjet to fiscal austerity and characterized by the commercialization/privatization of public sector functions–this question repeatedly arises: have matters improved now that the Bretton Woods Institutions (the World Bank and International Monetary Fund) and major donor governments are permitting countries to improve their state health systems and increase spending? And what are civil society watchdog groups and debt advocacy movements such as the Jubilee network saying about recent modifications to neoliberalism, especially the Poverty Reduction Strategy Papers and Highly Indebted Poor Countries debt relief initiative?


There are several issues associated with the direct impact of structural adjustment programs–and neoliberalism more generally–on health and health services in Africa. Effects included disincentives to health-seeking behavior, witnessed by lower utilization rates and declines in the perceived cost and quality of services. Household expenditures on health care and ability to meet major health care expenses dwindled, as did nutritional status. Health services price inflation and additional costs put often unbearable burdens on household disposable incomes and on food consumption. A dramatic decline in employment status had a negative effect on disposable income, time utilization and food purchasing. Other symptoms of neoliberal policies such as urban drift and migrancy contributed to the HIV/AIDS pandemic.


Effects on health workers were also mainly negative, including cuts in the size of the civil service, wage and salary decay, declining morale, and the brain drain of doctors and researchers. Likewise, the effects on health system integrity included declining fiscal support; difficulties in gaining access to equipment, drugs and transport (often due to foreign exchange shortages accompanying excessive debt repayment); and the diminished ability of health systems to deal with AIDS-related illnesses. Finally, other aspects of SAPs and neoliberalism introduced adverse health implications, such as the increasing commodification of basic health-related goods and services (such as food, water and energy) that made many unaffordable.


The broader context was one of contraction of the economies of sub-Saharan Africa and a decline in the most critical health indicators, alongside growing criticisms of the Bretton Woods Institutions’ role. With respect to governance, ‘IMF Riots’–urban uprisings catalyzed by the reduction or elimination of subsidies (on food, transport or other necessities)–occurred increasingly across Africa during the 1980s, culminating in the sweep from state power of no fewer than 35 ruling parties between 1990-94, mainly through elections.


Meanwhile, the HIV/AIDS pandemic was putting enormous pressure on the continent’s health services. According to a World Bank discussion document, HIV/AIDS patients occupy between 30 and 80% of hospital beds in countries in the Southern African region (1). The beds needed for HIV/AIDS patients will exceed all available beds in 2002 in Botswana, in 2004 in Swaziland and in 2005 in Namibia. On the assumption that health staff have similar prevalence rates as the population as a whole, there will need to be an increase in training of 25 to 40% just to keep staff numbers constant. Assuming a cost of US$1,100 per patient per year, providing triple therapy to cover 10% of those who need treatment amounts to 0.2% of Botswana’s GDP and 2.4% of that of Malawi, these figures rise to 0.5% and 4.0% respectively in 2010.


Such statistics call for a massive rethink on the allocation of resources to the health sector. Yet one World Bank researcher concludes that aside from the ‘possible exception’ of Botswana and South Africa, ‘none of the countries in the region will be able to offer general access to highly active anti-retroviral therapies through the public health service… Given the serious shortages in personnel and infrastructure the health sector is facing, the scope for alleviating the impact of HIV/AIDS on the health sector through financial aid is limited’ (1).


Meanwhile from 2002 into the foreseeable future, a food crisis has affected an estimated 20 million people across the southern African region, including Malawi, Zimbabwe, Zambia, Mozambique, Angola, Lesotho, and Swaziland. Oxfam (2) has documented the role of neoliberalism in the famine:



The food crisis has many causes, which vary in magnitude from country to country. Climate, bad governance, HIV/AIDS, unsustainable debt, and collapsing public services have all contributed. However, one major cause of the food crisis is the failure of agricultural policies. This paper asks why, after years of World Bank and IMF designed agricultural sector reforms, do Malawi, Zambia, and Mozambique, face chronic food insecurity. The simple answer is that the international financial institutions designed agricultural reforms for these countries without first carrying out a serious assessment of their likely impact on poverty and food security. Far from improving food security, World Bank and IMF inspired policies have left poor farmers more vulnerable than ever.


In addition, as we consider in more detail below, the commodification of Africa’s water also provides evidence of persistent neoliberalism. In March 2000, the Bank’s Orwellian-inspired Sourcebook on Community Driven Development in the Africa Region (3) laid out the policy on pricing water: ‘Work is still needed with political leaders in some national governments to move away from the concept of free water for all… Promote increased capital cost recovery from users. An upfront cash contribution based on their willingness-to-pay is required from users to demonstrate demand and develop community capacity to administer funds and tariffs. Ensure 100% recovery of operation and maintenance costs’. One implication of the enforcement of this policy in 2000 was disconnection of water to low-income South Africans that was the most direct cause of the country’s worst-ever cholera epidemic (4).


In short, doubts remain about whether the Bretton Woods Institutions were, indeed, ever serious about reforming the core

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