In the coming weeks, this series of blogs will highlight how health systems in Africa came to be, what challenges we face, and solutions implemented to improve health outcomes and achieve universal healthcare.
Outline
Introduction
In recent years, the emergence of disease outbreaks at regional and global levels has underscored the pressing need to expedite the achievement of universal healthcare (UHC). However, the pursuit of UHC in Sub-Saharan countries, especially in Africa, remains an arduous task. This is primarily due to the prevalence of the out-of-pocket healthcare model, which dominates in countries where financial resources are deemed insufficient to support alternative models.
Out-of-Pocket Healthcare Model
The prevalence of the out-of-pocket model in many regions of Sub-Saharan Africa highlights the link between healthcare accessibility and income levels. This situation can be attributed to several underlying factors:
Budgetary Constraints: Governments with limited financial resources often face challenges in allocating sufficient funds to healthcare due to competing priorities. This leads to a heavy reliance on out-of-pocket payments to finance healthcare services.
Inadequate Health Financing: Many countries fall short of the recommended allocation of 15% of the budget to healthcare. The resulting funding gap affects the availability of affordable healthcare services and contributes to the reliance on out-of-pocket payments. This challenge is observed in various countries where healthcare budgets do not match the level needed to ensure universal access.
Quality of Public Healthcare: Insufficient resources in public healthcare facilities, such as medication shortages and a lack of essential equipment, contribute to the need for out-of-pocket payments. This is a common issue across several countries in the region, where public healthcare facilities often struggle to provide the necessary quality of care, leading individuals to seek alternative options and incur out-of-pocket expenses.
Understanding Neoliberal Policies
Neoliberal policies constitute political and economic systems deeply rooted in free-market capitalism. They rely on the premise that demand dictates supply, operating under a willing buyer-willing seller model with minimal regulations. This system assumes that supply and demand fluctuate until an equilibrium price is reached. Some of the potential impacts of neoliberal policies on healthcare access include:
Emphasis on Market Forces: Neoliberal policies prioritise the role of free markets in driving economic growth and efficiency. They believe that allowing market forces, such as supply and demand, to determine prices and allocate resources leads to better outcomes than government intervention. While this encourages innovation and increased investment, it can be a double-edged sword as the cost of access increases, thus excluding communities that cannot afford care.
Privatisation: Neoliberal policies often advocate transferring state-owned enterprises and public services to private ownership. The aim is to introduce competition and increase efficiency in delivering goods and services. For example, sectors like telecommunications, energy, or transportation may be opened up to private companies. However, privatisation and lower taxes in the health sector diminish government financing for national insurance and welfare funds, leading to inflation and consequently inflated healthcare costs.
Reduced Government Intervention: Neoliberal policies seek to limit government involvement in the economy. Involving reducing regulations, bureaucracy, and barriers to entry for businesses. The idea is that by giving businesses more freedom and reducing government interference, they can innovate, compete, and drive economic growth. However, reduced protection against unfair practices and diminished government control over healthcare as an economic activity can result. For example, the deregulation of the pharmaceutical sector has increased the prices of essential medicines, limiting access to the most vulnerable populations. Nonetheless, some countries like Rwanda and Mauritius have taken proactive measures to regulate healthcare providers and ensure equitable access to healthcare services, deviating from strict adherence to neoliberal principles.
Deregulation: Neoliberal policies aim to reduce regulations and bureaucratic obstacles that may hinder business operations, such as simplifying administrative processes, streamlining regulatory frameworks, and promoting a business-friendly environment. However, it weakens unions as employment is subject to the free market and has implications for healthcare workers' rights and remuneration.
It is important to note that while neoliberal policies have been implemented in various countries, the impact and outcomes can vary. Proponents argue that these policies promote economic growth and efficiency, while critics raise concerns about potential inequalities, social impacts, and the role of government in ensuring public welfare. The application and effectiveness of neoliberal policies depend on various factors, including the context and specific implementation strategies.
The free market assumes that buyers and sellers possess complete information and that prices and quantities are determined through informed negotiations. However, healthcare rarely aligns with these assumptions. Patients often lack comprehensive information about the best services available or fair pricing, and the demand for healthcare persists even when prices increase.
Why Aren't Neoliberal Policies Being Reviewed for Essential Services?
Given the evident detrimental effects of neoliberal policies on essential services, it is crucial to question why policymakers have not reassessed their application. The answer to this question is partly in the persistent influence of neocolonialism, as many governments continue to operate within economic systems established during colonial times. Additionally, international financial institutions actively advocate for these policies, further reinforcing their implementation.
The global health system, which multilateral financing and development institutions have long governed, prioritises neoliberal reforms, including increased privatisation, in low and middle-income countries. This approach, promoted by these international financial institutions, emphasises economic growth over equitable access to essential services like healthcare.
Countries that receive loans and financial support tied to these neoliberal policies often prioritise their economies at the expense of healthcare. This focus on economic development can lead to inadequate investment in essential services, including healthcare infrastructure, workforce, and access to affordable treatments. Consequently, those who cannot afford private healthcare are left with limited options and face significant barriers to accessing the care they desperately need.
To address these issues, it is imperative for policymakers to critically examine the impact of neoliberal policies on essential services, particularly in healthcare. By questioning the prevailing power dynamics and challenging the influence of international financial institutions, countries can shift towards a more balanced approach that prioritises well-being and equitable access to quality healthcare for all.
Recognising the Power Structures at Play
Despite our countries' autonomy, covert power structures subtly disempower us. Development loans come with conditions that extend beyond interest rates and push for the implementation of free-market models in all sectors, including healthcare. User fees, driven by neoliberal policies, have been imposed in many African countries, leading to decreased healthcare utilisation among people with low incomes due to financial barriers. Additionally, privatisation reforms, influenced by neoliberal policies, have widened the healthcare gap in countries like South Africa, where private healthcare has become more accessible to the affluent. At the same time, the majority relies on underfunded public healthcare facilities.
Limited government investment resulting from neoliberal policies has contributed to the deterioration of public healthcare infrastructure and shortages of essential medications. Brain drain, driven by limited job opportunities and poor working conditions resulting from neoliberal policies, has led to the emigration of skilled healthcare professionals from countries like Nigeria and Kenya due to the same neoliberal policies that shift the advantage to the global north countries with the capacity to pay more, exacerbating the shortage of healthcare workers.
Furthermore, insufficient regulation stemming from neoliberal policies has allowed the proliferation of unregulated private healthcare providers in some African countries, compromising the quality and safety of healthcare services. However, there is hope, as some development organisations acknowledge the impact of these neoliberal policies and neocolonialism on public health. They advocate for policy reforms prioritising populations' health and well-being over purely economic considerations and adopting new approaches, such as donor allocation, encouraging south-to-south partnerships, and engaging academic institutions.
The Significance of the Matter
Neoliberalism has commoditised healthcare, prioritising profit over the provision of essential services. While capitalism fosters innovation, crucial for health advancements, the escalating cost of healthcare renders it unattainable for many, deepening inequalities in access to quality care. Universal healthcare offers a viable solution to address these inequities and prevent catastrophic medical expenses in Africa. The definition of UHC varies depending on a population's health needs rather than privileging one group over another in terms of access. UHC ensures individuals can access necessary health services without financial hardship or catastrophic expenditure. Unfortunately, market-driven healthcare, stemming from the absence of regulations on providers and costs in the out-of-pocket system, poses significant challenges to achieving UHC in Africa.
Policymakers must make a concerted effort to review policies, especially concerning essential services like health and education, to achieve this vision. By learning from countries like Rwanda, African nations can navigate the complexities of their unique contexts and forge a path towards inclusive and sustainable healthcare systems.
Dr. Achieng' Aling' is a global health professional with a strong focus on health system strengthening and sexual reproductive health. Passionate about advancing global health, she is committed to knowledge sharing to drive positive change and promote healthy lives.
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