BMJ No 7120 Volume 315
Education and debate Saturday 29 November 1997
Personal paper
Africa in the 21st century: can despair be turned to hope?
Dorothy E Logie, Solomon R BenatarThe free flow of trade and money around the world has brought economic growth for the fortunate in the largest and strongest economies but has also created widening gaps in wealth and health between, and within, countries. These polarising forces have intensified in the past decade, creating a hundred million poor within the rich "core" in addition to the 1.3 billion people in the "periphery" who exist on $1 a day or less.(1)
| Summary points |
| Two thirds of people living in sub-Saharan Africa are desperately poor |
| Health and education standards continue to deteriorate |
| More money is spent on debt servicing than on health and education |
| Within Africa, corruption, wars, and lack of commitment to health (especially women's health) have contributed towards the appalling health indices |
| The role of the industrialised countries in destabilising Africa needs to be openly debated |
Afro-pessimism
Sub-Saharan Africa is the most dramatic loser. Here poverty is at its most stark and marginalisation from the global economy most pronounced. The continent contains 33 of the world's 50 poorest countries. Improvements in health, education, and living standards have reversed in the past two decades, and standards continue to fall. By the end of the decade, two thirds of Africans will live in "absolute poverty."(2) More than half still lack safe water and 70% are without proper sanitation; 40 million children are not in primary school. Infant mortality is 55% higher than in the rest of the world's low income, developing countries, and average life expectancy, at 51 years, is 11 years less.(3) Malaria and tuberculosis are increasing, and in parts of central, southern, and eastern Africa 30-40% of pregnant women are now HIV positive.(2)
| Poverty causes ill health, but ill health also imposes immense economic costs on individuals, their families, and society. African productivity could increase by 15% if illness and disability were attacked more strenuously.(4) The economic cost of malaria is estimated at 1% of gross national product, while AIDS strikes adults in their most productive years (figure). In families with AIDS, the children are forced to leave school early to work, weakening their long term financial prospects. New ways of coping with the cost of illness (selling cattle or land) cause further long term economic hardship (J Tumwine, personal communication). |  | |
| Mortality in 20 Zambian companies. Reprinted with permission.(5) |
Where does blame lie?
Many of Africa's setbacks have been associated with global economic policies over the past two decades which, in a complex way, reinforce the legacies of colonialism and imperialism and exacerbate Africa's internal problems. These external forces include:
A crippling debt of $300 billion which soaks up one fifth of
Africa's savings and drains the continent of more than it receives in
aid or loans.(6) More money is spent on debt servicing than
on health and education. In Uganda, which has one of the highest
maternal and infant
mortality rates and an AIDS epidemic, the government spends $2.50
(£1.69) per head of the population annually on health - and $15 per
head on debt servicing.(7) In Zambia, where for every $1
spent on health care $4 is spent on debt servicing, infant mortality is
rising in the face of collapsing provision of health care, clean water,
and sanitation(6)
The World Bank's economic adjustment policies, which have restricted
social spending and encouraged export manufacture at the expense of
food production. User fees have excluded poor people from health and
education and have especially affected women, contributing to their
lack of empowerment to restrict the number of children they
bear,(8) while the population of the continent grows at 3%
a year(3)
Trade protectionism, which has played a large part in the region's
stagnation. Low commodity prices have lost Africa $45-55 billion
between 1980 and 1992(9)
Falling foreign aid. Aid from rich countries has fallen to a trickle,
well short of the UN target of 0.7%, and the trend is downward.
Foreign aid has failed to bear economic fruit, entangled as it is with
promoting trade and arms sales and sustaining the opulent lives of
despots. Donors' experience of investing in health is also
disappointing where there are low levels of health financing:
inappropriately targeted aid can fragment a fragile health service;
projects collapse after investment ceases because of inadequate
empowerment of local personnel; donors demand quick and measurable
results to satisfy their funding
sources(10)
The brain drain; encouraged by active recruitment by some northern
countries, this is causing an exodus of Africa's ablest professionals,
engineers, scientists, physicians, and technical workers
But Africa too must bear responsibility for its current state.
Poor governance, tribalism, pervasive corruption, and a lack of
democracy have caused social and political tensions resulting, in
extreme cases, in collapse of states, with devastating humanitarian
consequences. Weakness of political commitment to fund better health
and social services, accompanied by a disinclination to develop
preventive and primary health, has meant that few people (mainly those
in c
In the past year, three international events have given rise to
cautious optimism that Africa's health, and economy, can be improved.
Firstly, the World Bank's new president, James Wolfensohn, has staked
his reputation on alleviating poverty.(13) Secondly, the
United Nations has embarked on a joint venture (the special initiative
for Africa), pooling the expertise of all its agencies and those of the
World Bank.(14) Thirdly, there has been an important
movement on debt relief (the highly indebted poor countries
initiative).(15)
In March 1996, the UN agencies launched a 10 year, $25
billion initiative for Africa to reduce poverty and to coordinate
follow up from the global conferences of the 1990s (box). Eighty five
per cent of this money (controlled by Africans themselves) will go to
expanding basic education and health. Social development cannot take
place without peace, so transparent governance and conflict prevention
are high on the agenda. The health plans (box) emphasise cost effective
packages of basic health care and more equitable use of public funds,
but many are disappointed that charges imposed at the point of delivery
of care are still promoted, with their detrimental effect on health
seeking behaviour and their potential for weakening preventive
health.(16)
What makes this programme different from other high profile
efforts to help Africa? Firstly, it has not been imposed from the
outside but is based on home grown themes reflecting Africa's own
development priorities. Secondly, there is a commitment to listen not
just to governments but to ordinary people, including non-governmental
organisations. And thirdly, there are none of the conditions (meaning
that "if you don't adopt our priorities you don't get the money")
which have so dominated Africa's development over the past decade.
Even so, African organisations are concerned that the annual allocation
of $2.5 billion will not be "new" but redirected money. "The
people of Africa," says President Rawlings of Ghana, "will know it
[the special initiative] is successful when we see schools where
there were no schools, when we have health services where those
services were inadequate before, when households have access to safe
water."(17)
1996 brought an unprecedented opportunity to diminish the debt
crisis of the poorest countries (box). The World Bank and International
Monetary Fund accepted that some debts cannot be repaid and that the
flow of money from poor to rich countries must be stopped. Although
there are problems in the design (slow implementation, thresholds of
debt sustainability too high, and debt relief not adequately set into a
broader programme of human development), the initiative provides new
thinking.
But already the initiative has received a setback. Uganda, with an
excellent economic track record and six years of adjustment programmes,
was to be the first to benefit (followed by the Ivory Coast and Burkina
Faso), but relief was blocked for one year by political in-fighting
among donors. This delay means Uganda will receive £119 million ($193
million) less than hoped for (and six times Ugandan government spending
on health) - money the Uganda government had already planned to use for
health and education.(18)
The harsh requirement of six years' adherence to adjustment programmes
means that Ethiopia will not qualify till the end of 2000 (despite
drought and postwar reconstruction); Mozambique, Tanzania, Niger, and
Zambia will not qualify till 2002 or later; and Rwanda may not qualify
at all despite its desperate post-genocide reconstruction.
There is an increasing groundswell of demand for a one-off debt
cancellation of the poorest countries to mark the start of the new
millennium.(19) This "once only" gesture would not set a
precedent for repeated cancellation - the "moral hazard" so feared
by the international financial institutions - but would accept that both
creditors (like the Swiss banks accepting the illegal booty of
dictators) and debtors have made mistakes. Starting the new millennium
by such a gesture, and structuring new loans with greater
accountability, could remove a great barrier to progress and
justice.
South Africa represents the continent's problems in microcosm.
The apartheid regime borrowed to oppress and kill people; now, those
who suffered are being asked to repay the debt. Like the rest of
Africa, South Africa has a fast growing population (swollen by illegal
immigration) which puts pressure on overstretched housing, education,
and health and swells unemployment - which, in turn, unleashes violence
and crime. Like the rest of Africa, the country faces a balancing act
between achieving economic growth by participating in globalised free
markets (with their potential to enrich some people at the expense of
others) and redistributing resources through paradigm shifts in
approaches to health, education, housing, and other socioeconomic
inequalities.(20)
A mixture of hope and fear underlies the call for a "new push for
Africa": hope that internal reconstruction, with greater focus on
democracy and new visions of external support, can create sustainable
development; fear because Africa has been marginalised and eliminated
from the foreign policy agenda of most wealthy nations, and the window
of opportunity to achieve these goals will not remain open
indefinitely. As has been recognised in South Africa, policies which
exclude peoples, nations, or continents have only limited potential and
must eventually be replaced by longer term visions.
But no more should be expected of Africa than can be delivered by
wealthy nations, who in turn must set an example through reform of
their consumption patterns and energy expenditure. It is vital that
industrialised countries acknowledge the adverse role they play in
Africa. Pessimism, based on economic considerations, should be
countered by an understanding that the cost of eradicating poverty is
less than people imagine, about 1% of global income.(1)
Effective debt relief for the 20 poorest countries is even cheaper,
with a price tag of $5.5 billion - the cost of building
Euro-Disney.(21)
(Accepted 22 September 1997)
Medical
Action for Global Security, University
of Cape Town,
Correspondence to: Dr
Logie
email: delogie@aol.com
References
1 United Nations Development Programme. Human
development report. New York, Oxford: Oxford University Press,
1997:9, 116
2 Bergstrom S, Mocumbi P. Health for all by the year 2000?
BMJ 1996;313:316.
3 United Nations. Implementation strategy for the health
sector. United Nations Special Initiative for Africa. New
York:United Nations, 1996.
4 World Bank. Better health in Africa: experience and
lessons learned. Washington, DC: World Bank, 1994:24.
5 AIDS and the work place. South African Economist
1997 April 15:7.
6 Oxfam. The Oxfam poverty report. Oxford: Oxfam,
1996.
7 Oxfam. Poor country debt relief: false dawn or new hope
for poverty reduction? Oxford: Oxfam, 1997. (International
position paper.)
8 Harrison K. The importance of the educated healthy woman in
Africa. Lancet 1997;349:644-7.
9 Flanders S. New ways for Africa. Financial
Times 1997 April 14:13.
10 LaFond A. Sustaining primary health care. London: Earthscan,
1996.
11 Gervasi S, Wong S. The Regan doctrine and destabilisation of
Southern Africa. In:George A, ed. Western state
terrorism. Cambridge: Quality Press, 212-52.
12 Cornia G A, ed. Africa's recovery in the 1990s.
Florence: Unicef, 1992:19.
13 The World Bank, listening and learning [editorial].
Lancet 1996;347:411.
14 The UN System-wide Special Initiative for
Africa. UN. New York: United Nations, 1996.
15 Pettifor A . World Bank/IMF proposals for comprehensive debt
relief for the Poorest Countries. London: Debt Crisis Network, 1996.
(Available from PO Box 100, London SE1 7RT.)
16 Woodward D. User charges for health services in developing
countries: an approach to analysing the effects on utilisation and
health outcomes. Discussion paper prepared for the Department for
International Development, May 1997. (Available on the internet:
http://cichich.ucl.ac.uk)
17 Novicki M. A new impetus for African development. Africa
Recovery 1996 May:12.
18 Oxfam. Debt relief and poverty reduction: new hope for
Uganda. Oxford: Oxfam, 1996.
19 Jubilee 2000. A debt cutter's handbook. London:
Jubilee 2000, 1996.
20 Benatar S. Towards social justice in the new South Africa.
Medicine, Conflict and Global Survival
1997;13:229-39.
21 Brittain V, Elliott L. Dollar-a-day losers in the global
economy. Guardian 1997 June 12:12.
War - in the 1980s an almost invisible war, waged by South Africa and
the United States, destabilised much of southern Africa. History will
record the terrible scars: "A million and a half or more dead,
millions dCan Africa's relentless slide be halted?
However, these generalisations are only part of Africa's reality
and it is neither fair nor objective to overlook the resilience of the
African people or their achievements. For example, after independence,
Zimbabwe's primary education increased from 36% of school age
children enrolled in 1960 to 79% in 1980, and child mortality
halved.(12) More recently, peace has returned to Angola,
Ethiopia, Eritrea, and Mozambique. In South Africa, apartheid and its
evil legacy has been dismantled without civil war, which brings hope
that fundamental shifts can occur through thinking and acting in the
best interest of future generations. 
South Africa's fast growing population puts pressure on
housing, education, and health Cautious Afro-optimism
Key goals of the UN Special Initiative for Africa
1 Primary education for all children within 10 years, with
emphasis on girls 2 Basic health for all, with improved quality of
and access to primary health care 3 Improved security of food and
water
4 Safe water for drinking and cooking 5 Improved
irrigation, drought management, soil nutrition 6 Improved
sanitation 7 Transparent, responsible government by improving an
independent judiciary and the electoral process and making public
administration more accountable 8 Improved public information,
particularly radio broadcasting 9 Support for women in food
production (African women produce 80% of the continent's food supply) The UN Special Initiative for Africa
UNSIA's health plan
Targeting the commonest preventable diseases Promoting the essential drugs programme Increasing and strengthening Africa's existing 40,000 primary care
centres Decentralising health planning and administration Integrating the delivery of reproductive health care Giving women a say in decisions on health Improving health promotion Highly Indebted Poor Countries Initiative
Highly Indebted Poor Countries Initiative: principles
All creditors (bilateral and multilateral) will work together for
comprehensive debt reduction Debt will be approached from a completely different angle - namely, the
ability of the debtor to pay, as opposed to meeting the creditor's
claims In judging the economic performance of countries, note will be taken of
their performance in social indicators such as health, education, and
sanitation The International Monetary Fund, in a major policy shift, has agreed,
in some cases, to provide grants for the payment of debt service as
opposed to loans Afro-pragmatism: on a knife edge?
London N19 4DJ
Dorothy E
Logie, general practitioner
7925 Cape Town,
South Africa
Solomon R
Benatar,
professor of medicine
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