Intended for healthcare professionals

Education And Debate

Personal paper Africa in the 21st century: can despair be turned to hope?

BMJ 1997; 315 doi: (Published 29 November 1997) Cite this as: BMJ 1997;315:1444
  1. Dorothy E Logie (delogie{at}, general practitionera,
  2. Solomon R Benatar, professor of medicineb
  1. a Medical Action for Global Security, London N19 4DJ
  2. b University of Cape Town, 7925 Cape Town, South Africa
  1. Correspondence to: Dr Logie
  • Accepted 22 September 1997


The 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


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

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

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 (1). 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 permission5

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 ofAfrica'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 sanitation6

  • 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 year3

  • 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 19929

  • 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 sources10

  • 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

  • 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 displaced from their homes, with economies in ruins, millions facing starvation and disease.”11


South Africa's fast growing population puts pressure on housing, education, and health


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 cities) have benefited from health expenditure.4 Failure to value women's contribution to society and the denial of women's rights has had a huge negative impact on the health of African women and their families.8

Can 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.

Cautious Afro-optimism

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

The UN Special Initiative for Africa

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

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)

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

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

Highly Indebted Poor Countries Initiative

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.

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

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.

Afro-pragmatism: on a knife edge?

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


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