Fragmenting Health Care: The World Bank Prescription for Africa

Abstract

Health care in Africa is in crisis.1 The signs are compelling: from the deterioration of the well-being of most of Africa's children to the resurgence of infectious diseases previously controlled, and from the exodus of health professionals to the crumbling of health care facilities. These signs are the consequences of the continuing impoverishment of the mass of Africans, in spite of more than ten years of Structural Adjustment Programmes led by the International Monetary Fund (IMF) and the World Bank (WB) - programs designed to address the economic conditions lying at the root of Africa's impoverishment. The Bank's response is in a benchmark publication, the World Development Report 1993: Investing in Health (WDR), and an accompanying document dealing specifically with Africa, Better Health in Africa (BHA).2 These reports lay out a neoliberal framework for global health care into the twenty-first century. The discussion that follows is a critical analysis of these reports. This article argues that the WDR and BHA are best understood in relation to broader shifts in health and development that are occurring as part of an emerging global neoliberal hegemony. For the purposes of this discussion, neoliberalism refers to the ensemble of market-driven institutional processes and cultural practices and signifiers that valorize efficiency, self-interest, competitive individualism, and antistatism, as set against collective welfare and communal responsibility. Underlying these changes are global transformations in production, distribution, accumulation, and consumption, which along with the introduction of a range of novel technologies have induced a radical reconstitution of the international division of labor, with a corresponding polarization of wealth and poverty. One feature