Third World Quarterly, Vol. 30, No. 5, 2009, pp 991–1005
Health Reform in Latin America and
Africa: decentralisation, participation
and inequalities
KATIE WILLIS & SORAYYA KHAN
ABSTRACT As part of broader neoliberal economic policies most governments
of Latin America and sub-Saharan Africa have implemented reforms of the
formal health sector since the early 1980s. Driven both by the need for greater
efficiency and calls for increases in patient choice and participation, these
reforms have taken on different forms across the regions, but the main features
have been decentralisation, increased user fees and the introduction of forms of
health insurance. This paper considers the nature of these reforms, how the
broad category of ‘neoliberal health sector reform’ has played out in different
places and the impact of these reforms across socioeconomic groups.
Shifts in the relationships between state institutions, citizens and private
sector organisations are at the heart of processes of neoliberalisation.
However, the particular nature of these shifts and their outcomes within
specific places and communities cannot be assumed. While some research on
neoliberalism and development has attempted to identify general trends,
research in development studies, geography, anthropology and sociology is
increasingly engaging with the diversity of neoliberalisation processes and
their effects.1 Thus, what may be regarded as a ‘global’ process is, as the
burgeoning literature on scale demonstrates, constructed through the ‘local’.
This focus on the ways in which policies are created and developed through
the actions of individuals and institutions is key in both describing and
explaining how ‘global’ processes are created, but also to highlight how ‘local’
differences exist and how spaces for alternative possibilities may be created.
Access to health care and improvements in health status are often at the
heart of concepts of ‘development’, as conceived as an improvement in an
individual’s quality and standard of living. For example, life expectancy at
birth is used as part of the UNDP’s Human Development Index,2 and the
Millennium Development Goals (MDGs) include a number of health-related
targets.3 Amartya Sen also uses good health as a route to greater freedoms
and therefore ‘development’.4 With good health individuals have greater
Katie Willis and Sorayya Khan are both in the Centre for Developing Areas Research (CEDAR),
Department of Geography, Royal Holloway, University of London, Egham, Surrey TW20 0EX, UK. Emails:
[email protected]; [email protected].
ISSN 0143-6597 print/ISSN 1360-2241 online/09/050991–15 Ó 2009 Third World Quarterly
DOI: 10.1080/01436590902969742
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KATIE WILLIS & SORAYYA KHAN
ability to participate in work activities (both paid and unpaid) and education,
so improving their life chances and choices.
While formal healthcare provision has experienced change since its
inception, the shifts associated with neoliberal policies since the 1980s have
been regarded as particularly dramatic.5 The provision of health care is
increasingly being incorporated into the logic of the market, where it is
viewed as a ‘commodity’ to be bought and sold, rather than a service which
is provided to individuals as citizens of a nation-state. While ‘good health’
may be regarded as a basic human right, rather than ensuring this through
state provision, the tendency is towards a market-led approach, with varying
degrees of safety-net provision for marginalised groups.6 This process is
found throughout the world, although, as mentioned earlier, the processes of
implementation and the effects of such policies have local specificities. The
involvement of the private sector in direct healthcare provision and health
insurance has been a key element of health sector reform in many parts of the
world, including the global South. However, the wider introduction of user
fees in state-provided services has also been evident as part of the wider costrecovery agenda.
Associated with a growing use of fees and private-sector actors, health
sector reform has often involved decentralisation of healthcare provision
within the state sector. Such moves are aimed at promoting greater patient
participation and choice, as well as improving efficiency in service delivery. In
seeking to achieve ‘Health for All’ as the World Health Organisation (WHO)
declared in the Alma Ata Declaration of 1978,7 decentralisation and
marketisation have been increasingly adopted as the key processes through
which this will be achieved.8
In this paper these general trends in health sector reform will be discussed
in the context of sub-Saharan Africa and Latin America. After a brief
overview of neoliberal health sector reform, we focus on the two regions in
turn. Considering differences within and between the regions highlights the
ways in which neoliberalisation within the health sector is implemented and
experienced differently. While many Latin American countries had reasonably well established state healthcare and insurance systems which covered a
significant proportion of the population before reform, albeit with highly
differential services, in sub-Saharan Africa state healthcare provision was
often, and continues to be, very limited, both geographically and socially.
Decentralisation and participation
Neoliberal policies throughout the world have been associated with attempts
to decentralise decision making in order to promote greater involvement of
people and communities. Such processes are supposed to lead to greater
efficiency and democracy through processes of inclusion and participation.9
Geographically decentralisation is meant to shrink the distances between
central decision-making institutions and the people, so diffusing power
throughout a national space, bringing the state nearer to the citizens and
enhancing democratisation in previously autocratic regimes.10
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HEALTH REFORM IN LATIN AMERICA AND AFRICA
Within health care, decentralisation has been regarded as a key element in
promoting greater equity in access while also recognising limited government
budgets. In sub-Saharan Africa decentralisation within health care was
institutionalised through the 1987 Bamako Initiative (see below), but similar
agendas have been followed in other parts of the global South. Decentralisation implies a transfer of authority and responsibility from the central level of
government to the district and local levels, which are thereby strengthened.
By bringing governance structures down to the local level, state health care is
supposedly more responsive to community needs.11
Community involvement is often encouraged through the setting up of
consultative processes, whereby community members are able to respond to
local health initiatives or even contribute to their development. Throughout
the world, including in countries of the global North, state health providers
are increasingly developing new forms of ‘inclusive governance’ in an
attempt to promote greater patient participation in framing local health
policy.12 However, as the UNDP concludes in its evaluation of decentralisation policies in the context of the MDGs, decentralisation does not inherently
lead to greater participation, democracy or accountability. For example,
prerequisites for successful decentralisation include sufficient local administrative capacity and a well developed civil society which can lobby for change.13
An associated concern has been that decentralisation of decision making
has not always been associated with the parallel decentralisation of finance
and budgeting. Rather, decentralisation may be associated with local health
authorities having to raise money from the local tax base and/or through the
charging of user fees in health facilities.14 In both cases, these may exacerbate
existing social and spatial inequalities (see below).
Marketisation and inequalities
A key element of neoliberal policies in relation to health care has been the
growing role of the market in both healthcare provision at all scales and in health
insurance. The growing commodification of health care is a reflection of a
number of interlocking processes: first, the inability of national governments to
provide sufficient funding, particularly in the context of Structural Adjustment
Programmes (SAPs) or the more recent Poverty Reduction Strategy Papers
(PRSPs); second, the view that state healthcare provision is usually inefficient—
both in resource terms and in providing a good service to patients—has led to a
belief in the market as an impartial and efficient arbiter of service provision;15
and, third, the growing discourse of patients as consumers, linked to neoliberal
ideas around individualisation and the importance of individual choice in
allowing people to improve their own life chances.
Such policies have led to the greater use of user charges for clinic visits and
medicines, as well as to shifts in health insurance schemes (where they existed)
from social security schemes partly funded by government towards greater
private sector involvement. As was found in relation to SAPs,16 health reform
policies have increasingly included basic health provision for the very poorest in
the form of a guaranteed basket of basic health services, usually including
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KATIE WILLIS & SORAYYA KHAN
childhood inoculations and information about common diseases such as
malaria (where appropriate). The introduction of such provision is a recognition
of how market-driven health care excludes large sections of the population
based on income. A more recent trend in many parts of the global South,
including Latin America and sub-Saharan Africa, is to expand health insurance
schemes to include economically poorer or informally employed individuals.
The role of the government in health expenditure differs both between and
within Latin America and sub-Saharan Africa (see Table 1). There is no clear
pattern. This reflects the range of situations and alternative sources of
healthcare expenditure as it is much more complex than a government/
market dichotomy. In some cases, such as Cuba, government spending as a
percentage of total health expenditure reflects state commitment to health
provision for the entire population. However, in most cases high shares of
health expenditure coming from government represent overall low levels of
expenditure by state, market, community and individual sources.
The role of non-governmental organisations (NGOs) in providing healthcare
services has grown significantly as a response both to the withdrawal of the state
from formal provision, and the growth of large donors within the health sector
who channel funds through national and local NGOs, as well as through
national governments. The importance of NGOs is also interpreted as increasing
the potential for democratisation and participation for local service users,
despite the evidence that NGOs are not inherently participatory and often
reinforce existing inequalities at a community level.17
The remainder of the paper considers these broad themes within the
context of Latin America and sub-Saharan Africa. While these trends are
apparent in both regions, the implementation and impact of health reforms
differ widely.
Perspectives from Latin America
In general Latin American health and social security systems have been viewed
as more extensive and inclusive than equivalent systems in most other parts of
the global South. However, as part of neoliberal restructuring policies, state
health provision and insurance throughout the continent are being reconstituted to increase the role of the private sector. Reform in the health sector is
not new in Latin America as change has always occurred.18 However, it is
important to recognise the extent of this change in the past 20 years and how the
changes have been packaged under a heading of ‘reform’.
Health reform in Latin America and the Caribbean has been a key focus of
external assistance in health, both in terms of funding and technical support.
For example, 35% of OECD health aid to Latin America and the Caribbean
during 1998–2000 was targeted towards ‘health policy and administrative
management’, compared with 29% for all aid recipients.19 Health sector
reform at a government level takes place within a discourse of promoting
‘health for all’. The language clearly resonates with neoliberal perspectives on
resources. For example, Dr Héctor Acuña (Chair of the Pan American
Health Organization (PAHO) in the 1970s and 1980s) stated:
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HEALTH REFORM IN LATIN AMERICA AND AFRICA
TABLE 1. Health indicators for selected Latin American and sub-Saharan Africa
countries
Latin America
Argentina
Bolivia
Brazil
Chile
Colombia
Cuba
Dominican Republic
Ecuador
El Salvador
Guatemala
Honduras
Mexico
Nicaragua
Peru
Uruguay
Venezuela
Sub-Saharan Africa
Angola
Botswana
Cote D’Ivoire
Equatorial Guinea
Ethiopia
Ghana
Guinea
Kenya
Lesotho
Malawi
Mali
Mozambique
Nigeria
Sierra Leone
South Africa
Tanzania
Zambia
General government
expenditure on health as %
of total expenditure on health, 2006
Physicians per
1000 people, 2000–04
45.5
62.8
47.9
52.7
85.4
90.1
31.2
43.6
58.7
37.7
47.8
43.3
54.7
57.1
43.5
49.5
n.a
12.0
12.0
11.0
14.0
59.0
19.0
15.0
12.0
9.0a
6.0
20.0
na
12.0a
37.0
19.0
86.6
53.3
23.0
78.3
60.4
36.5
12.3
48.2
61.6
72.1
51.7
69.4
30.1
49.0
41.9
59.2
46.8
51.0
4.0
1.0
3.0
51.0
2.0
1.0
1.0
51.0
51.0
51.0
51.0
3.0
51.0
8.0
51.0
1.0
Note: a 1999 data.
Source: World Health Organisation Statistical Information System, at www.who.int/whosis/database,
accessed 10 March 2009.
The challenge of achieving the goal of health for all will require the unflagging
commitment of governments, the allocation of required resources, and the
reform and restructuring of health systems in order to obtain maximum equity,
efficiency and effectiveness.20
Within the region healthcare provision as part of a welfare state has been
achieved in only five countries. Cuba is the only one which has achieved
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KATIE WILLIS & SORAYYA KHAN
universal coverage, while access has been partial in Argentina, Chile, Costa
Rica and Uruguay.21 In other parts of the region health care has been
provided by the state to different degrees. Access to such health care has,
however, been greatly limited by income, leading to inequalities between
rural and urban areas, between class groups in towns and cities, by gender
and between ethnic groups. In all cases, apart from Cuba, these systems have
experienced reforms since the 1980s which are broadly identifiable as fitting
into a neoliberal agenda. While these reforms have been conducted within a
discourse of promoting equity and participation, this has rarely been the case
in practice.
Decentralisation
In most countries in the region decentralisation in the health sector has been
implemented alongside decentralisation in other spheres as part of a general
goal to promote efficiency and participation. In Mexico health reform started
in 1989 and decentralisation of health as well as education services was
completed in 1997.22 However, in Mexico, as in other parts of Latin America,
decentralisation took place within certain limits; most notably, while
decision-making power and responsibility was transposed to state and
municipal levels, funding did not always follow.
Decentralisation in Chile has had the longest history, dating from attempts
under the Pinochet regime in 1974–75 to move responsibility for service
provision away from the national to the sub-national level. In 1980 the
responsibility for primary health care was given to municipal authorities,
with health professionals being employed by those authorities. This took
place within a system of mandatory health insurance with FONASA, the public
sector health financing institution, being the main provider. Jasmine
Gideon’s research in a low-income district of Santiago highlights how the
system failed to provide the equitable and quality service which decentralisation promised. The main problems were insufficient funds, as the entire
national healthcare budget was not decentralised, there was a lack of staff
(both medical and administrative) and local decision making regarding the
level of user fees was constrained. Thus decentralisation came with increased
responsibilities for the municipal authorities but often without the freedom
and economic resources to deliver. An additional problem was the use of the
public sector facilities by users who were registered for private health care
through ISAPRES, the organisation of private health insurance companies.23
The national health system (Sistema Único de Saúde, SUS) in Brazil has had
similar diverse outcomes in the government’s attempts to develop a universal
health service based on individuals’ rights as citizens. Developed in the postmilitary dictatorship period of the 1980s and in response to grassroots
activist campaigns for health reform, the SUS involved the almost complete
decentralisation of primary healthcare provision to municipalities by 2002
from a position of only 25% municipal control in 1994. Health councils
(conselhos de saúde) at state and municipal levels include user and service
provider representatives, as well as state officials. These then feed into larger
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HEALTH REFORM IN LATIN AMERICA AND AFRICA
scale health conferences, with national health conferences involving representation from throughout the country. While these processes of decentralisation
have resulted in much greater debate around health provision and participation
by a broader range of people, including women, indigenous peoples and AfroBrazilians, existing problems of clientelism, bureaucratisation and power
inequalities remain.24
The setting up of the SUS in Brazil was partly driven by non-governmental
activist movements mobilising around community health concerns and the
need for health reform. In Latin America, as elsewhere in the global South,
NGOs have been viewed as key actors in health provision in decentralised
systems.25 Both local and international NGOs in the region tend to focus their
activities on certain illnesses (such as malaria and HIV/AIDS) or particular
populations, most notably mothers of young children and indigenous
populations.26 NGO activity in the health sector varies greatly across the
region because of factors such as the state of official healthcare provision,
funding availability and the nature of civil society. While NGOs can make
important interventions to improve the health status of marginal populations,
they sometimes rely on the unpaid or undervalued contributions of community
members, usually women.27
User fees and insurance
The pattern of health expenditures across the region varies greatly (see Table
1), but there is agreement that out-of-pocket expenses by individuals at the
point of service is the least desirable form of expenditure. As user fees rise,
without appropriate safety nets for the poorest and most marginalised sectors
of society, health sector reform will exacerbate inequalities within what is
already the most income-unequal region of the world.28 For example, at the
start of the 1990s public expenditure represented 58% of total health
spending in Mexico, with 40% from households and 2% from private
insurance companies. Less than a decade later the figures were 52% from
households, 46% from public spending and 5.7% from private insurance.29
Promoting health insurance schemes to cover both regular and emergency
health care has become a key focus of Latin American government policy
and has also begun to receive significant attention in sub-Saharan Africa (see
below) and other parts of the global South. Mexico’s Seguro Popular and
Chile’s Plan AUGE are particular high-profile examples which will be
considered in more depth below.
Seguro Popular (‘Popular insurance’) is part of the Sistema de Protección
Social en Salud or System for Social Protection in Health (SSPH) scheme
which was piloted in Mexico in 2001–03 and was then rolled out across the
country. Under the Seguro Popular scheme, insurance covers 94 medical
interventions at both primary and secondary care levels, so it is much more
comprehensive than the safety net coverage which exists to provide 18 medical
services for free to the very poorest households. The aim of Seguro Popular is
to provide coverage to the roughly 50% of the Mexican population not
currently covered by insurance (provided through the state schemes for
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KATIE WILLIS & SORAYYA KHAN
public sector workers (ISSSTE) or private sector workers (IMSS) or through
private sector provision). Premiums are based on financial capacity, with the
first and second income deciles not paying anything.30 This is trying to move
away from the user fees system which went before and had resulted in the
exclusion of the economically poor from formal health care, or in households
being forced to use savings on emergency health treatment, with longer-term
implications for vulnerability.
Seguro Popular has been successfully taken up across the country, with
significant differences (see Table 2). For example, in Oaxaca State, one of the
poorest states in the country, in 2005 28.7% of the population was covered by a
form of health insurance, with just over a third of these having Seguro Popular.
For the country as a whole, over 50% were already insured and Seguro Popular
only accounted for 20% of these beneficiaries. The government’s aim is to have
universal coverage through Seguro Popular by the end of 2010.
In Mexico, as in a number of other Latin American countries, conditional
cash transfer payments have become an increasingly important dimension in
social policy. The Oportunidades programme is targeted at the poorest
households, with payments being given to women if they ensure that their
children attend school and they attend appropriate health and nutrition
workshops.31 In 2005 over 50% of Oaxaca state’s population had access to
health care through this scheme (see Table 2). Most beneficiaries of the
programme are found in rural areas, as this is where income poverty is
disproportionately concentrated.32 Similar cash transfer programmes in the
region include Bolsa Familia in Brazil, Red de Protección Social in Nicaragua
and Juntos in Peru.33
The targeting of women as recipients of cash transfers in such schemes
reflects both an assumption that it is women who are largely responsible for
family health and the care of children, as well as attempts to empower women
by providing funds and training.34 However, within the broader field of social
policy, and particularly reforms in health insurance, an awareness of
gendered processes has often been lacking, leading to the exclusion or
marginalisation of women. For example, Chile’s Plan Acceso Universal con
TABLE 2. Health sector use by insurance status, Mexico and Oaxaca State, 2005
Insured
IMSS
ISSSTE
Seguro Popular
Other institutions
Non-insured
SSA
IMSS–Oportunidades
Others
Source:
998
INEGI,
Mexico (%)
Oaxaca State (%)
56.1
62.8
12.9
20.4
3.9
43.6
76.2
23.0
0.8
28.7
39.5
22.2
33.8
4.4
71.3
48.2
51.8
0.0
Anuario Estadı´stica, Oaxaca Tomo I, Mexico City:
INEGI,
2006, Table 2.4.1.
HEALTH REFORM IN LATIN AMERICA AND AFRICA
Garantias Explicitas en Salud (Universal Access and Explicit Guarantees in
Health Plan—Plan AUGE) is an attempt to ensure that the diagnosis and
treatment of a number of specified health conditions (currently 56) is covered
regardless of whether patients have public or private sector insurance (see
above). Plan AUGE is not based explicitly on a male breadwinner/female
homemaker distinction, but it still has important gendered impacts, not least
the need for unpaid care of patients, which would usually be carried out by
women.35
Perspectives from sub-Saharan Africa
The trend towards decentralisation within healthcare provision in subSaharan Africa has been supported by donors as a key strategy for good
governance and as a pragmatic response combined with neoliberal economic
policies to encourage international healthcare reform since the 1980s.36 In
1987 WHO and UNICEF sponsored the Bamako Initiative, which called for the
decentralisation of the public health systems and strengthening of community
participation in health and included suggestions for cost-recovery programmes at the community level, via the establishment of user fees for
services and essential drugs and revolving drug funds. However, its lack of
comprehensiveness has resulted in limited effects.
In assessing the impacts of health sector reform, a variety of elements need
to be considered, such as how reforms have influenced provider and user
behaviour, patterns of service provision and whether these have improved
services by extending health coverage and raising quality.37
In most parts of sub-Saharan Africa decentralisation of government to
local communities has led to the decentralisation of health services, with the
aim of bringing greater efficiency in local governance in the periphery.
Examples from Botswana and Senegal38 suggest that decentralisation
brought the ‘government closer to the governed’ through increased and
more effective community involvement in their own welfare, improved
intersectoral collaboration and faster and more appropriate handling of
administrative problems, although the structures used differed. In Botswana
community involvement was facilitated by existing structures at district level,
including district councils, village development committees and family
welfare educators,39 while in Senegal community involvement was centred
on health committees, which were given responsibility to gather and utilise
resources to improve the quality of care in health facilities.40 In Ghana
management and decision-making functions have also been transferred to the
local level, leading to management and technical efficiencies where
appropriate training was provided to facilitate the move from a centralised
system.41
However, such reforms have not been without obstacles. These have
included opposition by health personnel, lack of qualified personnel to
implement reform, the inability of management committees to ensure efficient
management of health centres, and scarcity of resources through the lack of
both financial and skills transfer to the local level to ensure effective delivery
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KATIE WILLIS & SORAYYA KHAN
of primary health care. These obstacles have wide resonance in West Africa,
and studies have been conducted to see the impact of such schemes in several
countries in the region.42
Decentralisation, structural adjustment and their impact on health
Sahn and Bernier also question whether the process of structural adjustment
has improved the quality and quantity of vital services, improved economic
well-being of households, thereby increasing demand for health care, and
enhanced the environment for the private sector as a provider of health
care.43 They suggest that these are three aspects that reform must enhance for
it to improve health.
The introduction of user fees as a result of the Bamako Initiative of
primary health care in 1987 has led to mixed results in terms of healthcare
utilisation among the most deprived and vulnerable sections of the
populations of many African countries. Charging fees for service at the
point of delivery has meant that many of those most in need of care do not
access the health services because of the financial burden placed on their
already meagre subsistence livelihoods. In Mali, for example, many pregnant
women do not visit the health centre not only because of the cost of transport
to the facility, but also because of the subsequent charges for service and
prescriptions. Similarly, in other parts of Africa, user fees have led to a
decrease in health service utilisation, where an already existing paucity of
health care has had a negative impact on overall health of communities.44
There has been considerable discussion between governments, multilateral
and bilateral agencies and advocacy groups on whether user fees in the health
services in developing countries should be abolished.45 An experiment in the
elimination of user fees from first-level government health facilities in
Uganda in March 2001 led to a much more rapid increase in the utilisation
rate of health services among the poor than by the non-poor. While the
utilisation rate increased, the incidence of health expenditure did not fall,
possibly because of the frequent unavailability of drugs at government
pharmacies forcing patients to purchase these from private providers, as well
as increased informal payments to health workers to offset lost revenue from
fees.
However, there are studies which suggest that, where the introduction of
user fees is matched by an improvement in quality of service, increased health
service utilisation occurs, for example in Cameroon and Senegal. In the
Adamaoua province of Cameroon this was investigated though household
surveys before and after the introduction of a scheme involving user fees and
quality improvement measures, using communities excluded from the scheme
as a control.46 User fees in primary healthcare facilities in Pikine in the
suburbs of Dakar, Senegal were also associated with increases in utilisation in
the 1980s, from rates as low as 5% to around 60% in most districts. A safety
net of free provision was provided for some particularly vulnerable
individuals, such as blind people and widows. The introduction of fees was
accompanied by the setting up of an elected community health committee.47
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HEALTH REFORM IN LATIN AMERICA AND AFRICA
Health insurance schemes
Mutual health organisations (MHOs) are voluntary membership organisations
providing health insurance to their members to improve access to health
care.48 Such schemes have arisen out of a need to improve health service
utilisation rates and as a means for providing financial risk protection.49
The concept of mutual health insurance schemes aims to increase the
availability of resources and to enhance the quality and reliability of services,
thus making health workers become more accountable to their ‘clients’.50
The recent growth of such insurance schemes throughout West Africa has
enabled rural populations to access health care by reducing out-of-pocket
expenses faced by households.51 Such organisations, known as tontines
(revolving savings groups) and mutuelles de sante´ in parts of francophone
West Africa, have resulted in more people seeking health care, particularly
in Ghana and Mali, for modern curative treatments. However, some
countries, such as Burkina Faso, offer some of its state employees social
health insurance through national social security funds. The provision of
such insurance schemes inevitably leaves out a significant proportion of the
rural population who are not public sector employees. More broadly such
health insurance schemes are being advocated as a viable alternative to user
fees in developing countries, as in the Latin American examples discussed
earlier, and recent studies have shown the positive impact of such
mechanisms on health service utilisation.52 However, measuring equity in
access and utilisation of health care remains an important further research
area.53
Health insurance schemes in East Africa are not widely established.
However, a number of studies elucidates similar issues with enrolment levels
in Uganda and Sudan: mixed understanding of the basic principles of
community health insurance, lack of good information, poor quality of
health care, problems in ability to pay premiums and lack of trust.54 Some
schemes are also too rigid in their regulations for people to feel comfortable
in joining.
Awareness raising in health insurance schemes is taking place in Mali,
where a few such schemes have recently begun forming part of the national
health policy.55 There are two main actors in the health insurance arena.56
The first includes the technical services of the social development department
at the regional level and the health service at the district level (Centre de
Santé de Référence—CSREF). Information is disseminated by the technical
staff in the villages on what health insurance schemes are and the advantages
of joining such a scheme.
The second actor is the national Union Technique de la Mutualité (UTM),
created in 1998,57 to which certain schemes adhere and which serves as a
national umbrella organisation. In such schemes there is household
membership which allows each member to benefit from belonging to such
insurance schemes, where the UTM covers 75% of the costs with 25% borne
by the patient’s household. However, membership may only be affordable for
certain sections of the population.
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KATIE WILLIS & SORAYYA KHAN
Another such scheme is the MiPromo—mutuelle interprofessionelle de
Mopti, where salaried employees benefit from a health insurance scheme.
However, despite efforts to disseminate the virtues of health insurance
schemes widely, membership has been low as it depends on capacity to pay.
Even in the district of Bamako and the regions of Sikasso and Ségou, where
there are more established health insurance schemes than in other regions in
Mali, membership levels are not very high. Various explanations are likely:
the level of understanding of health insurance and the uncertainty of the
future inhibits people from joining where daily income is more important
than saving for the future. In addition, where there is only one chief earner
who has to bear the cost of each family member, this impedes joining health
insurance schemes. Furthermore, there is a lack of confidence in the
management of such schemes;58 communities’ lack of trust in office bearers
echoing to feelings towards village-based organisations which are run on
similar lines.
The lack of enrolment in such schemes may also reflect cultural reticence
on the part of the communities. Where health is not seen as a priority,
enrolment in such schemes remains low, particularly in rural areas. However,
the average number of members per health insurance scheme is about 200.59
A study by De Allegri et al carried out in the Nouna district of Burkina Faso
in 2004, highlights the importance of taking into account consumer
preferences and decision-making factors in enrolling in community health
insurance programmes which may lead to increased participation rates
in the schemes. 60
Conclusions
In this paper we have outlined key dimensions of health sector reform which
are often bundled together under the heading of ‘neoliberalism’. The reform
policies and processes experienced in both Latin America and sub-Saharan
Africa share some characteristics, most notably a reduction in state provision
of health care, growing private sector healthcare and health insurance
services, and an increase in the charging of user fees and in attempts to
expand insurance schemes to the most marginal. However, the ways in which
these policies have been implemented and their impacts differ widely.
Despite political and activist rhetoric to the contrary, the outcomes of
health sector reforms can rarely be pre-judged as either positive or negative in
social justice or equity terms. Instead, the impacts of reforms need to be
examined within the broader context of existing healthcare provision,
poverty levels and capacity (to both manage and provide health services). In
addition, while attempts to promote community participation in health
service decisions and provision have been effective in a number of cases, often
decentralisation leads to a reinforcement of existing inequalities and power
relations.
Finally, given the nature of change in healthcare provision in both Latin
America and sub-Saharan Africa, and the importance of context, future
research needs to examine how policy changes operate in particular
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HEALTH REFORM IN LATIN AMERICA AND AFRICA
situations. This will be of immense importance in examining the impacts of
the growing number of ‘popular’ or ‘community’ insurance schemes in both
regions. The challenges of implementing such policies and ensuring growing
social equity remain significant. The global economic crisis of 2008 onwards
has added pressure to existing systems of healthcare provision and new and
innovative forms of healthcare support for poor and marginal groups will be
in even greater demand.
Notes
The research on which this paper is based was partly funded by The British Academy (Willis), the
University of London Central Research Fund and The Helen Shackleton Fund, Royal Holloway,
University of London (Khan).
1 See, for example, K England & K Ward (eds), Neoliberalization: States, Networks and Peoples, Oxford:
Blackwell, 2007; and A Smith, A Stenning & K Willis (eds), Social Justice and Neoliberalism: Global
Perspectives, London: Zed Books, 2008.
2 See www.undp.org for further information on the calculation of the Human Development Index (HDI).
3 MDGs 4, 5 and 6 explicitly refer to health: MDG 4 ‘Reduce child mortality’; MDG 5 ‘Improve maternal
health’; MDG 6 ‘Combat HIV/AIDS, malaria and other diseases’. Other MDGs, most notably MDG 8 on
global partnerships for development, also include health-related aspects.
4 A Sen, Development as Freedom, Oxford: Oxford University Press, 1999.
5 The concept of ‘formal health care’ usually refers to health care provided in or through hospitals and
clinics based on ‘Western’ biomedical health traditions. ‘Informal’ healthcare provision may include
informal trading of pharmaceuticals and self-diagnosis, or health-seeking behaviour based on nonbiomedical approaches to health, such as those using what are classified as ‘traditional’ or ‘alternative’
medicines or therapies. However, the distinction is often difficult to make. For example, in the state of
Oaxaca, Mexico, in 2001 Article 16 of the Ley de Derechos de los pueblos y comunidades en el estado de
Oaxaca, ‘traditional medicine’ and its practitioners were granted the same legal status as ‘Western’
medicine by the state legislature. This was meant to lead to increased financial support for ‘traditional
medicine’ but this has been limited, despite the efforts of organisations such as the Comisión Nacional
para el Desarrollo de los Pueblos Indı́genas (National Commission for the Development of Indigenous
Populations—CDI) and the Consejo Estatal de Médicos Tradicionales de Oaxaca (State Council of
Traditional Healers of Oaxaca—CEMITO).
6 T Evans, ‘A human right to health?’, Third World Quarterly, 23 (2), 2002, pp 197–215; and P Farmer,
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7 See http://www.who.int/hpr/NPH/docs/declaration_almaata.pdf.
8 See K Sen (ed), Restructuring Health Services: Changing Contexts & Comparative Perspectives,
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18 C Abel & P Lloyd-Sherlock, ‘Health policy in Latin America: themes, trends and challenges’, in
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Notes on Contributors
Katie Willis is Reader in Development Geography and Director of the Centre
for Developing Areas Research (CEDAR) at Royal Holloway, University of
London. Her publications include Geographies of Developing Areas: The
Global South in a Changing World (with Glyn Williams & Paula Meth, 2009)
and Social Justice and Neoliberalism: Global Perspectives (as co-editor with
Adrian Smith & Alison Stenning, 2008). She is editor of Geoforum and of
International Development Planning Review. Sorayya Khan is a doctoral
candidate in the Department of Geography at Royal Holloway, University of
London. Her research focuses on participation in the control of malaria in
West Africa, with extensive experience in social development in South Asia,
Europe and West Africa. Her interests include local governance and
participation, and public health.
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