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A ‘New Scramble for Africa’: TheStruggle in Sub-Saharan Africa to Setthe Terms of Global HealthSandra J. MacLean a & David R. MacLean ba Department of Political Science , Simon Fraser University ,Canadab Faculty of Health Sciences , Simon Fraser University , CanadaPublished online: 09 Jun 2009.

To cite this article: Sandra J. MacLean & David R. MacLean (2009) A ‘New Scramble for Africa’:The Struggle in Sub-Saharan Africa to Set the Terms of Global Health, The Round Table: TheCommonwealth Journal of International Affairs, 98:402, 361-371, DOI: 10.1080/00358530902895535

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A ‘New Scramble for Africa’: TheStruggle in Sub-Saharan Africa to Set theTerms of Global Health

SANDRA J. MACLEAN* AND DAVID R. MACLEAN***Department of Political Science, Simon Fraser University, Canada

**Faculty of Health Sciences, Simon Fraser University, Canada

ABSTRACT At population levels, health outcomes are determined more by social conditions thanby either biology or technological interventions. Therefore, entrenched and increasing inequalitiesassociated with global transformations in political economy are among the most significant causalfactors for so-called ‘global health’ problems that disproportionately afflict sub-SaharanAfricans. Growing attention is being paid to the social causes of ill health, as evidenced in theWHO’s recently introduced Commission on the Social Determinants of Health. However, thepredominant paradigm continues to support a biotechnical/clinical health model that privilegespharmaceutical treatment of individual diseases over support for broader social change that wouldinclude improved broadly based national health systems as well as revised international economicstructures. This paper examines the struggle involved in setting the normative framework forhealth in sub-Saharan Africa and the roles of major external actors in setting the policy agenda.

KEY WORDS: global health, sub-Saharan Africa, international actors, public–privatepartnerships, social determinants of health, disease, poverty

Introduction

According to some observers, a ‘new scramble for Africa’ is underway. Those whobelieve that we are witnessing a ‘new’ scramble see it especially in the current questfor natural resources, which echoes the exploitative energy of the earlier period of‘high’ imperialism of the late 19th and early 20th centuries, when Africa’sgeographical space and resources were divided among European powers (e.g. Lee,2006). Focusing on the recent explosion of interest in sub-Saharan African health(often now discussed under the heading of ‘global health’),1 we argue that variousactivities by a host of external actors in the health field constitute another dimensionof the ‘new scramble for Africa’. The set of external actors2 to whom we referincludes bilateral donors, international governmental organizations (IGOs) such asthe World Health Organization (WHO), the World Bank and the Organization for

Correspondence Address: Sandra J. MacLean, Department of Political Science, Simon Fraser University,

Burnaby, Canada V5A 1S6. Email: sandram@sfu.ca; David R. MacLean, Faculty of Health Sciences,

Simon Fraser University, Burnaby, Canada V5A 1S6.

The Round TableVol. 98, No. 402, 361–371, June 2009

ISSN 0035-8533 Print/1474-029X Online/09/030361-11 � 2009 The Round Table Ltd

DOI: 10.1080/00358530902895535

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Economic Cooperation and Development (OECD), influential business actorsincluding pharmaceutical companies and private (‘philanthropic’) donors such as theBill and Melinda Gates Foundation, as well as numerous global civil societyorganizations (GCSOs). It also includes combinations of these actors in public–privatepartnerships (PPPs) such as the Global Fund to fight AIDS, Tuberculosis and Malaria.

Recently, attention has been drawn, especially by the WHO, to the need to addressthe social determinants of health (SDH)3—particularly involving issues of inequalityand social gradients. Given compelling evidence that health at population levels isdetermined as much or more by social environment and relations than by geneticpredisposition or technical interventions, many of the major actors have endorsedthe WHO’s position. Yet, as we argue in this paper, for several decades, thesegovernmental and business actors have supported a neo-liberal ideology thatprivileges economic competition and exploitation, which has been reflected in thedominance of an entrepreneurially driven biomedical/clinical paradigm. Currently,despite efforts to promote a normative health framework based on the relationshipbetween health and social environment, the main emphasis of dominant externalactors in SSA continues to be on pharmaceutical solutions for a variety of infectiousdiseases (especially AIDS, TB and malaria). As a result, sub-Saharan Africa (SSA)’shealth systems are chronically under-funded and -supported, and there is scantattention paid to the social conditions that are fueling SSA’s growing burden ofchronic diseases (such as cardiovascular disease, diabetes, cancer).

The argument of the paper is not to replace the biomedical paradigm. To be sure,biomedicine and the associated pharmaceutical products are crucial to addressingthe health problems of SSA. However, the argument is that the almost exclusivefocus on this paradigm, which has been dominant since early in the 20th century,acts as a significant opportunity cost to effective intervention in the social conditionsthat influence population health. Effective control of disease (infectious and chronic)in industrialized societies is due largely to improvements in public health. Yet, thepost-Enlightenment ascendancy of scientism (encouraged by a powerful pharma-ceutical industry) has fueled acceptance of the belief that diseases are most effectivelytreated by biochemical solution. As a result, in developing countries, social needdraws considerably less large-scale donor attention.

Towards a Normative Shift in the Health Paradigm

In 1980, the United Kingdom (UK) Department of Health and Social Servicespublished a report (Black Report), which maintained that health, at least at apopulation level, was determined largely by social status and environment. Extensiveresearch over the next two decades supported the initial findings (e.g. Kawachi andKennedy, 2002). Yet, policy applications based upon these insights have beenminimal, although a normative framework is gaining ground in the North that shiftsthe emphasis from biotechnical intervention after disease develops to prevention ofdisease through change in social behavior (often supported by public policy as, forinstance, with policy on tobacco sales) and even business response (as with thedevelopment of low-fat, low-salt dietary products) (MacLean and MacLean, 2008).

In developing countries, despite some efforts to promote a similar normative shift,corresponding practices are occurring slowly, at best. This is interesting given that

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one important attempt to apply a SDH approach was directed mainly at Southernhealth. This was the World Health Organization (WHO)’s Alma Ata Declaration,released in 1978, which recommended a focus on broadly based primary health care,especially in poor countries where inadequate resources prevented the developmentof efficient tertiary care models. It also recommended a multi-sector approach since‘‘health is a most important world-wide social goal whose realization requires theaction of many other social and economic sectors in addition to the health sector’’.4

Alma Ata proved to be a failure, however, despite optimistic projections aboutachieving ‘Health for all by 2000’, and in a follow-up initiative entitled ‘Health for allin the 21st century’ (WHO, 1998), primary health care was not emphasized, andsocial determinants were largely ignored. Recently, however, support for socialdeterminants has been resurrected, and most explicitly in the launch of theCommission on the Social Determinants of Health (CSDH) in 2000. The unveiling ofthe United Nations Millennium Development Goals (MDGs) in 2000 also gave aboost to re-imaging health in terms of social determinants.5 In addition to goalsdirected specifically at health—to improve maternal and child health and toeradicate HIV/AIDS—three goals—to end poverty and hunger; provide universaleducation; and achieve gender equality—emphasize critical areas of SDH.

Sub-Saharan African health is now frequently monitored in terms of meeting theMDGs. In this regard, the WHO’s World Health Report 2008 (2008a, p. 3) assertsthat any progress towards meeting the goals in several sub-Saharan African countrieshas ‘‘stagnated or even lost ground’’. There has been some progress in the fightagainst malaria, apparently due to the increased use of insecticide-treated bed nets aswell as anti-malarial combined therapy (WHO, 2008b), and the HIV prevalence rateshave leveled off. However, the number of people living with HIV/AIDS continues togrow (UNAIDS, 2008, p. 4), and much of the other health-related news—from foodcrisis throughout the sub-continent to cholera in Zimbabwe—is grim. And, as iflingering traditional health problems were not enough, sub-Saharan Africa must nowcontend with a new problem, the so-called ‘double health burden’ where continuinghigh rates of infectious diseases are combined with growing rates of chronic diseaseincluding cardio-vascular diseases, diabetes, cancer, chronic respiratory disease andmental illness (WHO Africa Region, 2006).

WHO projects that 28 million people in the Region will die from chronic diseaseover the next 10 years. The rate of increase of deaths from chronic disease willoutstrip that from infectious diseases, maternal and perinatal conditions, andnutritional deficiencies more than four-fold in the next 10 years. Mostsignificantly, deaths from diabetes will increase by 42%. (Moeti, 2008, p. 2)

The relationship between disease and poverty is well established; it has been knownfor some time, for instance, that infectious disease rates are higher in poor countriesand regions. But, the emerging ‘double burden’ in sub-Saharan Africa provides clearevidence of the relationship between health and social change; in this case, alongwith changing demographics, factors of contemporary global political economy—movements of people and goods, changing behaviors and customs, new technolo-gies—are contributing to increased rates in chronic diseases. This evidence provides astrong rationale to address the SDH to improve health outcomes.

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According to the final report of the CSDH (2008, p. 2) the main challenges toaddressing SDHs are to ‘‘improve daily living conditions; tackle the unequaldistribution of money, power and resources; and measure and understand theproblem and access the impact of action’’. To affect action, three areas are to betargeted: surveillance and evaluation of health needs and policy impacts, nationalhealth systems and underlying political economy. These multi-dimensional objectiveswill require novel approaches to governance involving ‘‘civil society, governmentsand global institutions’’ (CSDH, 2008, p. 2). But, while the CSDH clearly outlinesthe ‘what’ that needs to be done, the ‘how’ is not absolutely clear. Therefore, themajor questions to ask involve whether or how a SDH approach can beoperationalized.

Towards Operationalizing a Social Determinants of Health Model in sub-Saharan

Africa

Surveillance and Monitoring

The CSDH notes that better surveillance and monitoring of current health situationsis key to identifying appropriate actions to improve health. Several internationalorganizations have begun to address this issue (e.g. OECD, 2005; Segone, 2008),especially since, to date, many of the interventions in sub-Saharan Africa have beenbased upon incomplete, even incorrect data. As the WHO (2008b, p. 31) points out,worldwide, ‘‘there were 78 countries without useable death registration data’’. Insome regions, ‘‘. . . no usable data source was found, and for others the latest datawere decades old. Typical uncertainty for regional prevalence estimates rangedfrom+10% to+90%, with a median value of+41%, among a subset of diseasesfor which uncertainty analysis was carried out’’ (2008b, p. 118).

Surveillance and monitoring involves more than counting the number of peoplesuccumbing to particular diseases; rather, it also involves research on the factors thataffect health outcomes. A recent Global Ministerial Forum on Research for Health(2008) called for more research on sub-Saharan African health that addresses issuesof development and equity (i.e. SDH). One aspect of the health research inequity isthe North-South ‘10–90 research gap’, in which 90% of the world’s diseases capture10% of research attention; this gap has not been significantly diminished since it wasidentified a decade ago.6 Second, a survey of the research now being conducted onsub-Saharan African health reveals that there is limited research interest in SDH;despite considerable attention now being paid to the health-social connections, theemphasis in the current research is decidedly in favor of biotechnology. Almost allmajor funders of health research—national funding agencies, the pharmaceuticalindustry and philanthropic organizations—currently register interest in ‘globalhealth’, but actually devote only a small proportion of resources to the topic.Moreover, they do not clearly define what they mean by ‘global health’, often usingthe term to describe any health issues in the South, rather than specifying onesassociated with global processes. Also, of the research that is conducted on ‘globalhealth’, however it is defined, the major proportion is focused on the biotechnicaltreatments of a few infectious diseases (MacLean and MacLean, 2009). Theemphasis on technical solution appears to be based largely on economic interests.

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For example, a 2006 UK government report on health research indicated that, whilegovernment actors were aware of pressures to provide more resources for researchon ‘‘the socio-economic burden of disease’’, their priority was to supporttranslational research (i.e. how to improve mechanisms for taking up technologicalinnovation). The report noted that ‘‘. . . emerging economies also provide newmarkets and opportunities which the UK is well placed to exploit . . .’’ (Cooksey,2006).

Promoting Effective Health Systems

The second recommendation of the CSDH is building capacity in national healthsystems. This is not a new idea, but one that has been promoted for over a decade(e.g. World Bank, 1993; Gilson and Mills, 1995). Despite efforts and good intentions,however,

. . . health systems development has been hampered by poverty; politicalinstability; poor economic performance; heavy disease burden; lack of qualifiedand experienced health workers; poor health infrastructure; low access to andquality of essential health technologies; and weak stewardship. This has sloweddown progress in attaining MDGs and other national, regional and globalinitiatives. (Ouagadougou Declaration, 2008)

Why, given that health systems have been a priority for so long, do such problemspersist? According to some analysts, the main problem lies in that health sectorreform, as part of neo-liberal structural adjustment programs in the 1980s and 1990s,involved the privatization and commercialization of health care and a seriousdenigration of health systems (Sanders et al., 2005). Healthcare services werenegatively affected during this period, partly because of the introduction of user fees,as well as the loss of health personnel to other regions. But, it is the erosion of publichealth that has been especially devastating to sub-Saharan African health (Sanderset al., 2005). Public health services include monitoring of a population’s health,disease surveillance and prevention, response to emergency health threats, settingand maintaining standards for air, water and food security as well as for workplacehealth and safety, health education and promotion; and research and evaluation ofhealth services and issues (WHO Regional Office for Europe). Sub-Saharan Africa’spopulation health statistics will not improve significantly without major improve-ments in the public health systems’ ability to provide these services, regardless ofhow extensive are the pharmaceutical interventions to treat specific diseases. Yet,although this is well-known, infectious diseases receive an immoderate share offunding. For instance, the WHO, which is one of the strongest proponents ofsupporting health systems (and SDH), has earmarked 45% for infectious diseases for2010–2011, compared with 13.4% for health services, 10.4% for research, 3.1% fornon-communicable diseases and only 1.4% for SDH (WHO, 2009).

Many scholars are worried that the skewed emphasis on pharmaceuticals versushealth systems has been exacerbated by the inordinate influence that philanthropic/business actors now exert on the health agenda. The large amount of capital that isbeing directed towards health in sub-Saharan Africa by such organizations as the Bill

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and Melinda Gates Foundation has the ability to sway the direction of research andpolicy.7 Given that the Foundation’s main emphasis to date has been on bio-technology, its ability to leverage its funds (i.e. donate to an issue on the provisionthat the sum is matched by an official organization), poses a significant opportunitycost to any actions directed at SDH. Moreover, much of the private funding isdelivered through public–private partnerships (PPPs), which are now among themost influential actors in health delivery in SSA. Most PPPs are mandated to dealwith infectious diseases; in 2004, for instance, 76 of 91 international PPPs operatingin health were so dedicated (Nishtar, 2004). Moreover, the support is usually forsingle disease initiatives (‘stovepiping’), with little attention being paid to SDH and/or health system reform (Garrett, 2007). Writing in 2005, for instance, Sanders et al.(p. 756) observed that ‘‘the Global Fund targets 49% of its expenditure on drugs andcommodities such as antiretrovirals and new antimalarials but only 20% on humanresources and training’’. And, the Global Alliance on Vaccines and Immunization(GAVI) continues to provide expensive new vaccines although existing ones havebeen distributed to only 50–60% of population (a coverage rate that has remainedconstant since 1990).

Another problem with the recent massive infusion of external funds throughprivate actors and PPPs, especially related to the fight against AIDS,8 is that it allowsa set of external actors to set the terms of health care in sub-Saharan Africa (in thiscase, in favor of biotechnical solutions). This can further erode already fragile healthsystems. As Roger England (2005, p. 565) argues, it ‘distorts countries’ efforts to dealwith their problems, because most of this new aid is delivered ‘off budget’, resultingin separate plans, operations and monitoring—all in parallel government systems.Also, health systems are further stressed by a lack of coordination among PPPs andbetween them and other health actors.

Efforts to improve this situation are underway and some are optimistic thatglobal health initiatives by PPPs and others can help to strengthen health systemsthrough such mechanisms as more direct funding, increased advocacy, and betterpolicy dialogue and alignment with recipient countries (WHO, 2006). As forcoordination, the Paris Declaration (OECD, 2005) is intended to enhancecoordination among major donors of development assistance, the InternationalHealth partnership and related initiatives that stemmed from it (IHPþ, 2007)address coordination in the health sector, while the ‘Three Ones’ Principlesestablished in 2004 is specifically directed at HIV/AIDS to address the issue ofcoordination among ‘key donors’ and between donors and country recipients offunding (UNAIDS, no date).

Some have argued that, with such measures, PPPs have already encouraged, ‘‘insome cases, an improved policy making environment, facilitated by country-levelcoordinating mechanisms’’ (UNAIDS, no date). Others, however, are sceptical. Forinstance, discussing the CCMs associated with the Global Fund to Fight AIDS,Tuberculosis and Malaria (GFATM), Sonja Bartsch (2009) argues that CCMs havenot received sufficient funding to perform the overseeing role with which they aretasked. Moreover, the CCMs, installed by external actors in a top-down process, arefurther removed from the people they are intended to serve, as civil society actors arenot widely included or even consulted (albeit in part due to the unwillingness ofgovernments in recipient countries to work with non-state actors).

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Overall, the concern is that PPPs have enough economic influence to reinforce anagenda that is ‘top–down, vertical’ as well as of a ‘narrow and technical nature’ andthat is not predisposed to ‘‘adequately tackle problems associated with capacity’’(Moran, 2009). Ultimately, the result is stovepiped responses to specific diseases,while health systems continue to be eroded. Delivering pharmaceuticals to sub-Saharan African is laudable and should be encouraged, but effective distribution ofthe drugs, as well as needed attention to the full slate of sub-Saharan Africa’s healthburden requires improved health systems. As, Sanders et al. argue, ‘‘The main dutyof the international community is to create the conditions that will allow Africa todevelop and flourish’’ (Sanders et al., 2005, p. 758).

Underlying Political Economy

The CSDH’s third recommendation for establishing a SDH approach is to correctthe underlying political economy through governance arrangements in which civilsociety, governments and international/global institutions collaborate. Again, this isnot a novel argument, and indeed, one might argue that the phenomenally rapiddevelopment of PPPs indicates that this collaborative project is well underway.However, as noted in the previous section, civil society organizations are not widelyconsulted at present, even though, as Sanders et al. point out, ‘‘. . . volunteer andcommunity health workers, supported in particular by faith based groups . . . oftenconstitute the only point of access for the poor and are an important component ofthe revitalization of African health systems’’ (2005, p. 758).

One of the main impediments to changing these dynamics is the inordinateinfluences that PPPs assert on the overall agenda. PPPs emerged as creatures ofglobal neo-liberalism with a predominately business-oriented outlook that is inimicalboth to working closely with civil societies and to addressing the inequities thatunderlie health problems in the South. According to Michael Moran, partnershipsare seen by several critics as

. . . part of a broader hegemonic shift, primarily discursive, which acts as acontinuation of the neo-liberal dominance of development theory and practice.The depoliticized language evident in much of the policy research and officialdocumentation on partnerships . . . falsely suggests that power relations withinpartnerships are equitable and benign – a kind of ‘win-win-win’ scenario inwhich all agents are party to an absolute gain. (2009)

Carmen Huckel Schneider (2009) traces the emergence of PPPs as responses towidening equity gaps associated with neo-liberalism. Organizations such as theWHO were faced with growing health problems, especially in developing countries,but with dwindling resources to respond. Also, inefficiencies and bottlenecks in thebureaucracies of international organizations such as the WHO rendered them unableto respond quickly and effectively with the immediacy of several current health issues(Martens, 2007; Buse and Walt, 2000). Laurie Garrett (2000) describes theseproblems as part of a ‘‘betrayal of trust’’ in ‘‘an age of antigovernmentalism’’. In‘‘the collapse of global public health’’ (Garrett, 2000), Alma Ata and the primaryhealth care approach failed, and as ‘‘business actors became wealthier and more

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influential [as a result of the neo-liberal formula] . . . the intergovernmental WHOneeded to seek innovative ways to ensure adequate resources’’ (Huckel Schneider,2009).

As for the increasingly influential private actors, some of the more prominentcontributors such as Gates and Buffet appear to be motivated by sincerephilanthropic ideals. It would be churlish to question their motivation, andinaccurate to deny the significant benefits to health that have resulted from theirbenefaction. However, the economic system which allowed a few individuals toincrease their wealth so that they are powerful enough to set the terms of governancein areas such as global health, is the same one that created the environment in whichgovernmental and intergovernmental (and arguably more accountable) health actorshave lost influence and capacity. It is also the system which has not necessarilycaused, but has certainly prolonged and exacerbated sub-Saharan Africa’s currenthealth crisis.

The system itself is now in crisis. The collapse of ‘casino capitalism’ lends supportto calls for a new global economic model based on neo-Keynesian principles or asGermany’s Chancellor, Angela Merkel, termed it, a ‘‘social market economy’’(Vinocur, 2008, p. 2). Yet, the prospects for this occurring in the near future are notgood. Richard Horton describes the ‘‘acute threat to health’’ of the current crisis:

The first predicament to recognize is that countries are not in a good place toweather another storm. Progress towards the Millennium Development Goalshas been slow and uneven. Inequities in health are deep and intractable. Donorfunding is unpredictable. International institutions suffer pervasive democraticdeficits—the views of low-income and middle-income countries are too oftenmarginalized or excluded. (2009, p. 355)

Conclusions: What Way Forward?

Over the last several decades neo-liberalism dominated the global economic order,exacerbating social inequalities. Throughout this period, global public health hasbeen seriously eroded and business actors have become increasingly prominent insetting the global health agenda. The prominence of the business model in this‘new scramble for Africa’ has reinforced a bio-medical paradigm that emphasizescurative care and technological interventions. Yet, in order to prevent theexacerbation of the SSA health crisis, it is imperative that more support be directedat strengthening health systems, that sub-Saharan African civil societies becomemore involved in establishing these systems and that the collapsed global economicsystem be remodeled to promote greater social equity. As the Director-General ofthe WHO, Dr Margaret Chan (2008) argued recently, such actions would producea global win-win situation. Supporting the social sector is not only necessary toprotect the most vulnerable, it also generates efficiency and is one of the most cost-effective strategies to stimulate economic recovery. Moreover, equitable distribu-tion of resources, as through policies designed to achieve heath equity, willencourage social stability and security. In the struggle to control sub-SaharanAfrica’s health, it is critical that the social determinants approach shouldultimately prevail.

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Notes

1. Global health has been defined in a variety of ways, but we understand it as health conditions in

the world that result from globalization; that is ‘‘. . . as health conditions and outcomes that are

determined by changes in relations among state, business, labor and civil society resulting

from increased interdependence and de-territorialization of social relations’’ (MacLean and Brown,

2009).

2. Certainly, various African actors play critical roles in setting health policies and norms; however, the

focus of this article is on the interests of externals actors and the roles they play in setting health

agendas on the continent.

3. The social determinants of health include social gradients, stress, health conditions and habits of early

life, social exclusion, work conditions, (un)employment, social support, addictions, food security and

type of transport. See Wilkinson and Marmot (2003).

4. The Declaration is available at www.who.int/hpr/archive/docs/almaata.html.

5. The website of the Campaign to End Poverty 2015, Millennium Development Goals is http://www.un.org/

millenniumgoals/, accessed 7 December 2008.

6. Reducing this gap was the mandate of the Global Forum for Health Research formed in 1998. A

decade later, there has been only slight improvement: ‘‘Together the G7 countries invested more than

88% of publicly funded health R&D in high-income countries (down from 92% in 2003)’’ (Burke and

Matlin, 2008, p. xvi).

7. The influence of the Gates Foundation in global health, already well established, was enhanced

significantly in 2006 with the infusion of US$37 billion from financier Warren Buffett. With assets now

of approximately US$60 billion, the Foundation’s annual donation of around US$3 billion to global

health research and aid makes it a major player in global health (Okie, 2006, p. 1084). On concerns

about the possible negative effects of the Gates Foundation influence, see Fidler (2007), Garrett (2007)

and England (2005).

8. The increase in funds has been considerable: for instance, it jumped from approxi-

mately US$2.8 billion in 2002 to an estimated US$10 billion by 2007 UNAIDS. See UNAIDS

(no date).

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