Public health care under pressure in sub-Saharan Africa.pdfVIP

Public health care under pressure in sub-Saharan Africa Pieter Streefland* Taking as point of departure the need for a strong public health care sector in develop- ing countries the article firstly outlines how in sub-Saharan Africa enhanced scarcity has characterized the content and quality of health care in the public sector. This has eroded the trust among the public in the government as provider of health care and guardian of public health. Secondly, it describes how workers in the public health domain have dealt with the implications of scarcity by etching out a ‘puvate’ zone in health care provision and how these informal activities need to be interpreted as “muddling through”. It also points out what are reactions of clients to a decline in public health care provision. Thirdly, it discusses the changing relation between the state as provider of health care and private sector health care provision at a time of emerging public–private partnerships. The article emphasizes the need for strong health services at basic health centre level. It is at that level that the state has to address problems of scarcity and regain public trust. It also is at that level where major long-term health policies like the imminent large-scale delivery of antiretrovirals (3by5) have to be accomplished. [Sub-Saharan Africa, public health care, public–private mix, scarcity, quality of care; 3by5] 1 Introduction The Report of the Commission on Macroeconomics and Health (CMH, Chair Jeffrey Sachs, commissioned by the World Health Organization) concludes that investing in health is an effective strategy for poverty reduction in developing countries [1]. One road towards health improvement is by way of better health care, and as a variable but considerable part of health care provision is situated in the public sector it appears crucial that this remains strong and viable. The CMH points out that public health * This is the last publication