The Global Financial Crisis and Access to Health Care in Africa

Joseph Mensah. Africa Today. Volume 60, Issue 3. Spring 2014.

Just when health care financing in Africa is expected to pick up due to perceptible improvements in many economies, including those of Ethiopia, Rwanda, and Angola, the global financial crisis gathers momentum for contagion. This paper examines how the financial crisis is undermining access to health care in Africa, and offers some suggestions to help improve the situation. The paper sees access as a multifaceted concept, imbued with various social, economic, and geographic characteristics. The study found that the revenue constrictions wrought by the ongoing financial crises (e.g., through reductions in donor funding, tourist bookings, and remittance to Africa) have affected the supply of health care services, put pressure on personal finances, and compelled many households to reduce their demand for formal health care services.

In the words of the Economist (2010:63), “After simmering for months, the Greek sovereign-debt crisis has boiled over.” Hope of containing the ensuing crisis had all but dissipated, with many governments scrambling to reduce its effect on their own economies as much as possible. The crisis had begun in September of 2008, when the Bush administration allowed Lehman Brothers, the American financial services powerhouse, to implode against the backdrop of an impending US election. By the summer of 2009, the worst of the fiasco had appeared to be over, but the broader economic implications were just beginning to settle in; it was around that time that the newly elected government of Greece discovered that the nation was running a deficit almost twice what the official records showed (Dickey 2012:34).

As the Greek economy went into a tailspin and investors lost confidence in its ability to recover in a timely fashion, the debt-to-GDP ratio in the PIIGS countries (Portugal, Ireland, Italy, Greece, Spain) became a source of angst and trepidation, not only for the euro zone, but also for the world economy as a whole. Now, with the euro zone shaken to its core and America badly bruised, the center of gravity of the global economy continues to shift to the BRICS (Brazil, Russia, India, China, South Africa), with countries such as Norway and Canada standing relatively unscathed, or only minimally affected, thanks to their characteristically stringent financial regulatory regimes.

Meanwhile, the stalwarts of the euro zone-notably, Germany and France-have been spearheading bailout efforts with the help of the International Monetary Fund (IMF), but investors remain openly jittery and wary of buying the debt of stricken countries. Leading the pack of proposed remedies are old-fashioned austerity measures, like the IMF’s and World Bank’s structural-adjustment programs (SAPs). The usual conditionalities in the SAPs’ arsenal, including increased taxation, removal of subsidies, and public-sector retrenchment, are already implemented or proposed for Greece and other affected countries. There is even a proposal for a 50 percent write-down on private-sector bonds, as there are discernible grumblings among Greeks for the nation to pull out of the euro and readopt the Greek drachma, with the opportunity to use currency devaluation to help resolve the crisis (Economist 2012). Others see increased productivity, efficient tax- collection systems, and the curtailment of corruption as the main antidotes. Unsurprisingly, these proposals and counterproposals are adding to the fear of a mutually reinforcing downward spiral of chronic unemployment, lower tax revenue, and a further fiscal squeeze. Nonetheless, it seems whatever the proposed solutions may be, the Greek situation is likely to get worse before it gets better, and given the extent to which the global economy is now intertwined, this crisis has the potential to draw several developed and developing countries, including many in Africa, into its detrimental vortex.

The objective of this article is to explore how the ongoing global financial crisis is potentially affecting African economies in general, and access to health care in particular, and to offer suggestions to help alleviate the adversities engendered by the situation. The emphasis on potentiality is not fortuitous, as a direct causal link between the global financial crisis on the one hand, and the state of African economies and access to health care on the other, is hard to establish, given the dearth of reliable empirical socioeconomic data across Africa. To accomplish this task, we first set the scene by way of a conceptual framework that theorizes access to health care from a multifaceted perspective. Following this, we profile the key shifts in the world economy, examine the global pattern of health care, shed light on health care financing in Africa, and examine how the financial crisis has affected access to health care in Africa. This article concludes with suggestions on the way forward for Africa, in the light of the ongoing crisis.

Theorizing Access to Health Care in Africa: A Multifaceted Approach

In the ensuing discussion, access is conceptualized as a multifaceted notion, imbued with various economic, geographic, and sociocultural characteristics. From the standpoint of economics, access to health care is seen mainly as the demand for, and supply of, health care services. It is attained when a well-informed individual has the opportunity to exercise effective demand- that is, demand backed by money-in the procurement of health care services (i.e., demand side) in a suitably resourced health care system or facility (i.e., supply side). In this economic sense, access connotes the “degree of fit” between the demand and supply sides of the health care equation (Harris et al. 2011:103). Implicit in this theorization is the assumption that health care is akin to any other commodity; however, this assumption is sharply contested by some analysts. For instance, the World Health Organization’s Commission on Social Determinants of Health contends that “health is not a tradable commodity” (2008:14): health care is a matter of human rights and social justice, a public-sector duty, which cannot be left in the hands of the market alone.

Since the degree of fit between the demand for, and supply of, health care often involves physical contact, we routinely think of access as a geo- graphic problem of overcoming the friction of physical distance. Undoubtedly, proximity or physical distance is an essential aspect of any geographic understanding of access to health care, but we must note that distance, or the friction imposed by it, is not merely physical, but also sociocultural. Thus, assuming a woman resides near a hospital and does not have to travel far to seek health care, she still needs to deal with the constrictions of sociocultural distance attributable to the ability not only to pay for care, but also to cope with the sociocultural context, the power dynamics, and red tape sur- rounding the provision of health care in that particular society. This socially informed notion of distance, or space, is not that new; it is what geographers such as Ed Soja (1980, 1989) and Doreen Massey (1984) have long popularized with their notion of sociospatial dialectics, the supposition that spatial and social processes are inherently interdependent, and any attempt to divorce one from the other amounts to the “separation of the inseparable” (Massey 1984:52).

At another level of sociological abstraction, we can conceive of access as entailing the interplay between agency and structure. Undoubtedly, access to health care brings agency, or the enactment of individual social practices, squarely against prevailing social structures. Used in this context, agency involves people’s ability to pursue health care freely and independently, with as few structural constraints as possible, while structure connotes the broader social patterns and arrangements within which the individual seeks health care. Clearly, then, one can have the wherewithal to procure health care, but if the prevailing health care structure is severely constrained by scarcities (as of health care providers or technological innovations), then accessibility becomes problematic, to put it mildly. Whether the primacy in agency-structure dualism belongs to the former or the latter has long been debated by leading social and economic theorists, from Adam Smith (1723-1790), through Karl Marx (1818-1883), to Émile Durkheim (1858-1917), and more recently by the likes of Pierre Bourdieu (1977, 1984) and Anthony Giddens (1984). Giddens, with his ingenious notion of “structuration,” has persuaded us not to give primacy to either agency or structure, and to treat them as par, with the realization that just as an agent can alter prevailing structures, the other way around is equally true. Bourdieu, for his part, used concepts such as “field” and “habitus” to show the dialectical interrelation- ships between agents and structures, a relationship in which the internal becomes externalized, just as the external is internalized. Drawing upon the works of Giddens and Bourdieu, one can conceptualize access to health care as a process caught between agency and structure, or as a process nested at the heart of the old debate between free will and determinism.

It is clear from the preceding that access to health care depends not only on individual and household factors (microdynamics) but also on broader social factors (macrodynamics). Implicitly, access involves not only internal (local or national) forces but external (international or supranational) ones. Among the factors affecting access to health care in any context is how socioeconomic and political power is distributed within and between groups, or nations, along the axes of gender, social class, race, ethnicity, geographic location, nationality, citizenship, and so forth. In many sub- Saharan African countries, including Ghana, Tanzania, and Kenya (Mensah and Oppong 2007), it is not uncommon to find disparities in the distribution of health care facilities favoring economically developed regions and urban centers at the expense of poor regions and rural areas. Additionally, intraurban disparities in the distribution of health care facilities are commonplace in large urban centers, such as Lagos, Accra, Nairobi, and Kampala (Mensah and Oppong 2007; Oppong 2001). And, because of long-standing patriarchy, access to, and utilization of, health care and medicine are generally skewed in favor of males, just as high- and middle-income households tend to have better access to care, relative to their low-income counterparts, especially where there is no social health insurance (Mensah, Oppong, and Schmidt 2010). In what follows, we highlight the key shifts in the contemporary world economic order before examining how the financial crisis has affected access to health care in Africa.

Significant Shifts in the World Economy

While several trends are underway in the global economy, our focus here is on two related ones to help contextualize our subsequent analysis of the effects of the financial crisis on the delivery of health care in Africa. These trends include a growing awareness of an unfair world order of heightened economic inequalities and a shift in the economic center of gravity, from the West (notably, Western Europe and North America) to countries in other parts of the world, especially those in Asia and Latin America.

A Sense of an Unfair World Order

Even though the political upheavals of the so-called Arab Spring in Tunisia, Algeria, Egypt, Libya, and Syria varied somewhat from the contemporaneous civil disobedience and protestations that occurred in Western cities, such as New York, London, and Toronto (dubbed the Occupy Wall Street movement), there was “a common understanding that in many ways the economic and political systems had failed and that both were fundamentally unfair” (Stiglitz 2012:ix-x). The idea that the rich keep getting richer while the poor get poorer is more or less a cliché in many countries now. With the notable exceptions of Scandinavian countries, such as Norway, Sweden, and Denmark, and a few others, like Canada and Switzerland, most governments have been unable to address the enduring problems of poverty and income inequality to any appreciable extent. Greed has practically taken the place of social justice and fairness in several countries, while promises of “change we can believe in,” à la Obama, have gone unfulfilled for years now. We thus find no less an economist than Joe Stiglitz observing that the “virtue of the market is supposed to be its efficiency. But the market is obviously not efficient” (2012:xi). How else could we have the ironic situation in America in which one finds as many homeless people on the street as there are perhaps empty homes, due mainly to the subprime financial disaster in the housing market, for instance (Stiglitz 2012:xii)?

As a corollary of these developments, economic disparities between and within nations continue to increase, despite spectacular innovations in science and technology in recent years. Billions of people continue to live in dehumanizing poverty with little access to health care in African countries such as Mali, Sierra Leone, Somalia, and Zimbabwe. In other African countries, such as Benin, Ethiopia, Niger, and Liberia, national debts have reached a point where they can hardly be repaid without completely obliterating the economies (IMF 2013), prompting Pettifor (1996) to describe the debt situation in Africa as the modern equivalent of slavery.

The growing economic inequalities are not only between rich and poor nations, or between Africa and the rest of the world, but also within the so-called developed countries. In a sobering account of the situation in the United States, Stiglitz describes how the political and economic system “has been working overtime to move money from the bottom and middle to the top” (2012:xxii), to the extent that “by 2007 the top 0.1 percent of American households had an income that was 220 times larger than the average of the bottom 90 percent … with the wealthiest one percent owning more than a third of the nation’s wealth” (2012:2). Unsurprisingly, roughly commensurate disparities in health care are evident, both between and within nations on the global scene. The renowned African development scholar Gerald Caplan notes in The Betrayal of Africa that on “every indicator, Africa is at the bottom of the world heap, with the distance between it and all other regions growing every day” (2008:37). While this may be true to some extent, especially at a higher level of generalization, it is worth stressing that Africa is highly heterogeneous with regard to its people, culture, economy, geography, and so forth, and such broad statements should always be taken with the proverbial grain of salt.

In fact, there are reasonable reasons to indicate that the socioeconomic and political situation in a number of African countries is improving. In the Harvard Business Review, Jonathan Berman enumerates “seven reasons why Africa’s time is now” (2013:34). Among these reasons are the facts that Africa has a huge market opportunity, with a fast-growing middle class with rising discretionary spending power; that Africa is increasingly becoming stable, with the number of coups d’état dropping precipitously since the early 1990s; that Africa by 2050 will have the world’s largest workforce, about 25 percent of the world’s workers; and that mobile technology in Africa is booming, employing some 3.6 million full-time workers in 2010 (2013:34-35). Other reasons cited include the facts that intra-African trade, the lowest of any region of the world, is now budding with the help of a new breed of African trade ministers and corporate executives; that 20 percent of government spending in Africa goes to education, a rate almost twice what OECD governments spend; and that Africa has the most uncultivated arable land in the world: with 60 percent “of the world’s potential farmland, Africa could become an agricultural powerhouse” (Berman 2013:35). Evidently, the human condition in Africa is improving, and it is high time the chorus of Afro-pessimism gave way to a drumbeat of Afro-optimism, for a change.

Still, when it comes to inequities in health care between Africa and the rest, or between the national haves and have-nots of the world, the social context of science and research is not helping the situation (Benatar, Daar, and Singer 2003). Notwithstanding what empiricists and logical positivists would have us believe, science has never been value neutral: it always has deep social foundations, couched in political economy and power relations. As the World Health Organization’s Commission on Health Research for Development revealed decades ago (1990), there is a gross mismatch between rich and poor countries regarding the burden of illness, on the one hand, and investment in health research, on the other. This mismatch-which later became known as the 10/90 gap-indicates that only 10 percent of the global expenditure on health research and development is devoted to the health problems that mostly affect the poorest 90 percent of the world’s population. Evidently, the questions addressed by scientists are not merely determined by the need for knowledge: “the interests of powerful nations, those who fund research[,] and perhaps even … many researchers often outweigh the interests of research subjects or society as a whole” (2003:110). Amid such inequities, it is hardly surprising that those left behind, who have little to lose, are prone to rebellion and sometimes violence, aimed at “destroying what others thoughtlessly and selfishly enjoy” (Benatar, Daar, and Singer 2003:109).

A Shift of the Global Economic Center of Gravity from the North to the South

Another remarkable feature of the global economy relates to a shift in the world economic center of gravity from the West to regions in the global South-what Ram Charam (2013) calls the Global Tilt-with the growth in gross domestic product (GDP) of Western Europe and North America lagging behind those of other regions. As a corollary, the G8 continue to lose its global sway, speeding its metamorphosis into G20 to include such non- Western European countries as South Africa, Mexico, Turkey, Saudi Arabia, Indonesia, South Korea, Brazil, Argentina, and India. Formally established in 1999, the G20 countries now represent about 80 percent of the world’s trade, and it is just a matter of time until they replace the G8 as the main economic body of wealthy nations. While the shift from the G8 to the G20 started in the late 1990s, the recent financial crisis and the concomitant downgrading of the credit ratings of many Western countries, including that of even the United States, has reinforced it.

With the ongoing financial crisis, the institutions of the Bretton Woods system have somewhat come full circle in their dealings with Europe. Originally established in 1945 to help reconstruct Europe and stabilize the world financial market following World War II, both the World Bank and the IMF have over the years shifted most of their attention to the development problems of the global South, imposing SAPs on many countries in the developing world. The stringencies of SAPs have been blamed for the persistent socioeconomic malaise in many African countries (Mensah 2006). The irony here is palpable: all the stringent SAP conditionalities now directed at European countries such as Greece, Spain, Ireland, and Portugal were originally designed for the developing countries in Africa, Asia, and Latin America. Conceivably, it is just a matter of time until IMF riots proliferate across Europe, with Africans reminiscing from afar.

Adding to the incremental decline in the economic power of the West and the rise of the BRICS is a call to establish a global reserve currency. Spearheaded by China since 2009, such a move will undoubtedly tip the balance of economic power further toward the emerging economies. The proposal is to have a currency anchored in a stable benchmark, not linked to the currency of any particular nation. The United States openly opposes this proposal, but the drumbeat continues (Economist 2011). Presently, the US dollar, the euro, the Japanese yen, the British pound sterling, and the Swiss franc act as reserve currencies; however, with more than 50 percent of global foreign-exchange reserves held in US dollars, and with China holding most of these, it is no wonder that the Chinese are getting jumpy, given the economic troubles in the United States (Economist 2011).

The Global Pattern of Health Care

Notwithstanding the extraordinary advances in science, technology, and medicine in recent years, intra- and international disparities in health and health care persist. As the WHO Commission on Social Determinants of Health noted in the preface of its final report, “we watch in wonder as life expectancy and good health continue to increase in parts of the world and in alarm as they fail to improve in others” (2008). With WHO’s success in curtailing diseases such as smallpox and guinea worm around the world, there was an understandable excitement in global health circles that perhaps most of the major diseases of our time, including tuberculosis, malaria, measles, hepatitis A-D, and cholera, could soon be eliminated. However, with the resurgence of malaria and tuberculosis in more resilient and drug- resistant forms, and the devastation of HIV/AIDS, especially among people in southern and eastern African countries (e.g., Republic of South Africa, Malawi, Kenya, Uganda, and so forth), our collective optimism is somewhat curtailed (Benatar, Daar, and Singer 2003). Gerald Caplan, writing under the pithy subheading “The Unhealthy Continent” in his The Betrayal of Africa, notes that “every week an estimated 130,000 Africans die of causes that in most cases are easily preventable,” and most of these deaths are attributed to AIDS, tuberculosis, malaria, unsafe water, respiratory illness, measles, and tetanus (2008:44-45). Communicable diseases continue to kill more people than other forms of illnesses in the developing world, and as the recent incidence of SARS and bird flu readily shows, such illnesses have no regard for national boundaries, especially in this era of globalization and time-space compression.

Since the publication of Omran’s Epidemiological Transition Model (1971), the general expectation has been that countries of the developing world, including those in Africa, will gradually move from mortality caused mainly by communicable diseases and pestilence through an age of receding pandemics before transitioning into an age of degenerative and chronic diseases. While the basic thrust of this argument remains valid, there are indications that things are getting more complicated in global health than can be sustained by a single theoretical model. In fact, chronic and degenerative diseases such as cancer, heart disease, diabetes, osteoporosis, and so forth are already becoming common in developing countries, to the extent that some scholars are even talking of a double burden of disease in Africa and other parts of the developing world (Benatar, Daar, and Singer 2003:111).

We now have a paradoxical situation, especially in advanced countries, “where for the first time in history the poor are-on average-fatter than the rich” (Wilkinson and Pickett 2010:5), with many among the poor struggling with obesity and related health problems. Undoubtedly, these trends have a lot to do with the proliferation of highly processed foods, the relentless consumption of tobacco and alcohol, and the lack of exercise among many people in developed and developing countries. People in Africa and other parts of the developing world generally have higher levels of premature mortality (WHO Commission on Social Determinants of Health 2008). At the same time, it is not the wealth of a nation per se that counts most when it comes to health outcomes, but the level of socioeconomic inequality (Stiglitz 2012; WHO Commission on Social Determinants of Health 2008; Wilkinson and Pickett 2010).

Health Care Financing in Africa

The Economist, in a special issue dubbed “The World in 2012” (2011), ranked five African countries-Libya, Angola, Niger, Ethiopia, and Rwanda-among the top ten growers in terms of rising GDP. Additionally, “Africa’s economy is growing faster than the economies of all other continents. About a third of the 54 African countries are seeing annual GDP growth of more than 6%” (Berman 2013:34) Unfortunately, just when health care financing in Africa is expected to pick up because of perceptible economic improvement, the global economic crisis seems to be gathering the momentum of contagion.

Available data indicate that while sub-Saharan Africa has 11 percent of the world’s population, it accounts for about 24 percent of the burden of diseases (measured by the loss in sickness and early mortality) and absorbs a mere 1 percent of global health care spending (Economist 2007:120). Money alone cannot solve all health care problems, but with such a small amount of it devoted to health care in Africa, it is not surprising that the levels of illness and mortality remain that high across the continent. Following the Millenniums Declaration of September 2000, with which the world community promised to help improve the human condition in poor countries, some forty-six members of the African Union (AU) met at Abuja, Nigeria, in April 2001 and pledged to boost their respective funding for health care to a mini- mum of 15 percent of government expenditure; this became known as the Abuja Declaration. At the time, the per capita median government expenditure on health from domestic sources across the AU stood at US$9.40. In a 2011 assessment of what has transpired among the AU countries in the ten years since the Abuja Declaration, the World Health Organization found (2011) that even though twenty-six out of the AU signatories of the declaration had increased the proportion of their government expenditure on health, only Tanzania had reached the targeted 15 percent. Moreover, it found that eleven countries had actually reduced their expenditure on health since 2001, with the proportion of health care spending in the other nine countries remaining virtually unchanged.

To show support for the Millennium Development Goals (MDGs) and the Abuja Declaration, the G8 nations, in their 2004 meeting at Gleneagles, United Kingdom, promised to boost their overseas development assistance (ODA) to Africa, with many of them reaffirming the promise to reach the 0.7 percent of GNI they had pledged for the attainment of the MDGs. According to WHO, the “OECD Secretariat estimated that the new pledge would increase aid from around US$80 billion in 2004 to nearly US$130 billion in 2010, at [a] 2004 constant price”; however in 2009, the actual net bilateral ODA to Africa was only US$27 billion, and only five OECD countries had reached the 0.7 percent of GNI pledged; in fact, in 2009, ODA represented only 0.31 percent of GNI, on average, in these OECD countries-a far cry from the 0.7 percent pledged (World Health Organization 2001:3). Overall, ODA to Africa has dropped in recent years, partly as a result of the global financial crisis (Othieno 2009).

The Financial Crisis and Health Care Access in Africa

By its very nature, the global financial crisis is deleterious rather than positive for Africa. Still, the real situation on the ground is not that straight- forward to assess: it is constantly in flux, with gainers and losers changing positions, depending on the scenario being appraised. The extent to which a particular country is monetized and connected to the global financial system will invariably determine its present circumstance vis-à-vis the ongoing crisis. Add to this the characteristic volatility of the commodity market, from which many African countries derive the bulk of their national incomes, and it becomes readily apparent that categorical statements, or ironclad generalizations, are virtually out of the question in any discussion about the effects of the financial crisis on African countries. Take the case of oil, for example: when its price goes up, it triggers a chain of negative consequences for many of the African countries that import oil; however, to the oil producers (e.g., Nigeria and Angola), such a price increase amounts to a windfall in national revenue, until they also venture into the world market to purchase other goods and services and come across a price increase to their disadvantage.

Accordingly, with the usual dialectical tension among supply, demand, and price in mind, we generalize about the effects of the financial crisis only at our own peril, even though, in the abstract, we can plausibly assert that the going has not been smooth for many African countries since 2008, when the crisis began. Additional caveats are in order. First, to the extent that African economies are not as connected to the global financial market as other regions of the world (Willem te Velde 2008), one can expect the effect of the crisis on African economies to be minimized. Also, in relative terms, African countries are arguably better positioned now than a decade ago to deal with this crisis. As we saw earlier on, many countries on the continent have improved their economies in recent years, and this, together with programs such as the Heavily Indebted Poor Countries initiative, has improved the debt and foreign-exchange reserve situations of many of them (IMF 2013). How has the crisis affected the facets of the African economy- notably, its external donor funding, commodity sales, tourist industry, and remittances from abroad-in general, and access to health care on the continent in particular?

Effects of the Crisis in General

Since Africa still depends heavily on external funding for the delivery of health care, especially when it comes to the prevention and treatment of HIV/AIDS, the ongoing global financial crisis could hardly be positive. For instance, Michel Kazatchkine, executive director of the Global Fund (to fight AIDS, tuberculosis, and malaria), reported that the fund was facing a financial gap to the tune of about US$4 billion by 2010, mainly because of the crisis (Musau 2010:5). Moreover, as the works of the Economist (2012), Othieno (2009), and Willem te Velde (2008) show, ODA, foreign direct investment, and external health care support to many African countries-notably including the Democratic Republic of Congo, Benin, Liberia, and Lesotho- have come under intense pressure since the global financial crisis. The UK Department for International Development is reducing its health support for Democratic Republic of Congo, just as the Belgian Cooperation is ending its external support for that country’s HIV program (Musau 2010). Similarly, Lesotho, which has had the longest running bilateral health care aid from the government of Ireland-since 1975-through Irish Aid, is in for some cuts, while Switzerland is likewise scaling down its health care support for Benin as a result of the economic crisis (Economist 2011, 2012; Musau 2010).

Even though commodity prices remain characteristically volatile, recent data suggest that they have generally been down since the start of the financial crises. Since mid-2011, their levels have been slightly higher, and this has boosted national revenue in many exporting countries. Then again, it all depends on which commodity is at stake. Consider the case of oil again: in the immediate aftermath of the financial crisis, the world market price of oil declined by about 65 percent, from US$125.75 per barrel in 2008 to US$43.48 by January of 2009, with African oil-exporting nations-such as Nigeria, Angola, Gabon, and, more recently, Ghana and Uganda-being caught in the current of the crisis (Musau 2010:2). In Nigeria, the situation was so bad that it rendered the national budget virtually unworkable, with cuts to nearly all sectors of the economies, including health (OECD Develop- ment Center 2012). Conversely, as noted earlier on, this decline in oil price bode well for the oil-importing countries. By April of 2011, however, supply concerns attributable mainly to the Libyan civil war had forced the price back up, only to go down again following the end of the Libyan conflict and expectation of lower global demand. Yet, with an exceptionally cold winter in Europe in 2011, coupled with international sanctions against Iran and the related geopolitical tensions concerning shipping in the Strait of Hormuz, the price of oil has picked up once again, with Africa witnessing some new oil exploration across the continent in recent years. India’s biggest oil explorer, Oil and Natural Gas Corporation, is buying a 10-percent stake in an offshore gas firm in Mozambique, just as Soma Oil and Gas, a UK company, is set to explore oil and gas in Somalia (African Business 2013:4); also, the Houston-based ConocoPhillips and the Norwegian oil and gas company Statoil are investing US$3 billion in wells off the coast of Angola (African Business 2013:4).

So far, gold is among the few commodities that has seen a general upward swing in price since the start of the crisis. This is not surprising, as gold often serves as a safe haven in times like this. With Africa accounting for about a third of the world’s production of gold through countries such as Ghana, South Africa, Mali, and Tanzania, any price increase is beneficial, at least for the exporting countries (OECD Development Center 2012). Amid the global financial crisis, the situation in the gold-mining industry, as in other mining sectors, has not been entirely rosy, with large companies, such as AngloGold Ashanti, planning to cut more than four hundred jobs in its Obuasi mine in Ghana by the end of 2013 to help reduce the cost of production (Dontoh 2013:1). Even the gold-mining industry in South Africa is struggling, with companies facing rising costs of labor, diesel fuel, and electricity (Creamer 2013:1-2).

The price of copper has by and large decreased since the global financial crisis, forcing leading African producers, such as Zambia, Lesotho, and South Africa, to lay off miners and adjust their national budgets accordingly. Zambia, for one, had to lay off as many as five thousand copper miners in 2008, and with each copper mining job sustaining an estimated twenty other jobs, we can see the ultimate effects of this labor retrenchment (Musau 2010:2). Recently, in a well-researched piece, Richard Walker notes that the trouble with the African mining industry goes beyond the ongoing global financial crisis: Africa “represents what is probably the biggest continental mining resource in the world … with 40% of the world’s gold reserves, 60% of the world’s cobalt, and 90% of the world’s ‘platinum group’ of metals … and almost half of the world’s manganese” (2013:51); yet mining companies are not making money on the continent. Among the factors undermining this industry in Africa, beyond the global financial crisis, are the long-standing infrastructure deficits in most African countries, increasingly tougher labor negotiations, stringent terms and conditions for mineral ownership and exploitation, and management challenges in the industry as a whole (Walker 2013:52-53).

With regard to agricultural commodities, weakened world demand has forced many prices down, putting the budget of several African producers in peril. In the case of cocoa, the price dropped even further in 2011, after the European Union lifted its export ban against Côte d’Ivoire, the leading producer, after its national election debacle was finally resolved. In an unforgiving irony in agricultural production, the price of cocoa declined further, following a heavy rainfall-induced bumper harvest in Ghana and Cote d’Ivoire, at the time when the financial crisis had weakened demand in the main consumer countries of the West (OECD Development Center 2012). Meanwhile, since the start of the global financial crisis, food prices have been rising in several African countries, prompting public unrest in Burkina Faso, Cameroon, Mozambique, and Niger (Othieno 2009:1).

Available data show that in the early months of 2008, revenue from tourism in Africa, as elsewhere, took a dramatic hit, with cancelations of, and reductions in, tourist bookings across the board. All the leading tourist destinations in Africa-including those in Egypt, Morocco, Seychelles, Kenya, South Africa, and Gambia-reported substantial drops in tourist receipts. The highest-hit countries included Egypt and Kenya, each of which witnessed as much as a 40-percent reduction in tourism in 2008 (Musau 2010). Still, there is some evidence that tourism in Africa has been bouncing back since 2009. According to the United Nations World Tourism Organization (2010), worldwide tourism arrivals decreased by 4.3 percent between 2008 and 2009, but arrivals in Africa for the same period increased by 3 percent. By late 2010, however, international tourism had bounced back in many parts of the world, with the emerging economies taking the lead in this regard: the number of international tourist arrivals worldwide rose to 935 million between 2009 and 2010, up by nearly 7 percent, with Africa witnessing a 6-percent increase in the same period, in addition to its positive results in the preceding year (United Nations World Tourism Organization 2011).

As with tourism, remittances have been a major source of income for African countries and their households over the past decades. Still, avail- able data show that remittances to African countries are small compared to those to other regions, such as Asia and Latin America. According to the United Nations International Fund for Agricultural Development, India alone received an estimated US$30 billion worth of remittances in 2007, amounting to 2.4 percent of its GDP for that year; this was far bigger than the estimated US$19 billion that went to sub-Saharan Africa as a whole in 2007 (Barajas et al., 2010). Other noteworthy countries in this regard include China, which received US$27 billion (0.8 percent of GDP) in remittances in 2007; Mexico, US$24 billion (2.8 percent of GDP in 2007); and the Philippines, US$18.6 billion (11.6 percent of GDP in 2007).

Barajas et al. (2010) examined the effects of the ongoing global financial crisis on workers’ remittances to Africa and found that half of the countries in their African sample of forty-four had remittance-to-GDP ratios of one percent or higher in the most recent year for which they had data, and the remaining half had ratios of less than one percent. Also, twelve countries had remittance-to-GDP ratios of 5 percent or higher, with Nigeria recording the highest ratio, 10.9 percent, in 2007. Other countries with sizable ratios were Sierra Leone (9.67%), Togo (9.63%), Guinea-Bissau (9.42%), and Senegal (9.41%). Clearly, even though remittances to African countries tend to be small, when they are set in proportion to the size of the African economy, they are quite substantial, as shown by the remittance-to-GDP ratio in table 1. Not only that: remittances to African countries sometimes exceed the size of ODA, and they have been a dependable source of income for many Africans for some time now. With many African migrants relying on informal money-transfer networks, perhaps more so than other migrants, we can reasonably assume some level of underestimation of the African figures when we rely solely on remittances through the formal banking systems, as we normally do, for obvious reasons of data constraints.

Of particular interest for our present inquiry is an estimated decline in remittances to African countries of between 3 and 14 percent during 2009-2010, mainly as a result of the global financial crisis, with African immigrants in Europe being the hardest hit, relative to their counterparts within Africa (Barajas et al. 2010; World Bank 2009). At the same time, the effect of the financial crisis on remittances to Africa is expected to be far less than other regions of the world. This is mostly because, as in many economic spheres, “Africa is still relatively underdeveloped and undiversified” (Barajas et al. 2010:11) when it comes to remittances, with many countries getting the bulk of their remittances from within Africa, where most of their international migrants reside (Global Forum on Migration and Development 2012).

At the same time, with the number of African immigrants in western countries-especially France, the United Kingdom, Spain, Italy, the United States, and Canada-rising annually (World Bank 2010), the ongoing crisis is bound to have discernible negative effects on the level of remittances to Africa, more so because Africans in the West are likely to remit larger amounts of hard currency, per capita, than their counterparts within Africa, because of the obvious economic disparities between countries in the these regions.

Effects of the Crisis on Health Care

How have the demand for, and supply of, health care at both the household and national levels been affected by the global financial crisis? From the pre- ceding, we know that donor funding to several African countries has come under intense pressure since the crisis. This has invariably affected the provision of health care in countries that depend heavily on foreign aid (Willem te Velde 2008). Also, as we just saw, revenues from tourism decreased in the early years of the crisis, and they are only now beginning to pick up. More- over, even though commodity prices continue their characteristic seesaw swing in the world market, with some countries gaining and others losing, depending on the commodity in question, the preceding analysis suggests that on the whole, the effect has been negative on African economies, primarily due to weakened commodity demand from OECD countries, most of which are major importers of commodities from Africa. We have seen that remittances to the continent have decreased since the crisis, albeit to a lesser degree than elsewhere.

Put together, these downward trends in national revenue have inevitably destabilized national budgets of some African countries, including Cameroon, Niger, and Zimbabwe (Othieno 2009), and, consequently, they have affected the availability of health care practitioners, equipment, medicine, and other resources that form the health care system or structure of these countries. Such reductions in national revenue are likely to put a concomitant pressure on personal finances, forcing many individuals and households to reduce their demand for formal health services and medicine or resort to the usual alternatives, including the services of traditional healers, spiritualists, and itinerant drug vendors. Thus, once personal and house-hold finance comes under pressure as a result of stress on national budgets, people adjust their demand (or agency) to deal with the situation, one way or the other. Implicitly, then, the ongoing crisis has affected the macro- and micro-dynamics of health care in ways that exacerbate structural inequities of access, especially along the axes of gender, ethnicity, geographic location, and social class. In the final analysis, though, given that the crisis remains a moving target, it is virtually impossible to predict its ultimate effects on access to health care in Africa, in general, and by extension on the health MDGs (notably, numbers 4, 5, and 6), in particular, with any appreciable degree of certainly, especially amid the dearth of reliable economic, social, demographic, and health data across the continent.

Conclusion: Ways Forward

We have seen how the ongoing economic crisis is adversely affecting national incomes and access to health care in Africa. One of the main lessons it teaches concerns the intricacies and consequences of contemporary global interdependence. Adequate attention to this lesson in particular is long overdue. In fact, the persistent economic disparities between and within nations, the looming ecological crisis of global warming and the like, the massive international migration and refugee movements, the ever-growing dangers of diseases (such as HIV/AIDS, tuberculosis, and malaria), and more recently the proliferation of terrorism and its attendant threats have all laid bare our inherent interdependence. Add to this the advances in time-space compression innovations, especially in information and communication technologies, and it becomes apparent that our interconnectedness has come full circle in the global village. Given the pervasiveness of these trends, we can no longer approach issues of health in a narrow, nationalistic framework and expect to get any lasting and meaningful solutions.

Illnesses have become just as mobile as the humans who carry them, and obviously the communicable ones have the added, and quite inimical, capability to move from person to person with little or no regard to social class, race, ethnicity, gender, and national borders. Therefore, we need to intensify our efforts in the area of global health, couched in cosmopolitanism and global ethics. The need to develop a global state of mind with a genuine concern for other people in tackling the pressing health problem cannot be overestimated, and, as Benatar et al. (2003), for instance, demonstrate-with insights from work of Gay and Edmunds (1998)-the call for global health consciousness should not be seen from the standpoint of altruism per se, as the appeal bodes well for our own long-term self-interest as well. With the aid of a statistical model, Gay and Edmund revealed that the resources needed to prevent one carrier of hepatitis B in the United Kingdom could be used to prevent as many as four thousand in Bangladesh, of whom four might be expected to migrate to the United Kingdom. Thus, by their estimation, it would be more cost effective by about fourfold to sponsor a vaccination program for hepatitis B in Bangladesh than in the United Kingdom.

With the reduction in national incomes from the ongoing crisis comes the obvious need for a more efficient use of available health care resources, backed by evidence-based health care decision-making and surveillance systems. At the very least, African countries should strive to meet their 15-per- cent target under the Abuja Declaration as soon as possible, even though this will not be easy to accomplish. Indeed, since money is tight in nearly all the African countries, the problem becomes one of rearranging priorities, especially when one considers how much some African governments spend on their military and on personal aggrandizement. Similarly, the international donor community should live up to its pledge of financial support (0.7% of their GNI) for the attainment of the MDGs, notwithstanding the hardships wrought by the ongoing financial crisis.

Another area that deserves attention is social protection in health care. Solidarity has long been a social ethic in Africa; however, besides the purchase of auto insurance (which is generally mandatory and actively enforced), formalized insurance-be it for health, property, life, or disability-is quite uncommon in Africa. Indeed, formal health insurance is only now appearing in many African countries. Generally, Africans rely on informal, kinship, and other communal networks and associations for mutual support and solidarity during illness, bereavement, and other contingencies. Solidarity and a collective sense of the self are common in many Africa cultures. We should build on this to advocate for social health insurance, where the rich and the young end up subsidizing the poor and the old. Tanzania, Kenya, Ghana, and Rwanda already have some form of social health insurance (Mensah and Oppong 2007); we need to draw on their experience to promote such schemes in other African countries. Finally, health-related civil-society organizations, NGOs, and philanthropic organizations, including the Gates Foundation, the Clinton Foundation, UNITAID, the GAVI Alliance, and the Global Health Equity Initiative, should continue their laudable support and creativity in furthering global health initiatives in Africa and other parts of the developing world where access to basic health care has been elusive.