The Impact of Structural Adjustment Programmes on the Public Health Sector: The Case of Zimbabwe
©2015
Textbook
120 Pages
Summary
Structural Adjustment Programmes of the International Monetary Fund (IMF) and World Bank (WB) were implemented as part of aid conditionality in Africa and Latin America since the 1980s. There is a wide range of literature critical of SAPs. Several debates have focused on whether the failure of SAPs was a result of the inherent weaknesses of the IMF/ WB sponsored structural adjustment or whether it was caused by structural failures of policy implementation within the African continent. The author uses the Zimbabwean case to analyze the impact of SAPs on social service sectors, in particular the public health sector.
Excerpt
Table Of Contents
vi
LIST OF TABLES
1
. Health Indicators in Zimbabwe's First Decade...4
2. Annual Earnings per Employee in Zimbabwe's Public Health Sector...61
3. Health Professionals Employed in Zimbabwe's Public Health Sector...62
vii
ACKNOWLEDGEMENTS
It is my pleasure to express my sincere gratitude to Professor Thomas
Kalinowski, for his constructive guidance throughout the course of writing this
book. I would also like to recognize the vital contributions of Professor Gabriel
Kabanda of Zimbabwe Open University who assisted in editing this book.
To my husband and the love of my life Takaindisa, I deeply appreciate
his support and genuine motivation during the course of writing this book. This
work is dedicated to my loving parents Enock and Maud Muvunzi. I thank them
for their support and for inspiring me.
viii
ABSTRACT
Structural Adjustment Programmes of the International Monetary Fund
(IMF) and World Bank (WB) were implemented as part of aid conditionality in
Africa and Latin America since the 1980s. There is a wide range of literature
critical of SAPs. Several debates have focused on whether the failure of SAPs was
a result of the inherent weaknesses of the IMF/ WB sponsored structural
adjustment or whether it was caused by structural failures of policy
implementation within the African continent. The author uses the Zimbabwean
case to analyze the impact of SAPs on social service sectors, particularly the
public health sector.
This book provides a case where the Zimbabwean health sector
demonstrated significant progress in public health delivery, and showed prospects
of further improvements before the implementation of structural adjustment
between 1990 and 2000. In this book I show that cost recovery systems and
reduced public expenditure on health led to rising costs of health services and
increased inequalities in health service provision. It also resulted in the
abandonment of critical public health programmes and consequently contributed
to poor funding for health infrastructure, maintenance, drugs and equipments.
Furthermore, retrenchments in the public health sector robbed it of critical and
well qualified staff and exacerbated brain drain. SAPs were implemented amid
public protests and demonstrations by the general public and organized interest
groups
.
This is not only because they brought negative impacts on livelihoods but
also because there were little consultations between the government and civil
society prior to their implementation.
This paper also illustrates that, to a larger extend SAPs increased
women's care burden and worsened their health situation. Household food
consumption and family health needs are responsibilities bestowed upon women
in Zimbabwe's patriarchal society. Therefore, user fees and reduction of public
health expenditure increased pressure on women to take care of the sick who
could not afford medical fees. Furthermore, rising costs of maternal health,
reduction of funds for preventive programmes and declines in public health staff
ix
had negative economic, psychological and health impacts on women.
[1]
I. INTRODUCTION
Structural Adjustment Programmes (SAPs) were implemented in over
forty countries in Africa for two decades (1980 to 2000) (World Bank 2006).
SAPs were designed by the Bretton Woods Institutions as a form of aid
conditionality (Rono 2002). SAPs generally required countries to adopt policies
such as reduction in government spending, monetary tightening, elimination of
government subsidies, privatization of state enterprises and reductions in the
barriers to trade and foreign investment (Jaunch 1999). Structural adjustment was
therefore comprised of a set of policies designed to replace state led economic
interventionism with market-based mechanisms whilst simultaneously seeking to
correct the imbalances between national income and spending (Olukoshi 2000).
SAPs were born out of the need by the Northern governments to aid
developing countries out of a debt crisis that hit mostly Africa since 1980,
following increases in oil prices in the 1970s (World Bank 2006). Thus, most
African countries were in economic crises when they adopted SAPs. A study of
SAPs in Mozambique by Hanlon (1994), Lugalla's (1996) research on the
[2]
implementation of SAPs in Tanzania, Jaunch's (1999) analysis of SAPs in
Uganda and Namibia to mention a few, all attest to the fact that these countries
were in economic crises exhibited by high external debt burden, negative GDP
growth rates, increasing poverty and declining exports.
This paper analyzes the case of Zimbabwe which implemented SAPs
from 1990 to 2000. Zimbabwe was not in a state of economic crises when SAPs
were adopted (World Bank 2004:30; Dashwood, 1996:3). Rather, the economy
was growing at an average GDP growth rate of 3.3% in the first decade of
independence, incidences of absolute poverty had declined from 75% in 1985 to
40.4% in 1989 and incidences of extreme poverty also declined from 31.3% to
16.7% during the same period (Zimbabwe Statistical Office 1999). The
implementation of SAPs was pushed therefore, by the need to accelerate the
process of economic development (for instance, to achieve a higher GDP growth
rate) and to meet the social needs of a growing population (World Bank 2004:30;
Dashwood 1996:3).
Though SAPs were adopted partly as a requirement for receiving
[3]
external financial aid, the government of Zimbabwe willingly, consistently and
persistently implemented them (according to T. Davies of World bank in an
interview; Jenkins and Night 2001). This book focuses on the impact of SAPs
on Zimbabwe's public health sector by answering two questions. Firstly, the
major question is: what explains the failures of SAPs in Zimbabwe's public health
sector? Thus, the book endeavors to compare the situation in Zimbabwe's public
health sector before, during and in some cases after the implementation of
structural adjustment measures. Secondly, what was the impact of the
implementation of SAPs in the public health sector on Zimbabwean women?
A profile of Zimbabwe's health sector shows that before the
implementation of SAPs (1980 to 1990), Zimbabwe's public health sector
performance was reasonable. Based on its socialist driven ideology at
independence (1980), the government embarked on designing programmes and
policies targeted at expanding health care to the majority of the black population.
Examples include the `Free Health for all Policy', rehabilitating and expanding
rural health centers (which increased by 58% from 1980 to 1985 according to
[4]
Dashwood 1996:36), Zimbabwe Expanded Programme on Immunization (1981),
declaration of diarrheal disease control as a national priority in 1982, Children's
Supplementary Feeding Programme, National Village Health Worker Programme
(1981), Traditional Midwives Programme (1981) and the Zimbabwe National
Family Planning Programme (1981) among other programmes and policies.
Reasonable progress was thus achieved in major health indicators as shown below:
TABLE 1: HEALTH INDICATORS IN ZIMBABWE'S FIRST DECADE
Health Indicator
1980
1989
Infant Mortality
86 per 1,000
54 per 1000
Immunization
25%
80%
Life expectancy
55 years
59years
Child Mortality
34 per 1000
23 per 1000
Source: World Bank Statistics
The adoption of SAPs in 1990 presented a change in public health
policies. Streamlining of public sector employees, privatization, user fees and
reduction of the public health grant were rolled in as driving forces of SAPs. This
book shows that each of these four components of SAPs impacted negatively on
[5]
the public health sector as illustrated by the diagram below.
FIGURE 1: Effects of SAPs on Zimbabwe's Public Health Sector
This book therefore articulates how cuts in public health grant led to
reduction of subsidies, decline in drug budget, reduced maintenance, reduction of
Privatization
Reduced
Employees
Cost
Recovery
Reduced
Public Health
Grant
z Staff shortage
z Dilapidated health infrastructure
z Inaccessibility of health services
z Inequalities in health delivery
z Shortages of medical equipment
z Shortages of drugs
z Poor service
GENDER DIMENSION
-Women's expanded care roles
-Impact on women's health and
well being
PUBLIC REACTION
-
Bitterness
-
Protests
Structural Adjustment Programmes
[6]
salaries and incentives for health personnel as well as cuts in expenditure for
public health programmes. It also shows how cost recovery led to lack of
affordability and accessibility of health by the poor, high medical costs, increased
circulation of unprescribed drugs and brain drain. Furthermore, the reduction of
public sector employees led to increased migration, lack of health staff, increased
number of unregistered practitioners and loss of qualified personnel. This paper
also demonstrates how privatization was associated with lack of incentives for
private hospitals to operate in remote areas, how it resulted in inequalities caused
by the majority poor continuously relying on public health while the rich could
access affluent private clinics and how it led to abandonment of crucial public
health programmes.
Consequently, significant declines were made in major indicators of
health and Zimbabwe failed to maintain the progress it had made in the first
decade of independence. Maternal Mortality increased from 238 per 100 000
deaths in 1994 to 1068 in 2002, infant mortality increased from 54 per 1,000 live
births in 1990 to 62.25 in 2000 while child mortality rose from 23 per 1,000 live
[7]
births in 1990 to 36 in 2000 just to mention a few health indicators.
This book further illustrates the gender dimensions of the implementation
of SAPs in Zimbabwe's public health sector by assessing their effects on women.
The prevailing gender divisions of labor in Zimbabwe's patriarchal society gives
women responsibilities over child care and household management, particularly
food provision and bestows upon them major responsibilities in health care at
household level. Reductions of public health personnel, cuts in public expenditure
and institutionalization of cost recovery which resulted as part of the
implementation of SAPs tended to increase the care roles of women as they were
expected to take care of the sick family and community members. Women's health
situation was also affected given the lack of preventive programmes to educate
them on critical health issues like breast and cervical cancer as well as
inaccessibility of maternal care caused by increased costs among other issues.
In this book I also elaborate how the public reacted to the adoption of
SAPs, particularly in the health sector. I try to explain that though the government
was eager to implement SAPs, the general population, organized interest groups
[8]
and civil society showed their bitterness against their implementation through
public protests and demonstrations.
The effects of SAPs on Zimbabwe's public health sector were analyzed
using mainly secondary data and rely heavily on qualitative research. The
available archival secondary data are collected from the databases of authoritative
government departments, published academic journals, media articles, World
Bank, World Health Organization and Zimbabwe Central Statistical Office.
Interviews were also held with a world bank expert based in Zimbabwe (Mr. T.
Davies) and the former Zimbabwean Deputy Minister for Health and Child
Welfare (1985-1992). However, the views of the World Bank and IMF regarding
the implementation of SAPs in Zimbabwe's public health sector were not
explored due to lack of detailed publications. This might be an area that needs
further research in future studies.
The book has been systematically divided into sections. In the following
section relevant literature on SAPs is analyzed. The third section provides
background information of Zimbabwe. In the fourth section, the health situation
[9]
during the pre-SAPs era is provided, articulating the major policy framework that
existed as well as describing the trends in health indicators. The fifth section looks
at the introduction of SAPs and the resultant impact on the public health sector. It
also provides an assessment of poverty trends in recognition of the fact that good
health is not only a function of good health care facilities, but poverty levels are
also vital in influencing health conditions. An assessment of the reaction of the
people towards the implementation of SAPs in the health sector is also made. The
sixth section analyses the gender dimensions of the implementation of SAPs in the
health sector. The final section summarizes the main central points of the thesis
and provides policy recommendations for the health sector.
[10]
II. LITERATURE REVIEW
Structural Adjustment Programmes were originally developed from the
`Washington Consensus', a term Williamson initially coined in 1989 to refer to
specific economic policy prescriptions that constituted the standard reform
package promoted for crises hit developing countries by International Monetary
Fund (IMF), World Bank (WB) and the United States Treasury Department
(Williamson 2004).
These policies, as indicated by Williamson (2004), included fiscal
discipline, a redirection of public expenditure priorities, tax reform, interest rate
liberalization, competitive exchange rates, trade liberalization and liberalization of
inflows of foreign direct investment, privatization, deregulation and securing
property rights. The IMF and WB adopted these policies as conditions for
providing aid to developing countries under the assumption that this would lead to
[11]
development as had been witnessed in Europe. Hence, most countries followed
these conditions across Africa and Latin America.
Walle et al. (2003) indicates the major reasons why structural adjustment
was implemented in Africa. Highlighted is the fact that the Bretton Woods
Institutions took the view that the Post Colonial African state had failed in its
developmental mission because of its excessive and counterproductive
intervention in domestic economic processes, its over-bureaucratic and excessive
size, the domination of its apparatus by clientelist networks and an urban coalition
that orients it against the rural sector, its monopolization of the main economic
levers of society with the resultant proliferation of rent seeking activities and its
over-centralization which discouraged local initiative. It is in light of these factors
that SAPs aimed at rolling back the frontiers of the state, trimming its size and
encouraging the emergence of economic rationality.
According to Walle et al. (2003) it was assumed that through the
unfettered rule of the impersonal market forces, and promoting the growth of the
[12]
private sector, there would be sustainable democracy and a better system of
governance, which would replace the neo-patrimonial structure that pervaded the
African continent and underlie public policy.
Since their inception, the major controversies surrounding Structural
Adjustment Programmes relate to the procedural framework hence the discordant
tunes about what SAPs were capable of doing or incapable of doing, and where
they failed, whether the blame lies with the donor or the recipient governments.
Answers to such conceptual issues continue to be a characteristic feature of
today's development studies. Only a few scholars highlight successes of SAPs
while the majority agrees that they were a total failure in Africa and Latin
America. However, the reasons given for their dismal performances differ as shall
be elaborated below.
The often cited cases of successful implementation of SAPs in Africa
include Ghana's economic miracle under the Provisional National Defense
Council as revealed by Kwame (1999:2), and Uganda which is cited by Ronald
[13]
(1999:83). However, Jaunch (1999:83) argues that despite some statistical
economic growth in these countries, SAPs exposed the poor by pressing severe
hardships on them and it became increasingly difficult for economic progress to
be sustained over time.
Olukoshi (1998) explains how the bank carried out comparison exercises
aimed at comparing countries with adjustment programmes to those without,
reaching the conclusion that the former did better on the whole than the later.
However, the major concern with this argument is that, entirely, no country was
able to sustain the seemingly short progress that occurred soon after the
implementation of SAPs.
One view concerning Structural Adjustment Programmes supports their
implementation as a form of aid conditionality. Morrisey (2004:162) indicates that
in general the results of aid and adjustment has been associated with declining
levels of economic growth and that success stories are the exception rather than
the rule. He, however, explains these unpleasant results in terms of the moral
[14]
hazards that led recipient governments to treat aid as a substitute for actions
viewed by the donor as developmental, rather than a means for facilitating such
actions. Dollar and Stevenson (1998:3) share the same view and further argue that
the deficiencies associated with SAPs concern the fact that the donors poured in
funds with little consideration of whether the recipient governments were
committed or not. They argue that policy based aid works and to ensure its
success, donors have to be more selective focusing only on identified reformers
and not try to create new reformers. Hence, these scholars blame the failures of
SAPs on the domestic political economic factors of recipient governments.
In support of SAPs as aid conditionality, Muuka (1998:2) argues that it is
highly legitimate for those who provide assistance and loans to take an active
interest in the design of the recipient countries' policies. Birdsall, Torre and
Caicedo (2010), draw attention to the argument that, the Washington Consensus
was fundamentally right in its principles, content and overall design. They allude
to the fact that the problems associated with the failure of reforms is that
reformers were too impatient, unreasonably expecting results to materialize
[15]
sooner than warranted and were quick to abandon them, while structural reforms
typically required long implementation and gestation periods.
Collier (2007:109-111) brought another dimension to this argument by
indicating that, the strength of the SAPs project was hindered by the fact that they
generated resistance, recipient governments lacked accountability and evaded
responsibility by blaming the donors if the reforms failed to yield results.
Moreover, he argues that no incentives for inducing both the donor and recipient
countries to produce results were put in place. Aid was based on promises to
implement reforms yet follow ups and incentives that would ensure the
implementation of such policies lacked.
The former president of the World Bank, Conable (1995:5) argues that
the failure of the magical market forces to stem Africa's economic crisis was
rooted in the African governance problems. Further noted is the assumption that,
the African situation bad as it was, would have been worse had structural
adjustment not been implemented. Taking the same line of reasoning, Olukoshi
[16]
(1998:7) incriminates the persistence of African economic crisis on widespread
slippage and lack of commitment to the reform package by the local political
elites, and describes this as the `stop- go- stop approach to adjustment'.
Contrary to the views cited above, some scholars are highly critical of
SAPs both in their content and philosophy, but however approached their views
from different angles. Some scholars believe that the Washington consensus, upon
which the basis of structural adjustment laid, was profoundly flawed. Some
attacked the whole essence of aid conditionality and others focused on the visible
impacts of the SAPs.
Bhagwati (1998:5) and Stiglitz (2006:27) both argue that the sequencing
of reforms is very essential. They believe that wrong sequencing of reforms can
rapidly wipe out gains achieved over several years. The Washington consensus
provided a set of policy prescriptions, but was silent on the sequencing. Stiglitz
(2006:28) indicates that effective reform agendas have to be carefully tailored to
[17]
individual country circumstances, both in the design and implementation
sequence.
Magumhe (2007:26) highlights the fact that SAPs were based on traditional
western economies that were not appropriate in African contexts with their limited
production possibilities and shortages of essential factors of the means of
production, skills, capital and foreign exchange. Therefore, these scholars attacked
the fact that reforms that were considered to have led to successful cases in
Europe established the basis of the policy prescriptions upon which Structural
Adjustment Programmes were based.
SAPs were also condemned as a form of aid conditionality. Killick
(1997:493), argues that SAPs as conditionality are not an effective means of
improving economic policies in recipient countries. Morrissey (2004:160)
presents this fact and further intricate that the general failure of SAPs indicates
that conditional lending is an ineffective mechanism to induce reform from
unwilling governments and an inappropriate mechanism if governments are
[18]
enthusiastic to reform. Hence, these scholars highlight that SAPs evidently failed
because they reflect high levels of aid conditionality.
Closely related to these arguments, Easterly (2006:5) focuses on the perils
of externally driven policies, describing development as a microeconomic
phenomenon that is supposed to be generated from bottom up rather than from the
planners who perceive to know everything about the recipient countries.
Furthermore, Easterly shares the same argument with Ohler et al. (2010) who
argue that recipients do not implement many of the conditions specified in the
lending agreements with international financial institutions because of the lack of
motivation and absence of monitoring mechanisms. They make reference to a
study carried out by Dreher's (2009) measuring compliance with IMF
conditionality, which found out that compliance rates were roughly 50%.
The other set of critics of SAPs refer to the devastating results that they
produced contrary to the perceived assumption that they were going to induce
growth and increased production. As indicated by Jauch (1999), SAPs meant that
[19]
most countries had to cut their budget expenditures, thereby reducing social
service provisions. He alludes to the fact that this was associated with the
privatization of social services, cuts in education and health services and
elimination of food subsidies among other things, leading to the poor and
vulnerable members of society being unable to access these services from the
private sector. Ronald (1999:4), studied the African case and concludes that SAPs
produced devastating results citing among other things external debt burdens,
heightened inequality gaps, intensification of brain drain, deepening capital flight,
weakening of balance of payments, deteriorating infrastructure, escalating
unemployment, declining agricultural productivity and worsening political and
civil strife.
Reimers (2002) articulates the issue of education expenditures during the
SAPs era in Latin America and Sub-Saharan Africa. He concludes that adjusting
countries reduced public education expenditures leading to deep cuts in teaching
materials and deterioration of the salaries of teachers. The relative number of
children enrolling for school declined and this affected girls more than boys.
[20]
Central to the argument of Reimers (2002) is the fact that the failure of adjustment
stems from the inability to include education and human resources development at
the centre of the restructuring process. Kanji and Jadowska (1993) specifically
give attention to the education sector in Zambia and conclude that increased
school fees, reduction of subsidies on education and limited poor household's
ability to educate their children among other factors immensely affected Zambia's
education sector.
AFRODAD (2007) analyses this factor, particularly looking at the case of
Malawi and elaborates how reduction of subsidies led to disconnections to basic
services, denial of basic human rights and consequently irreversible life impacts.
AFRODAD (2007) highlights the shortages in electricity, health, education and
water that pursued the implementation of SAPs and how Malawi was trapped in
the vicious cycle of deterioration of infrastructure, high system losses, high costs
and low revenue following the withdrawal of public expenditures from these vital
services.
[21]
One argument posited against SAPs has to do with the associated high
momentum that required complete turnaround in major sectors of the economy.
Rono (2002) explores the effects of SAPs on poverty in Kenya and indicates that
the reforms remained unpopular basically because they were accompanied by a
series of conditions that were harsh and rapid based on economic models that did
not fit the Kenyan social structure and conditions. He further indicates that the
pace provided by IMF and WB was too rapid and it was not possible to reform
everything over night. Furthermore, Rono (2002) concludes that SAPs increased
the gap between the poor and the rich since they did not provide any social safety
nets for the poor members of the society.
There are also several other studies that were carried out across the
African continent that led to the conclusion that SAPs had shockingly negative
impacts on the social services sectors and disproportionately affected the poor and
vulnerable sections of the society. For instance, Idemuda (1991) analyses the
Nigerian case, Steward (1992) looks at Ivory Coast, Mbilinyi (1990) at the
Tanzanian case and they reached a similar conclusion that women and children
Details
- Pages
- Type of Edition
- Erstausgabe
- Year
- 2015
- ISBN (eBook)
- 9783954896356
- ISBN (Softcover)
- 9783954891351
- File size
- 385 KB
- Language
- English
- Publication date
- 2015 (January)
- Keywords
- Politics Public Health Economics International Political Economy Economic Structural Adjustment
