1The last time that Politique africaine published an issue dedicated to health was in December 1987.  [1] This special report aims to fill that thirty-plus-year gap, acknowledging the considerable changes that have recently come about in public health in Africa. There has been a profound transformation in the configuration of health policies in Africa in the three decades since the previous special report on the topic, and it is this shift that provides the empirical basis for the present special report. The five articles within this volume reveal the ruptures caused by the globalization of health policies, each taking one specific issue as its starting point: universal health coverage through digital technology; performance-based financing (PBF); the fight against diabetes; universal access to antiretroviral treatment; and the supply of antimalarial drugs. In this introduction and throughout this special report, we scrutinize the development of global health,  [2] its stops and starts, its logics and contradictions. We will begin this introduction with a historical examination of the changes that have accompanied these developments, and we will then highlight three important factors that will allow us to analyze them: the ideologies behind global health; the dynamics of what has been described as the “return of the state in Africa” in the early twenty-first century; and the markets that exist alongside these new policies.

The shift toward global health in the early 2000s

2One central issue has been at the root of the series of developments that have taken place in the field of health since the late 1990s: the AIDS pandemic. The shock of the epidemic and the human cost of the disease in sub-Saharan Africa led to an international response, with a major turning point in the early 2000s.  [3] The creation in 2002 of the Global Fund to Fight AIDS, Tuberculosis and Malaria (hereinafter the Global Fund) in response to calls made by the secretary-general of the United Nations, Kofi Annan, was symbolic of this change. This new transnational actor in the field of international public health is generally held up as one of the principal embodiments of our passing into the era of global health.  [4] Global health is indeed closely associated with the emergence of new institutions and new actors, including philanthropic foundations such as the Bill & Melinda Gates Foundation, and new types of interventions led by public-private partnerships.  [5] Another important element of these changes is the considerable growth in the resources provided. Between 2002 and 2018, the Global Fund invested $27 billion in the fight against AIDS, malaria, and tuberculosis,  [6] and the Gates Foundation has a bigger annual budget than the World Health Organization (WHO).  [7] Beyond financial matters, and in collaboration with the actors involved, one key factor in global health is the definition of new health policy priorities. “Global Health can be understood as the outcome of the permanent and reciprocal influence between international relations and health problems.”  [8] Public health actors define global health in relation to what they consider to be relatively new epidemiological data. The executive committee of the Consortium of Universities for Global Health explains that “the rapid increase in speed of travel and communication, as well as the economic interdependency of all nations, has led to a new level and speed of global interconnectedness or globalization, which is a force in shaping the health of populations around the world.”  [9] This new era simultaneously represents a continuation of and a break from the notion of “international health,” which developed as part of the post-1945 world order alongside the newly created World Health Organization and was intended as a means of dealing with health matters at a supranational or multilateral level. The shift that took place at the start of the 2000s involved more than just supervision upstream of the decision-making process; it ushered in a global approach to dealing with health matters. Global health transcends national borders and links people and other living species together beyond states, continents, or regions, making particular health problems supposedly central for the whole world, in the name of security imperatives and humanitarian values.  [10]

3In the quest to make sense of these new realities, the number of social science publications on the topic of global health has grown exponentially.  [11] The analyses that the social sciences have provided on health issues in Africa have become increasingly politicized since the 1980s, especially in francophone academia. It was anthropology that blazed the trail. In his introduction to the 1987 issue of Politique africaine, Didier Fassin opened up the field of health to political questions: “Health is also, and primarily, a daily political matter for all those involved, whether as patients, therapists, or decision makers.”  [12] Thus, in the 1990s, political science followed the path set out by anthropology, concentrating initially on issues around AIDS.  [13] Adopting an understanding that differed from that offered by public health, mentioned above, these researchers tended to treat global health as an “arena” in which various actors intervene according to specific logics and objectives, where questions of power and economic concerns are of particular importance.  [14]

4Indeed, a number of actors and financial mechanisms that were “partly free of the boundaries and authority of governments”  [15] appeared, including the Global Fund and the Bill & Melinda Gates Foundation, as already mentioned. Other examples include Gavi, the Vaccine Alliance, created in 2000, and Unitaid, a Franco-Brazilian initiative set up in 2006.  [16] These new actors joined older established bodies, including nongovernmental organizations (NGOs) and bilateral and multilateral institutions, some of which expanded their activity from the start of the 2000s. These included the World Bank  [17] and American cooperation programs such as the President’s Emergency Plan for AIDS Relief (PEPFAR) and the President’s Malaria Initiative (PMI). In the face of budgetary and institutional difficulties in the 1990s, WHO repositioned itself as a strategic planner of global health initiatives, coordinating several partnerships between different types of actors. Gro Harlem Brundtland, director-general of WHO from 1998 to 2003, was the chief architect of the organization’s transition.  [18] The questions raised by these new dynamics are of especially acute importance in Africa because of the economic fragility of most of its countries and the resulting power of transnational actors.  [19] The logics of these actors, the ideologies driving them, and the relationships they maintain between one another and with the national actors in the African countries where they are active have now become subjects of research in the social sciences.

5Our goal here is not to call into question the progress that has been made on various health issues. The establishment of the Global Fund undoubtedly led to a series of breakthroughs in the treatment and prevention of HIV/AIDS, and subsequently tuberculosis and malaria.  [20] The Global Fund is estimated to have saved 22 million lives, around 70 percent of them in Africa, where AIDS-related mortality is reported to have fallen by 30 percent by the tenth anniversary of the Fund’s existence.  [21] The prevalence of the disease fell in twenty-two sub-Saharan African countries from 2000 to 2010, and there has been a significant increase in the number of people on antiretroviral treatment (ART). Significant progress has also been observed in the mortality figures for malaria, although these seem to have plateaued since 2015.  [22] In the era of global health, the new global governance of health has undoubtedly had positive effects in Africa. However, our task is to analyze the reconfiguration of this world of public health since the start of the 2000s and to highlight, beyond the advances in health care itself, the political and ideological issues generated by this reconfiguration, as well as the contradictions that have arisen and the limits of these health policies,  [23] while recognizing the role of other key players such as states and “epistemic communities.”  [24] We will develop these themes using three elements of analysis. Starting with the field of global health as it has developed since the early 2000s, this introduction will look at health policies targeting infectious and communicable diseases. But this is a fast-moving field, so, beyond these initial themes, our attention will turn—albeit in a variable way—to other health issues and arrangements, such as universal health coverage (UHC), currently a much-highlighted topic.  [25] Thus, the three elements of analysis that we propose below appear to us to be relevant (beyond the issue of communicable infections)  [26] in examining the various health policies that are currently being pursued by actors in the field of global health.

Global health, its ideology and its tools: Vertical programs, technical solutions, and new public management

6The undeniable progress that has been made in combating diseases, with the support of the Global Fund, has given rise to rich, if contradictory, debate. Criticisms have generally highlighted the fact that “vertical” programs—those targeted at a particular disease or service, which generally have their own mode of governance and specific infrastructure and are “vertically funded, managed, delivered and monitored”  [27]—have penalized so-called “integrated” policies, according to which funding, organization, and management are “integrated” into the health system as a whole. These criticisms highlight how vertical programs have upset the balance of healthcare systems.  [28] These disagreements between experts have given rise to various works on the topic and, ultimately, to a WHO working group on the impact of global health initiatives (GHIs) at the turn of the millennium. This group, which includes researchers from both the Global North and the Global South, framed a counterargument around the contention that:

7

The disease-specific investments by GHIs have produced fortuitous or planned benefits for the general strengthening of systems.  [29]

8The article by Jessica Martini, Annick Tijou Traoré, and Céline Mahieu reveals the severity of some of the criticisms regarding noncommunicable diseases, which are not the highest priorities for global health. The example of diabetes in Mali shows community organizations taking care of patients, but without being able to free up and accelerate the political response to the disease. In analyzing the configuration of the actors involved, the apparently isolated work of the various associations and health professionals serves to highlight the comparative strength of the programs established under the global health approach, which involve transnational actors and significant funding, and which have so far focused on a number of infectious and communicable diseases. Several examples illustrate the marginalization that this has caused for diseases whose response does not lie in a large-scale transnational initiative, despite the available knowledge and the pharmaceutical and therapeutic innovations that have been made. This has particularly been the case for hepatitis and cardiovascular diseases, whose prevalences and diagnostic and therapeutic tools are known.  [30] Amid the plethora of initiatives that took place in the 2000s, noncommunicable diseases such as diabetes (examined in the case of Mali by the three authors mentioned above), as well as communicable diseases such as hepatitis, have revealed global health’s soft underbelly. These conditions have been allocated very few resources compared with the three more lethal diseases (AIDS, malaria, and tuberculosis) that have been the targets of global programs, or the so-called neglected tropical diseases that have also featured on the global health agenda, albeit not so high up.  [31] As explained above, global health is currently tending to address health issues that go beyond infectious and communicable diseases, in connection with today’s major, well-publicized global issues.  [32] As well as universal health coverage, which we have already mentioned, these include antibiotic resistance and wider environmental issues under the “One Health” approach.  [33] The fact remains that the policies developed in this area broadly remain vertical in nature, involving significant funding and leaving other health issues that still merit some attention to one side.

9In addition to the question of vertical programs, two further aspects that could be said to form the global health ideology have been the focus of criticism from the social sciences. The first of these, sometimes described as the “magic bullet” policy, consists in making technical solutions available to populations (including seemingly basic yet potentially expensive items such as mosquito nets, diagnostic tests, and measuring tools), as well as supplying medicines, but without setting precise goals for improving healthcare systems or widening access to care for individuals.  [34] The second aspect regularly criticized by the social sciences is the tendency to focus on quantitatively measured effectiveness above all else. Jean-Benoît Falisse addresses this by examining the question of performance-based financing (PBF) based on the example of free health care for mothers and babies in Burundi. He highlights the constraints imposed by global health institutions, referring to “the power of procedures.”  [35] Falisse offers a contextualized critique of New Public Management in health policy in Africa, even though it has been generally successful in this particular case. This management model, which transfers practices from the private sector to the public sector, represents the alpha and the omega of health programs funded by international organizations.  [36] The situation that Falisse describes falls between the imposition of management norms and an ideology of rationalizing costs and improving efficiency. His article shows how this procedural framing can be relativized by the facts, with health staff devoting part of their working time to “monitoring and evaluation” visits, such that the fantasy of these management practices being necessary or genuinely effective can be laid bare. Recent and ongoing work on universal health coverage has generally revealed similar pitfalls.  [37]

10Focusing on the ideology of global health, social science researchers have undertaken a critical, targeted analysis of these health programs and strategies based on the “politics of simple solutions” founded on figures and performance indicators, in such a way that measurement and evaluation become ends in themselves, rather than a means to an end. The article by Martini, Tijou Traoré, and Mahieu amplifies this criticism in the case of diabetes. The disease’s complexity, its long-term implications, and the necessarily qualitative support that must be provided for patients’ behavioral changes make the disease poorly suited to the quest for short-term measurable results. As Jean-François Bayart points out, health was not the first area where New Public Management was implemented in Africa. Indeed, it became one of the chosen areas for this approach after other sectors, following structural adjustment programs (SAPs).  [38]

The return of the state in Africa: States facing global health

11Analyses of global health have tended to consider African states as “low capacity states,”  [39] with a “passive adherence”  [40] to international recommendations. These studies have not generally examined the role of states in depth, nor have they analyzed how the measures taken have impacted societies—a point that has been made by some researchers.  [41] Yet, the way in which different states have become involved in the tangle of partnerships that accompany aid initiatives reflects the historical trajectories and particular characteristics of each state.  [42] Political science research has helped to underline the individual specificities of different African states,  [43] and this special report aims to extend this by assessing a range of situations that call into question the “poly-governance” of public policy in Africa. This question is discussed in the contribution by Falisse and in the article by Martini, Tijou Traoré, and Mahieu. Further useful illustrations are found in the articles by Charlotte Pelletan and Jessica Pourraz, which deal with similar topics (state regulation of local pharmaceutical manufacturing). These writers analyze, from different perspectives, the clash between global norms and the history of national industrial policy, in South Africa and Ghana respectively. The arenas they describe reveal some rarely discussed situations in the field of health in Africa, where political, economic, and infrastructural history leads to clashes with prescribed international standards (Jessica Pourraz on Ghana) or with the state’s desire to regulate a web of pharmaceutical companies (Charlotte Pelletan on South Africa), even after all the debates sparked by the iconoclastic proclamations of the country’s heads of state in the post-Mandela era.

12Indeed, President Mandela himself admitted that he had done less to tackle the AIDS crisis than he would have liked, and his successors have not always had a positive input on the matter.  [44] By contrast, the urgency of the response by South African industrial actors is striking in the context of the regulatory tendency imposed by what Charlotte Pelletan refers to as the “soft power” of the authorities. South Africa bears witness to the complexity of the links between health indicators and the economic, social, and political factors that allow countries to maintain their equilibrium. While it is a fact that South Africa is the country with the greatest number of people living with HIV in the world, Pelletan shows how South Africa’s industrial response to AIDS is unmatched anywhere else in Africa. The country’s response has relied on an economic fabric that is rare in Africa, thanks to which South Africa, along with Botswana, now has the highest proportion of HIV-positive patients receiving antiretroviral treatment in the form of triple therapy. On Ghana, Jessica Pourraz shows how, despite strongly supporting the infrastructure of the pharmaceutical industry since independence, the state has come face to face with global health policies that are reliant on importing medicines, rather than developing the domestic industry. Quality standards and the managerial operation of transnational programs have prevailed over Ghanaian economic and industrial interests. Despite this, amid this unequal yet dynamic situation, the government has built up some room for maneuver and has at last sought to bolster its pharmaceutical production through alternative alliances and partnerships.

13When the structural adjustment programs (SAPs) came to a close at the end of the 1990s, a range of transnational actors joined states in various fields of public policy.  [45] The cursor of public policy is shifting according to the issues, sectors, and historical circumstances, and states must identify the most effective combination of relationships for each policy. Global health actors are convinced that theirs is the priority sector, whereas political science puts all the issues faced by public authorities into perspective in order to understand their choices. This special report represents one illustration among many of the continual tension between global health and public authorities—between policy and politics.  [46] It helps to explain the field of possibilities for health policy in connection with other areas. By taking into account the bijective relationship between donors and public authorities, we can avoid the stereotypes of actions being forced through or of failed African states.

14On April 27, 2001, in Abuja, Nigeria, African heads of state pledged to increase public health expenditure to at least 15 percent of their respective national budgets. However, by 2019, the Abuja Declaration was being adhered to by only seven countries: Rwanda (18.8%), Botswana (17.8%), Niger (17.8%), Malawi (17.1%), Zambia (16.4%), Burkina Faso (15.8%), and South Africa (15%). However, given the economic and demographic disparities between these countries, as well as within some countries such as Nigeria, what does the overall figure of 15 percent actually represent for the most impoverished of them? One observer in Burkina Faso sardonically but succinctly pointed out that “15 percent of nothing is nothing.”  [47] It should also be borne in mind that, when the heads of state signed the Abuja Declaration, almost all of them were emerging from a drastic austerity regime that had weakened all social sectors (health and education in particular), and they were facing a multitude of political and economic issues. On the day when the declaration was signed, the secretary-general of the United Nations, who took part in the meeting, launched the idea for the Global Fund, which became a reality less than a year later, in January 2002.  [48] In other words, when they were signing the document, the African leaders knew that they would benefit from subsidies for tackling three diseases that were undermining the health of their respective populations, and without any immediate trade-offs. The Fund and its associated pledges did not have any equivalent at the time—for education, agriculture, security, infrastructure, or indeed any other sector. Why, then, would these leaders have respected this commitment? It seemed highly likely that, given what Kofi Annan promised at the Abuja conference, this double bind would be manifested in goodwill on the part of African heads of state, including on strategy. When petitions and appeals for the Abuja commitment to be upheld were repeatedly launched by global health actors, they revealed a closed world whose completely legitimate priorities masked the multiplicity of factors that African states have to manage and address.

The markets of global health

15One common reason why global health has drawn criticism from the social sciences, although it is not always sufficiently substantiated or specifically explained among other associated processes, is that there is a commercial dimension, or even a profit-driven one for certain actors, to the policies that global health promotes.  [49] Marine Al Dahdah fully addresses this issue in her article, showing how the development of mHealth (the use of mobile phones for delivering health policy), in conjunction with mMoney (the use of mobile phones for accessing banking services) set up by private economic actors, has paved the way for new markets under the cover of health care. Al Dahdah thus demonstrates the shift from infrastructure and competences linked to care (hospitals, medical staff, access to care) to infrastructure and competences linked to the profitability of a digital platform—in other words, a transition from a public service principle to a market logic. Her study highlights the fact that, in this era of global health, transnational, national, and civil society actors are joined by private actors, whose primary objective is economic profitability. In the context of a “return to growth” among African states, these actors and the interests they represent for Africa should not be ignored.  [50]

16These global health markets can easily be brought into play for the technical solutions, such as those previously highlighted, that are prioritized as part of these health policies (e.g., mosquito nets, medicines, diagnostic tests, product quality testing, authentication measures, condoms). But the producers and distributors of such items should always be identified. The potential economic interest, for certain actors, of global health policies has mostly been highlighted in relation to medicines and pharmaceutical firms, as such products always feature in these policies: for example, mass treatment with the aim of eradicating specific diseases (such as helminthiasis and trachoma)  [51]; early intervention (“test and treat”) and an “HIV prevention revolution” in the case of AIDS  [52]; and intermittent preventive treatment for children and pregnant women to tackle seasonal malaria in the Sahel. This criticism is especially leveled at the so-called “pharmaceuticalization” of society.  [53] Even beyond medicines, there is a whole economy around global health, incorporating technical tools, as well as consultants, providers, “recipients,” and other “implementing partners,” typically in the private sector.  [54] Again, the identities of these actors and of those funding the policies should always be sought.

17Thus, through global health markets, the goal is to bring certain solutions front and center (a type of medication, rapid diagnostic tests, a piece of technology) and to use the private sector, its many and heterogenous actors, and the dynamics they create, in order to utilize market mechanisms to achieve declared public health goals (such as lowering morbidity and mortality among vulnerable populations).  [55] This raises the question—as posed in Marine Al Dahdah’s article—of whether these objectives are in fact the means rather than the end.

18Thanks to the contributions of the five articles in this special report, the elements of critical analysis of health policies in the global health era are thoroughly dissected through a specific set of questions taking into account the particular trajectories of five African states: South Africa, Kenya, Burundi, Mali, and Ghana. This set of articles hence contains examples that underpin the notion of diversity of situations in Africa, specifically in the field of health, in Southern, Central, East, and West Africa. The articles also cover a wide range of questions that are currently being addressed by global health, albeit to varying degrees: infectious diseases (such as AIDS and malaria), chronic diseases (such as diabetes), healthcare funding (universal health coverage), the functioning of healthcare facilities (through performance-based financing), and the supply of medicines (the manufacturing and/or import of antiretrovirals and artemisinin-based combination therapies). Each of these contributions assesses the innovations that have appeared, albeit not without tensions between the different actors involved, and the re-emergence of old causes, the combination of which has defined the dynamic and fluctuating nature of global health.

19This special report calls on us to speak of Africa and of health in the plural. Indeed, an analysis of health policies in Africa reveals a diversity of situations and trajectories that can be seen in a new light through the paradigm of global health, its actors, its dynamics, and its goals—both explicit and implicit. This volume allows us to address the ruptures, the advances, the promises, the failures, the successes, and the performative political discourses specific to global health. These new languages participate in a form of hegemony—that of a humanitarian, security-based, and speculative approach whose foundations and effects must be examined, along with its unthought-of aspects. Each of the articles in this special report illustrates this point. Finally, this collective work marks a continuation of the renewed assessment of public policy in African contexts, revisiting the classic paradigms of policy analysis. The African states that we examine, with their plethora of actors and in the context of globalization, provide an empirically fertile ground without parallel in the contemporary world.  [56]