Engaged Universals: Ethnographic explorations of ‘Universal Health Coverage’ and the public good in Africa

Project Information

UNIVERSAL HEALTH

Grant agreement ID: 759820

DOI

10.3030/759820

Project closed

EC signature date 26 January 2018

Start date 1 September 2018

End date 31 August 2024

Funded under

• EXCELLENT SCIENCE - European Research Council (ERC)

Total cost

€ 1 484 797,00

EU contribution

€ 1 484 797,00

Coordinated by

UNIVERSITETET I OSLO
Norway

Periodic Reporting for period 4 - UNIVERSAL HEALTH (Engaged Universals: Ethnographic explorations of ‘Universal Health Coverage’ and the public good in Africa)

Reporting period: 2023-03-01 to 2024-08-31

Summary of the context and overall objectives of the project

UNIVERSAL HEALTH is an anthropological project that follows policies and reforms, dreams and aspirations concerning the creation of more equitable health systems in Africa, paying particular attention to the social and political collectives forming around struggles for public health, through ethnographic and historical research in five African countries: Kenya, Tanzania, Zambia, Ghana and Madagascar.
Defined by the WHO as ensuring that “all people can use the health services they need without financial hardship”, Universal Health Coverage (UHC) figures prominently in the 2015 Sustainable Development Goals and approaches public health as a matter of justice, obligation, equity and solidarity. In African countries, moves towards UHC appear to represent new ways of thinking about poverty and redistribution, the state and citizenship, healthcare and development, reflecting turns towards greater state responsibility for welfare and social protection in the Global South.
Our project employed anthropology and history to situate UHC reforms within neoliberalism and late capitalism and the complex frameworks of governmentality in postcolonial Africa and global health. Here, the state is not a predictable, monolithic power; transnational agents are creating enclaves; colonial and post-colonial legacies of hierarchical exclusions exist alongside new regimes of consumer choice and patient’s rights; and private healthcare is emerging as a lucrative market for global investors. Amidst continuing austerity in public health, hopes for universal health coverage are being translated into the provision of limited services, offering a minimalist biopolitics of care. The evisceration of public healthcare is driving the expansion of private healthcare markets catering to a growing middle class.
Approaching UHC not as a universal model but a contested field, UNIVERSAL HEALTH explored frictions surrounding questions of universality, equity, solidarity, and responsibility as they took shape in different sites, asking: 1) How do moves towards UHC engage with the role and responsibility of the state towards its citizens? 2) How do actors at national and local levels approach the concept of health as a ‘public good’? 3) How does UHC intersect with formal welfare and social protection interventions, and with informal networks of mutual support and obligation? 4) What relations exist between public healthcare reforms, private healthcare markets and the state in African countries?

Work performed from the beginning of the project to the end of the period covered by the report and main results achieved so far

Our team consisted of 6 anthropologists and a historian working in Kenya, Tanzania, Ghana, Zambia and Madagascar. After six months collaboratively developing the overall project and individual sub-projects, gaining ethical approvals, developing a project archive and holding an opening workshop, most team members began fieldwork in 2019, meeting together in Kenya to compare sites and develop themes. The covid-19 pandemic interrupted our fieldwork but at least we had already gathered considerable material. Our research offered comparative insights into how colonial and postcolonial histories of state development, architectures of global health funding, relationships between public healthcare systems and private healthcare markets, and citizen protests and activism shaped translations and frictions surrounding universal health coverage policies in different national and local contexts. We did not assess countries’ progress towards universal health coverage. Rather, we attended to, the frictions and tensions that surrounded this process, the actors and institutions involved, and to unanticipated developments.
The project built ongoing collaborations, notably with universities and researchers in Ghana, Kenya, Tanzania, Uganda, and South Africa. We also built up a collaborative network with current and retired health officials and health professionals working in our country sites and for WHO Africa. An open access archive on “Healthcare and the Public Good in Africa” will be available from March 2025, offering a resource for historians and scholars, policy makers and planners. Developed in collaboration with two Wellcome-Trust funded projects, the archive is based on witness testimonies with key African and Africa-based public health planners, policy makers, health officials and medical professionals with long experience with African health systems. It will be published in the open access journal Michael and also hosted online at the Medical and Health Humanities Africa network.
The project team has published over 40 articles and chapters, 2 journal special issues and a monograph. A third special issue is forthcoming; 2 monographs and a co-written book are in preparation. Our research is published in American Ethnologist, Social Anthropology, Medical Anthropology, Social Science and Medicine, Global Public Health, and Development and Change, among others.

Progress beyond the state of the art and expected potential impact (including the socio-economic impact and the wider societal implications of the project so far)

UNIVERSAL HEALTH brings a critically engaged medical anthropology into dialogue with moves to decolonise global health. As African countries seek to expand access to health care for their citizens amidst dwindling international aid, ‘Universal Health Coverage’ – conceived of as expanding access to healthcare alongside social and financial protection – has become central to goals of health system strengthening. In this context, key questions arise. Who do public health systems serve? How should they be financed? What does state responsibility entail? Who is responsible for whose healthcare needs and costs? Is healthcare a right or a privilege? Such issues are important given the histories of public health on the continent, where development, welfare and global health have long been sites of experimentation and selective governmentality.
Studying the frictions surrounding a global health policy across different African countries and sites, the project explored how histories of state formation and citizenship, patterns of inequality and the politics of class shaped contestations concerning health equity, and forms of inclusion and exclusion. Our research examined how attempts to make healthcare more equitable take place alongside increasing socio-economic inequalities, the enclaving of middle-class aspirations within private health care, unpredictable national politics, and the powerful influence of external actors and their interests. At the same time, the research highlighted how Africans are debating and addressing these issues, attending to Africa-based innovations, experiments and proposals while exploring how these must navigate architectures of global health and financing, infrastructures of corporate healthcare and fintech, and the contingencies of national politics.
The project followed a critically engaged anthropology, addressing both the politics of the possible and the ways progressive policies are shaped by economic and political interests and ideologies. Eschewing questions of success or failure, we aimed for anthropological engagement with global health that moved beyond critique to take African aspirations for improving health equity seriously and that attended to what emerges through these engagements.
In the final phase, the project brought our research into conversation with policy makers, global health experts, medical professionals and government officials to develop new modes of engagement and collaboration that go beyond mere critique.

An advertisement for a conference about achieving Universal Health Coverage, in Kisumu, Kenya