Beyond realism: Africa’s medical dreams: Introduction

The promotion in international health circles of ‘selective primary healthcare’, guided by cost-efficacy evaluations (Walsh and Warren 1980), and of economic liberalization through structural adjustment measures in international financial institutions (such as the World Bank, which was becoming increasingly active in healthcare lending and reform) narrowed the scale and scope of public health provision in Africa (Prince 2013). Much criticized for their failure to (re)build national infrastructures of research, prevention and care – as exposed by the recent Ebola crisis in West Africa – and indeed for weakening what remained of existing health system structures through fragmentation and distortion, major global health players such as the Gates Foundation are backing old and new ‘technical fixes’ for health in Africa – often accompanied by quasi-utopian marketing, for example regarding the promise of ‘mobile’ and ‘e-health’ (Duclos et al. 2017). Continuously trailed by critical social scientists, the global health ‘enterprise’ nevertheless often outpaces them with surprising innovations – such as the ongoing turn to ‘universal health coverage’, which ambiguously references seemingly anachronistic 1960s visions of health systems while at the same time ushering in a new kind of marketization of health insurance and care provision (Lagomarsino et al. 2012; Prince 2017). Yet, while exposing the harsh reality of most Africans’ lack of access to health services, or even to the basic conditions for protecting and prolonging life, this critical work – somewhat like the health economists’ calculating ‘realism’ that it politically opposes – left little space for dreaming, even for those dreams that African health workers and professionals, sick people and their relatives, have continued to dream: dreams, for example, of decent working conditions, medicine stocks, affordable care or publishable research.