Coloniality, social protection and health in Africa

Julia Ngozi Chukwuma and Kevin Deane

January 2026

The social protection agenda in Africa has become increasingly narrow in scope over the last few decades (Adésínà, 2015). In particular, cash transfers (CTs) are now central to social protection programming across the continent (Barrientos, 2011). More recently, there has been significant interest in the role that CTs can play beyond reducing extreme poverty. One key avenue is the extent to which CTs can lead to improvements in health outcomes amongst low-income population groups, either through enabling recipients to access healthcare services or by encouraging healthier behaviours through ‘cash plus’ (CT+) programmes. Applying a coloniality lens, this blog post discusses the colonial legacies and post-colonial dynamics that have shaped the rise and dominance of CT and CT+ programmes, questioning their effectiveness in addressing the social determinants of health in Africa and promoting health equity.

The systemic roots of health inequalities

For the first time since 2008 when an expert commission concluded that ‘social injustice kills on a grand scale’ (WHO, 2008), the World Health Organization (WHO) has published a major report dedicated to the social determinants of health equity. Its ‘World report on social determinants of health equity’ makes a clear case: where and how we are born, live and work influences our chances of good health. Indeed, health outcomes are shaped by a person’s socio-economic position, which is itself influenced by the structure of economic systems, the availability of social services, structural discrimination, conflict and forced migration, and global trends such as climate change and digitalisation (WHO, 2025a).

Yet, in 2026, health inequalities persist both globally and within countries. Life expectancy remains significantly lower, and under-five child mortality rates are significantly higher, in low- and middle-income countries than in high-income countries. These health inequalities are neither random nor inevitable but arise from the conditions in which people are born, live and work, hence reflecting enduring patterns of unequal access to nutritious food, adequate housing, safe environments, healthcare, and secure labour markets (WHO, 2025b).

Social protection and health: the rise of cash transfers

In 2018, at least one CT programme existed in all sub-Saharan African countries, making it a key social protection instrument on the continent (Beegle et al., 2018). This focus on providing monetary transfers to targeted households, who are then expected to cater for their families’ needs through private markets, stands in stark contrast to the way welfare systems are structured in much of Europe (Adésínà, 2020). Most European countries provide free primary and secondary education, offer healthcare to their residents through tax- or social insurance-funded, solidarity-based healthcare system, and provide some form of old-age and/or unemployment protection (Blum et al., 2019).

In many African countries, policies aimed at achieving Universal Health Coverage (UHC) focus narrowly on health insurance models rather than broader public financing approaches (Smithers and Waitzkin, 2022). These schemes often fail to pool contributions into a single national fund – the most solidaristic option – and instead establish separate insurance arrangements for different population groups (for example, formal-sector workers, informal workers, and indigent populations) (Ly et al., 2022). Coverage is frequently limited to a basic package of essential healthcare services, while treatment for conditions such as cancer, chronic renal failure or diabetes is often excluded, exposing households to catastrophic health expenditures (Odonkor et al., 2023). Accordingly, progress towards the realisation of universal and publicly guaranteed healthcare for all has been slow, as the concept of UHC itself embodies a broader retreat from earlier comprehensive and rights-based visions of health for all (Rizvi et al., 2020).

In light of this, CTs have been promoted as an alternative approach to addressing poor health outcomes. They have received strong financial and technical support from international organisations such as the World Bank who have been central to their promotion (Heimo and Syväterä, 2022). Their use has now extended beyond just providing cash, to combining cash with narrowly framed behavioural health interventions. CT+ programmes are increasingly common, combining CTs with complementary programme components such as child growth monitoring, Vitamin A distribution, gender training and nutritional education campaigns (Roelen et al., 2017).

Proponents of CTs in the health sphere often claim that these CT interventions target the social determinants of health, such as poverty, gender inequalities, inequalities in access to education, and healthcare access (Owusu-Addo et al., 2018). For example, CT programmes have been promoted to address high rates of HIV amongst adolescent girls and young women in Africa, acknowledging that young women face significant economic inequalities regarding education and access to income generating opportunities and assets, alongside inequalities to negotiate safe sex with often older male partners (Rogers et al., 2024). Therefore, in theory, CT+ programmes aim to empower young women with financial support to help them start their own businesses and help reduce financial reliance on male partners and ultimately help them to engage in less risky sexual behaviours.

While the evidence for any large-scale impact of CT programmes on reducing HIV risk is limited (Stoner et al., 2021), these narrowly focused interventions are further legitimised given that they seem to respond to the social determinants of health agenda but also lend themselves neatly to evaluation through randomised control trials (RCTs) – the current ‘gold standard’ in impact evaluation, which has gained significant traction in global health (as exemplified by the awarding of the Nobel Prize in Economics to Esther Duflo, Abhijit Banerjee, and Michael Kremer).

Coloniality and systemic drivers of poor health

The dominance of CT and CT+ programming as the key social protection instrument in Africa, emblematic of the narrowing scope of social policy, is not without its critics. Prominently, Adésínà (2020, p. 564) contends that the ‘proclamation of social assistance, in the form of means-tested cash transfers, as a “quiet revolution” in the global South or a “development revolution” … is conclusive evidence of the “impoverishment of the concept of development”’. Inherent to this critique is the reality that development under contemporary capitalism is conventionally understood as poverty alleviation, while deliberations of wider social and economic transformation receive limited attention (Fischer, 2018).

However, the CT approach obscures the historical roots of global health inequalities and the contemporary postcolonial forces that continue to sustain them. Many of the structural injustices we observe today, and which make the attainment of health equity a challenge, have their origins in colonialism. During the colonial period, European powers established welfare systems that provided social services, including healthcare, primarily to colonial administrators and a small local elite, with the ultimate aim of maintaining labour productivity (Rad, 2025) and putting into place systems to control the spread of infectious diseases to European countries (Holst, 2020; Packard, 2016). Consequently, many former colonies inherited inadequate healthcare infrastructures and welfare systems at independence. These structural weaknesses persist today. Moreover, the migration of medical professionals from African and Asian countries to overstretched healthcare systems in Europe, North America and Australia, further depletes fragile health systems in countries of origin (Eaton et al., 2023).

Another significant legacy of colonialism lies in the structure of the global economy. Under colonial rule, European administers structured local economies to facilitate the extraction of raw materials and cheap labour to serve the interests of imperial centres in Europe. Many colonies were turned into so-called cash crop economies, focused on producing commodities such as coffee, cocoa, tea, rubber, or groundnuts for the benefits of colonial powers (Tsowou and Ajambo, 2020). As a consequence, many countries’ capacities to manufacture higher-value processed goods (such as chocolate, speciality roasted coffee, or high-performance tyres) remain limited today. Instead, they are locked into the role of a low-value commodity exporter, occupying positions at the lower end of global value chains (UNCTAD, 2023). Today’s terms of trade continue to make it difficult for African countries to protect their economies from external competition (Afonso and Vergara, 2022). Powerful global institutions, such as the World Bank Group, the International Monetary Fund, and the World Trade Organisation promoting free trade and budgetary discipline (fiscal consolidation), function as contemporary (post-colonial) platforms that help to consolidate the existing unequal economic order.

As a direct consequence, the ability of many formerly colonised nations to implement economic policies that could meaningfully advance structural transformation, as well as social policies that support socio-economic development, remains constrained. By way of example: in 2015, several East African governments backed away from banning the imports of second-hand clothing to protect their local textile industries following pressure from external trading partners (notably, the US’ threats to limit access to benefits under the African Growth and Opportunity Act) (Olingo and Esiara, 2024). Many countries therefore remain structurally dependent on foreign exchange to finance imports of high-value goods, including medical supplies and pharmaceutical products (Kamara et al., 2024). Locked into this position within the global economy, the capacity of many African countries to mobilise sufficient financial resources to fund universal social service provision systems remains limited. Instead, many African and Asian countries face high levels of public debt, accumulated in part due to their reliance on costly imports, placing further strain on already squeezed public budgets. In 2024, 32 African countries spent more on debt servicing than on their national healthcare systems (Christian Aid, 2024).

Inadequately funded public healthcare systems are a key factor contributing to poor health outcomes and solidifying health inequalities. Diseases such as malaria, for example, continue to place enormous burdens on populations in former colonies, not because of inherent biological or ecological factors, but because their healthcare systems and economies were shaped by colonial extraction that left little room for robust socio-economic development. Climate change adds an additional layer of injustice: those least responsible for carbon emissions face the greatest health and environmental risks, further entrenching health inequalities introduced by colonialism (Singer and Negev, 2025).

A move away from neoliberal capitalism

Given the historical and systemic drivers of health inequities in Africa, it is highly questionable that CT or CT+ programmes can significantly reduce health inequities. Indeed, such programmes often (deliberately) underplay these structural drivers of health inequity (Stevano, 2020). The hegemony of CTs hence reflects the broader dominance of neoliberal thinking, promoting liberalisation, a lean public sector, fiscal discipline, and marketisation (including of social sectors) and individualistic approaches to health. Dominant exploitative economic systems continue to limit the ability of African countries to mobilise resources for health, while simultaneously promoting individual-level approaches as solutions to structural health inequalities. The rise of CTs is thus rooted in colonial legacies but reinforced under contemporary capitalist and postcolonial conditions.

CTs have also to some extent colonised the current policy space. An alternative approach would be to return to a much broader vision of social policy, described as ‘transformative social policy’ (Mkandawire, 2007, 2012). Within such a framework, healthcare systems must be adequately funded and organised around the principle of solidarity, rather than market logic. At the same time, the social determinants of health – including housing conditions, access to nutritious and affordable food, a habitable planet, and secure and democratic workplaces – must move to the centre of policymaking if health equity is to be achieved. Achieving this shift requires breaking with an economic system rooted in colonialism and reproduced through contemporary forms of capitalist exploitation. While formal colonial rule has ended, it has largely been replaced by global economic structures that continue to extract value, constrain development, and reproduce inequality. Fighting for health equity thus means recognising that health inequalities are patterned and rooted in unfair social, economic and political structures. It requires confronting these structural injustices head-on and committing to strategies that redistribute power and resources in ways that allow everyone to achieve good health.

This is the second blog in the open series The Long Shadows of Colonialism on Social Protection. This series explores how colonial legacies and continuities shape today’s social protection systems. It aims to deepen the conversation around what must change to achieve social protection for everyone, everywhere and to inspire political action towards this goal. The first blogs are based on the publications Colonial Continuities in the Area of Social Protection by IDOS/BMZ and Change Course Now! Only International Justice Can Create Social Security by Brot für die Welt. If you would like to contribute a blog to the series, please contact us.

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Acknowledgement

This blog was first posted by socialprotection.org.