No universal health coverage without strong local health systems

Despite the current global and national momentum,¹ universal health coverage could remain an empty promise unless it is focussed on the provision of quality essential services to everyone. And this, in turn, will not happen without strengthening local health systems.

More than 25 years ago, the framing was slightly different – primary health care instead of universal health coverage – but the assessment was similar. In August 1987, the World Health Organization organized an interregional meeting in Harare, Zimbabwe, that resulted in the Declaration on strengthening district health systems based on primary health care (the “Harare Declaration”).² In the decades that followed, many actors joined forces to implement the district strategy, which emphasizes the importance of organizing and coordinating health service delivery at the local level.

A quarter of a century later, it is clear that African health systems, particularly in rural areas, have been shaped by these efforts. The district strategy is the backbone of nearly every national health system in Africa; countries are covered by health facilities – organized in a tier system – whose activity packages focus on priority services. However, health indicators are still lagging behind those of most other regions of the world. One reason may be a selective and overly rigid implementation of the health district strategy.

Much has changed over the past 25 years in Africa and a thorough update of the district health system seems warranted. First, many new contextual factors – including administrative decentralization, market liberalization, increasing urbanization and new technologies – must be taken into account. Second, needs have evolved. Those related to widespread poverty persist, while new ones have emerged or are emerging as a result of evolving epidemiologic trends.

Profound changes at the global level have also affected Africa. One was the adoption of the Millennium Development Goals. While these sparked a renewal of political and financial commitment to the health sector, they also triggered a plethora of vertical initiatives that sometimes undermined local health systems. Theoretical thinking and knowledge have also evolved. For instance, the district model was formalized in the eighties, when concepts such as “stewardship”, “governance”, “institutional arrangements” and “incentives” were not yet mainstream.

It is against this backdrop that the Community of Practice “Health Service Delivery”, which brings together hundreds of experts as part of Harmonization for Health in Africa, convened a regional conference in Dakar, Senegal, from 21 to 23 October 2013. It was attended by around 20 country delegations and 170 experts who shared their experiences in organizing primary-health-care services at the local level. By highlighting African-grown innovative approaches to local health system coordination and service delivery and by featuring the use of innovative formats and platforms for creative discussion, the event kicked off a new era.³

Meeting participants observed that, in light of citizens’ rising expectations, ministries of health have to embrace a culture of upward and downward accountability. In many countries, this will mean involving new actors and substantially reshaping institutional arrangements. Participants also agreed that individuals, households and the community at large could and should play a much greater role in procuring their own good health and curbing the rising morbidity and mortality related to the demographic and epidemiological transitions. Individual and community education, empowerment, voice and freedom therefore require much more attention and intersectoral coordination is essential.

The opportunities – and risks – entailed in market liberalization were acknowledged by conference participants. African health authorities need to recognize the pluralistic nature of today’s health sector and the responsibilities bearing on them as stewards of the health system. This new vision has many implications. One is the need to adjust mindsets and skills, at the national and district levels, to allow the use of new policy instruments such as data intelligence, benchmarking, performance-based financing and similar mechanisms – all possibly enhanced by information and communication technology.

The district strategy should also be implemented more pragmatically. For instance, it should allow for a more flexible and decentralized definition of the role of a hospital depending on its context. Inclusiveness, openness to dialogue and support of innovation and learning at the organizational level should be hallmarks of the strategy.

Primary health care remains as relevant today as it was in 1978 (Alma Ata), 1987 (Harare) and 2008 (Ouagadougou).^4,5 African countries must update their local health systems to rise to today’s and tomorrow’s health challenges. The Community of Practice “Health Service Delivery” is poised to play a key role in helping them to achieve this in the years to come.