Jean- Louis Lamboray, Constellation
In the weeks and months ahead we will publish blog posts related to the Harare Declaration. In this first post, Jean- Louis Lamboray (Constellation) challenges the reductionist interpretation of community involvement which prevailed over the past 25 years and calls for citizens to manage their own health. The Harare Declaration paved the way for such an ambition. Will participants of the Dakar conference take stock and decide to engage on this more radical path?
In 1987, the year of the Harare Declaration, the map of Africa showed a red spot to mark the spread of HIV around the Great Lakes, with a red dot indicating its presence in Abidjan. The rest of the continent was free of HIV. 25 years later, the same map shows various nuances of red: on their own, health districts have been unable to stem the spread of HIV. Two hypotheses might explain this failure: either the Harare Declaration has not been implemented as intended, or its provisions are insufficient to safeguard and promote the health of populations.
The dramatic regression of HIV in Phayao Province, where the point prevalence of HIV among military conscripts declined from 20% in 1992 to less than 1% in 2000 gives us a clue. According to a UNAIDS review, the sole provision of multi-sectoral services (health, education, etc. ) was necessary, but insufficient to stem the pandemic. The key explanation lies in the ownership by the people themselves of the issue and of the actions to address it. Phayao people looked at AIDS as their own issue, and therefore discussed, reflected and acted to tackle it. Hence, from their perspective, the use of health services was one action among many. A World Bank review gives a similar explanation for the regression of HIV in Uganda and Brazil.
25 years of technocracy weaken Harare’s vision
The Harare declaration describes community involvement as Strengthen Community Involvement by creating appropriate mechanisms for providing support and increasing self-reliance by strengthening the knowledge and skills of communities in solving health and development problems. Technocrats reduced this ambitious vision to the participation by users and by potential beneficiaries in the planning, implementation and management of the health services and program they control.
We, “the experts” progressively accepted or did not effectively challenge the representation of health as resulting primarily from the consumption of health services. The Bamako Initiative adopted in 1987 by the 37th Regional Committee of WHO illustrates this representation, as it combines cost recovery for health care with community participation. The World Development Report 1993 narrowed even further the scope for participation as it presented health as resulting from the sole consumption of a care package carefully selected by experts on the basis of their cost-effectiveness ratio. The report “Improving Health in Africa “, written jointly by a team comprising WHO AFRO, UNICEF and the World Bank translated this view in operational terms. The WHO World Health Report 2000 stems from the same understanding. Even those who call for the integration and for the continuity of care to address the pandemic outburst of vertical programs do not fundamentally challenge this reductionist view of health. Nor do those who call for more equity in the provision of health services according various criteria such as gender, socio economic status, etc. Sadly enough, we regularly use the term “health system” to describe the “health services” subsystem.
The productivity view of health services dehumanizes both the caregiver and the care receiver, both servants of domestic and international objectives set without their knowledge, let alone their input. To be convinced of the need to re-inject humanity into health, consider the suffering of caregivers and patients in European hospitals submitted to the merciless law of efficiency of the production of services.
What will people in 25 years say about our proceedings in Dakar? Will the Dakar meeting be remembered as the turning point that ended the confusion? Harare +25 gives us an opportunity to correct the course, and to open our minds.
Let us rehabilitate health
At the Harare +25 meeting, let us open our minds. Let us shape health services in such a way that they effectively contribute to the production of health by individuals linked to their families and their communities. Let us recognize the human being as the main actor in health, as it is the human being who is able to give meaning to life, to dream and to act with others to fulfill that dream.
Let us therefore unambiguously affirm that: 1) people are the main actors in health, 2) they play a key role in a broad set of processes and of conditions that can affect their health, and 3) the health service subsystem can contribute to, but not substitute for what people do for their health.
Many African countries are now engaged into the epidemiological transition, as non- communicable diseases gradually replace infectious diseases as main causes of morbidity and mortality. In Africa as elsewhere, health services are not organized to deal with the root causes, the effective treatment and the consequences of conditions such as malnutrition, diabetes, obesity , strokes, accidents , civil violence and disaster. What changes in the health care system are required to support the societal changes required to effectively address those conditions?
One possible way would be to update and further explore the concept of “globality” promoted by the Kasongo project and by its followers. According to this principle, the health service serves the priorities of the individuals, their families and their communities, and not the reverse. Then participation becomes an honor reserved for care service providers who are invited by individuals, families and communities to become part of their lives.
How to ensure that health care providers are involved in the life of the community, and not the reverse? Isn’t that what Harare +25 should explore? Let us refuse to reduce people as consumers of care services and explore how health care providers can support them as the only actors capable of taking the full range of measures for the healthy lives of their families and their communities. Only then will Harare +50 participants be able to celebrate Africa as a continent where people live healthy lives.