Improving health in Africa is a team effort, involving many people from different backgrounds. The considerable gains made in recent years would not have been possible without the contribution of the people themselves, national and global political will, and the support of development partners. All too often, however, the role played by Africans themselves has been overlooked or downplayed in international policy making as well as in publications. It is time to redress the balance and celebrate their achievements.
Health leaders in sub Saharan African countries face some of the most demanding challenges anywhere in the world. Disease, poverty, the legacy of colonialism and, all too often, conflict, corruption, and political instability combined, make improving health extraordinarily difficult. Looking back we can see many great African health leaders who have played their part as the following few examples show.
In 1976 a young Kenyan doctor, Miriam Were – to the consternation of her professors in Nairobi – started her PhD on patient participation in rural Kenya. She went on to become one of the early exponents of community health workers in Africa and developed an approach through which local people worked with their neighbours to promote healthy behaviour and tackle diseases. As she puts it: ‘Through this approach, health-promoting and disease-preventing norms develop in the community’ and ‘If it doesn’t happen in the community, it doesn’t happen in the nation’. The impact of those early developments is enormous and can be seen throughout Africa.
“when you focus on the poorest first, you take the rest with you, When you focus on where the greatest gaps are, you make the biggest gains.”
In the same year Dr Pascoal Mocumbi became Health Minister in war-torn Mozambique and was charged with delivering health care at a time when most doctors had left the country. He had trained as both a nurse and a doctor, and recognised that some nurses could undertake surgical procedures, provided that they had the right training and supervision. He set up a programme to train the Tecnicos de cirurgia to perform obstetric surgery to cover the rural areas. Peer reviewed research over 20 years shows that the Tecnicos have the same success rate as doctors and at less than half the cost. The programme continues to save lives in rural Mozambique today.
Twenty years later, Dr Uche Amazigo became the Head of the African Campaign for Onchocerciasis (river blindness) Control and was faced with the daunting task of how to deliver prophylactic drugs to millions of Africans in remote villages. With colleagues, she set up a volunteer network of thousands of local people as community distributors who ensured that everyone in their home villages received the right dosage every year to control the diseases. By 2011 more than 600 million treatments had been given, and an estimated 7 million years of blindness prevented. Plans are being made to eliminate – not just control – the disease (L. E. Coffeng et al). This is one of the greatest mobilisations of a population as part of a public health campaign anywhere in the world.
These stories of leadership need, however, to be seen alongside the relationship of dependency that has grown over the years between Sub Saharan Africa and its development partners. As Francis Omaswa has written: ‘Africans went to the Bretton Woods institutions and other institutions and countries begging for advice and for money and we got both but in exchange for certain core values’.
Development partners have played an enormous role in bringing new resources and skills to the continent and provided benefits to millions of people. However, the very best of intentions by passionate donors has often created duplication of programmes, whilst lack of coordination has led to inefficiencies. Local expertise has frequently been ignored with the result that programmes are ineffective and parallel systems of health care have been created, thereby weakening rather than strengthening local health systems. Worse still, there has sometimes been fierce competition between foreign organisations as they manoeuvre commercial-like businesses to outflank their competitors for funding and prestige. This competition has sometimes been overlaid and complicated by different political and moral ideologies and agendas being fought out by foreigners in African countries.
International agreements from the Rome and Paris Declarations onwards have set out frameworks for effective development. There have undoubtedly been improvements – but not everywhere. The reality of ‘country ownership’ with partner support has yet to be realised in most of Africa. The idea of ‘mutual accountability’ between partners and countries is not yet working in practice. Now it is time to for Africans to reclaim leadership in their own countries and to re-balance this relationship.
Rwanda has been re-building itself over the 20 years since the genocide and now has a social insurance health system that reaches 98% of the population and effective local health services in almost all parts of the country. It has been hailed as an example of country leadership and partner support with strong and mature relationships being developed between the country and its principal partners. This has allowed the development of a distinctively Rwandan approach to health improvement suited to its own social, economic, and physical environment.
The Rwandan system has been built on the principles of equity and human rights, a holistic approach to health and its determinants – neither vertical nor horizontal in its application – the use of information, the spread of knowledge, and the engagement of the whole population. Private enterprise and incentives are deployed in the service of the public good and citizens are expected to take a measure of responsibility for themselves. At its heart is the idea that ‘when you focus on the poorest first, you take the rest with you. When you focus on where the greatest gaps are, you make the biggest gains‘ (P.E. Farmer). Whilst Rwanda still faces many challenges, it offers an example of how country leadership, supported by partners, can create a successful national system, and incidentally, pioneer innovations of relevance to other African countries and beyond. Everyone can learn from each other (Crisp).
Looking forward, and writing as parliamentarians in our respective countries, we recognise that it will take political will and sustained leadership to change attitudes and develop a new relationship between Africa and the rest of the world. We envisage the ultimate goal should be to establish something more like the post-war Marshall Plan through which America and the world banking system invested in Europe as its people built new institutions and economies rather than simply continuing the gift of charity from generous people to their poor neighbour. The world needs a strong Africa today just as it needed a strong Europe 70 years ago.
In the meantime, and while we press for this change, we believe it is important to recognise and celebrate African health leaders and the millions of people – paid and unpaid, professional and untrained – from African and partner countries who strive daily to improve health across the continent.
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