This week and last we’ve been talking a lot about mobile health (mhealth) and how it impacts communities in developing African countries. As the mHealth Summit 2010 takes place in Washington DC, I can’t help wondering if this represents a lack of perspective on developing traditional health infrastructure. Mobile is hip, easy, quick, and exciting however how do we measure its success. A recent article on MobileActive.org  asks if mobile technologies are “really impacting the poor?” As we sit in our nice homes, co-working spaces, conferences and offices we must not forget accountability and scale. Many during the mHealth Summit 2010 have noted that success comes through capacity building with locally based organizations. This could not be more true. Community-based initiatives that seriously invest in people will succeed.

“The most effective forms of organization are based on partly autonomous and contextually rooted local units linked by connective structures, and coordinated by formal organizations.” (Tarrow, 137)

This week I’d like to share a video from Josh Nesbit (co-founder SMS:Medic) demonstrating the successes of FrontlineSMS: Medic in scaling its work and staying accountable to the communities they support through local capacity building.

With the growing difficulties in providing health care to everyone, governments sought solutions. Among those solutions were: privatization, decentralization, and integration of traditional health workers. It has become ever more apparent that government planning and policies are inadequate. It is time to put the power back in the hands of the people. The authors, Sama and Nguyen, remind us that,

Years ago, organised health systems in the modern sense barely existed. Few people alive then would ever visit a hospital. Most were born into large families and faced an infancy and childhood threatened by a host of potentially fatal diseases – measles, smallpox, malaria and poliomyelitis among them. Infant and child mortality was very high as were maternal mortality rates. Life expectancy was short.[1]

The financing of health systems has changed only slightly over the years. The modern, Western approach is still pursued even when this is not the most effective approach for African health needs. Turshen notes that,

Economists at international financial institutions have taken a radical, free-market approach to financing health care. They say that even strong economies can no longer afford to pay for public services and that weak economies in the third world [developing] must strip their large bureaucracies if they are to remain eligible for loans and foreign investment.[2]

This “radical, free-market” approach has led many African countries to rely on private health services for their citizens. This is an effective way for health care to be provided to citizens, but it further marginalizes those who cannot pay. Unfortunately, “universal health care” schemes are also ineffective in reaching everyone in need because government financing quickly runs out as both the wealthy and poor access health care for free.

Decentralization of health care is by far an approach that has incredible potential for effective health care systems. Joseph Stiglitz wrote in a World Bank report,

In many cases innovative approaches to service delivery will involve greater participation by local communities and decentralization of decisionmaking.[3]

The model that many top (and top-down) economists should use is best known as “autonomous development.” Development that is defined and controlled by local people is autonomous. This type of development is exemplified by indigenous groups in the Andes, where they define development as “wellbeing not only of the individual, but also of the world around them (Saravia qtd. in Ruonavaara). Related to this, Esteva writes that people sought to liberate themselves from their economic chains and so created new commons in their neighborhoods, barrios, and villages (20). This decentralized approach is often referred to as a hub-and-spoke model within health care. Halvorson writes on the needs and benefits of this model,

Physician-centric, fee-based, Western-style medical-care systems will clearly not work in most of rural Africa […]. They are too expensive, too unfocused, too haphazard, and there are just not enough doctors. We need to abandon attempts to recreate this business model in the third world and replace it with a team-care model that uses a hub-and-spoke approach to maximize available resources, create new resources where needed, reduce costs, and multiply the quality and quantity of local care delivery. We need people who can provide the basic care villages need—and we need those people to be part of an integrated system. This new model of care would require new categories of basic health care workers who are linked with higher levels of caregivers in more central locations. The frontline caregivers should be the functional equivalent of well-trained military medics—able to diagnose and prescribe drugs for a few common diseases, get advice, and perform first aid, including basic cut suturing, leg setting, and wound repair.[4]

The Western health care model is one about money and not effective care. Replicating this will only perpetuate, or make worse, health issues across Africa. African communities need a model that has low capital need, easy integration of para-professionals, and is more decentralized within areas of coverage.

The coming revolution in African health care is one where systems will be structured more and more with community integration and participation. Carino and her colleagues researched five mechanisms for effective rural health care delivery. The combination of greater integration in a rural community and participation of community members created the most effective health care outcomes.[5] This fact is also confirmed by social movement strategist Tarrow,

The most effective forms of organization are based on partly autonomous and contextually rooted local units linked by connective structures, and coordinated by formal organizations.[6]

With a hub-and-spoke health care system model focused on decentralized para-professional health workers on the frontlines of health care delivery utilizing new technologies to remain in communication with the broader health care system, access to health care and meeting the basic needs of African populations can become a reality. The coming revolution in African health care will depend on four main components that allow people the power to be involved in their own health care: (1) cooperative financing, (2) increased opportunity to training community health workers (para-professionals), (3) capacity of information technology to share knowledge, and (4) improved accessibility to preventative health care measures. The revolution has come!

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[1] Sama, Martyn and Vinh-Kim Nguyen. Governing Health Systems in Africa. Council of Development of Social Science Research in Africa, 2008. (1)

[2] Turshen, 1.

[3] Stiglitz, Joseph. Assessing Aid: What Works, What Doesn’t, and Why. World Bank: November, 1998.

[4] Halvorson, George C. Hub-and-spoke health care. What Matters. 29 February 2009. <http://whatmatters.mckinseydigital.com/health_care/hub-and-spoke-health-care>.

[5] Carino, Ledivina V. and Associates. Integration, Participation and Effectiveness: An Analysis of the Operations and Effects of Five Rural Health Delivery Mechanisms. Philippine Institute for Development Studies. 1982. (6)

[6] Tarrow, Sidney. Power in Movement. Cambridge: Cambridge University Press,1998. (137)

Before you have anything else, you have your health. Hopefully if you have nothing else, at least you have your health. Unfortunately, for millions across the African continent this is not an absolute fact. Even more unfortunate is the fact that many Africans have no ability to change their health status. They are trapped in a system that is driven by Western market based, profit driven health care systems. As the failures of Western development practices come to light, alternatives to what has been are becoming increasingly visible. These alternatives will form a revolution in African health care delivery. This revolution will be fueled by health care delivery models that will give local communities agency in the provision of their own health care. Community-based models involving cooperative financing, proven para-professional training, new information technology, and social enterprise for the social good will drive the revolution in African health care. People will be able to determine for themselves, their level of health.

What does “Health” mean anyway?
This is a question often left to remain ambiguous. For the purposes of my writing I will provide a comprehensive view of “health” and all that is entailed in sustaining and maintaining health. “Health” in all instances will refer directly to the “basic needs” of a person in regards to health care.

Healing, like health, is obviously rooted in the social and cultural order. [...] To define dangerous behavior, and to define evil, is to define some causes of illness. As the definition of evil changes, so does the interpretation of illness. To understand change in healing, we must understand what it is that leads people to alter the definition of dangerous social behavior. It can easily be accepted that health and healing in Africa are shaped by broad social forces.

As Feierman and Janzen state, health (and healing for that matter) are directly linked to social forces. If a comprehensive understanding of health is to be understood, it must be studied in the context of politics, economics, and other societal structures.

Health is defined by the World Health Organization (WHO) as, “a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity.” The WHO and many other international organizations recognize that this broad and encompassing definition of health. Where this definition becomes ambiguous is what qualifiers meet, “a state of complete physical, mental, and social well-being.” In 1978 the WHO made primary health care its number one objective with the Declaration of Alma Ata. However, even this statement had no clear definition of health or its qualifiers.

Feierman and Janzen provide a more clear definition of the qualifiers of health in the preface to their volume: The Social Basis of Health and Healing in Africa,

[…] it [health] is maintained by a cushion of adequate nutrition, social support, water supply, housing, sanitation, and continued collective defense against contagious and degenerative disease. Such a view is necessary if we are to understand those contexts in today’s Africa where health levels deteriorate, and where they improve.

These authors provide a complete set of qualifiers, or “basic needs,” of health that can be researched further to understand where political, economic, and social structures interfere with sustaining and maintaining health and where health care is inadequate.

Health care should thus be understood as the system and structure that works to provide the above defined “basic needs” to each individual. Often this role falls to governments, but sometimes is taken up by communities and organizations when government’s fail to provide these basic needs.

This blog series will cover four key areas identified that will fuel this revolution in African health care: cooperative financing, para-professional training, information technology, and social enterprise. SCOUT BANANA works to tackle social medicine (social, economic, structures) while enabling others to provide medical services. Be sure to follow closely to learn more!