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)

At the very base of all human development is health. Before you have anything else in this world – you have your health. With your health you are able to do many things: be a productive citizen, attend school, go to work, and any other number of activities that require at least a basic good health and mobility. If you do not have your health, then all this disappears: You are too sick to go to work, to attend school, provide food for your family, grow and develop your community, among other things. Without your health you cannot fulfill the basics for living and therefore cannot improve your situation or that of your community.

Within the international development field, gross national product (GNP) and the global economy are often referenced. This broad macro view of development has contributed to foreign aid/ development failures for many decades. For far too long a macro, “modern” perspective has driven development practice allowing Western institutions and dollars to “intervene” and “develop” the underdeveloped. Gustavo Esteva does well to point out that in order to be involved in development an individual has to recognize that she or he is “underdeveloped.” This term more often signifies something that is not Western or modern, which is extremely problematic for many different peoples of many different cultures.

The paradigm of international development needs to shift from being focused on macro, modern initiatives and instead focus on individuals’ abilities to control and contribute to the development of their own communities. Once these tools are in place, then there will be effective and sustainable development where all needs are met. At the very core of development is health. We must understand that all development springs from the previously stated definition of health.

Development became a field for Western experts to push the ideas of “modern” society on “underdeveloped” [“uncivilized”] populations. Development was an arena focused on exerting power over others and it was very successful. The field of health care was not immune from the macro, modern failures of development practice. There needs to be a significant commitment to reversing the trends of the past to allow individuals and communities greater agency in their own development.[1] Development writer, Alan Thomas states,

The alternative vision, based on the realization of human potential in diverse ways, allows for the immanent development at the level of individuals and communities, which should become ‘empowered’ to develop themselves to their full capacities. However, there is no clear model for how development of this kind might build on itself to create a self-reproducing process of social change […][2]

This alternative vision requires a shift in the paradigms of development from a focus on Western “big plans” and a greater focus on the abilities of individual and communities to provide their own basic needs.

The people have the right and duty to participate individually and collectively in the planning and implementation of their health care.[3]

Especially in relation to health care, people should be able to determine their own level of participation in attaining better health.

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[1] Development as Freedom, Amartya Sen, 190.

[2] Development and Social Change, Alan Thomas, 36.

[3] Declaration of Alma Ata, IV.