Kristof Decoster (ITM)
For a number of reasons I felt very fortunate to attend the regional conference “Health district in Africa: Progress and prospects 25 years after the Harare Declaration” which took place from 21-23 October in Dakar, Senegal, and was organized by the Community of Practice “Health Service Delivery”, in collaboration with several Harmonization for Health in Africa (HHA) agencies (UNICEF, WCARO, WAHO, WHO, etc.) and Be-cause Health, with the financial support of the French Muskoka Fund.
The setting, first of all. I’m not very familiar with Africa – and that’s an understatement – so it was lovely to spend a couple of days in a bustling city like Dakar. Already at the (informal) pre-registration event, on Sunday evening, while sipping from La Gazelle Beer and watching the ocean from a rooftop terrace, I felt this was just the kind of place James Bond would enjoy. A stunning view. I expected 007 anytime to ride the waves of the ocean on a speedboat, chasing terrorists or other criminals. Even better, there were a few Bond girls around too at the conference, who said again health service delivery cannot be sexy?
The venue, then. Twenty-five years after the ‘Harare Declaration on Strengthening District Health Systems Based on Primary Health Care’, more than 150 researchers, district medical officers, national directors and other country experts, technical assistants, … gathered in hotel ‘Les Almadies’, to reflect on the role of health districts (also known today as “local health systems”), their design and implementation as well as the upgrade necessary in the context of a fast changing Africa. Bruno Meessen (ITM) explained the aims of the conference more in detail in a presentation on the first morning (see the slideshow). The hotel itself was a marvelous location, and buffet, coffee breaks (including lovely pastries), … all were top notch. Unfortunately, it was also hot in Dakar, very hot in fact – as everybody agreed at the evaluation on the last day. Airconditioning at the conference was not exactly top notch, to the extent that after some time, some people (including myself, I have to admit) were selecting sessions according to the predicted temperature in the room. Bond would have done the same, I comforted myself. A techno-geek like him would also have been less than pleased with the (unexistent) internet connection in the conference rooms. And unlike the (slightly masochistic) public health experts, who were so passionate about the topics discussed in the sessions that they rushed from plenary to parallel sessions and back, he would no doubt have enjoyed a cocktail at the swimming pool, in some nice company. The time afforded for ‘networking’ in the corridors was considered too limited by participants, at the evaluation, so perhaps this could be an idea for a future ‘face to face’ CoP event – instead of a coffee break, in the afternoon, CoP meeting participants could perhaps network and discuss further in the swimming pool. They will then – fully refreshed, and some perhaps a little bit excited – be ready again for another parallel session on, let’s say, PBF or decentralization. By the way, I was probably slightly underdressed for the occasion, in comparison to most of the other participants who had dressed up like Bond at the local casino. My mistake.
Then there was the mix of expert participants, as already mentioned, with a lot of institutional memory present as well, which led to very rich discussions, even more so because this was one of these rare occasions where Francophone and Anglophone Africa met. Experts noted, with me, that many of the constraints and challenges they face are in fact common, even if no setting is the same and solutions will always need to be context-specific. The translators did an ok job, by and large, but at times speakers spoke so fast that they had trouble to cope, and of course the nuances of the presentation sometimes got a bit ‘lost in translation’. That’s understandable, though, at an expert meeting like this one, where some jargon is unavoidable. I was very impressed by the commitment and passion most participants showed about local health systems and the Harare declaration, no doubt rooted in many years of professional experience and sometimes painful memories of women dying on their way to health centers where they were to deliver, or other unfortunate patients. Jean-Louis Lamboray (from Constellation), for example, eloquently reminded the people in the room of the many ‘compagnons de route’ who had tried to implement Harare during all these years, but had passed away by now, many of them Africans of course. Unfortunately, they couldn’t be with us anymore.
And then there was the content of course, with a mix of plenary sessions, intended to frame the discussion and provide participants with the necessary background (if still needed), and parallel sessions, to enrich thinking with new ideas, experiences and analysis.
On the first day plenary presentations focused on the conference objectives, the Harare Declaration, key concepts and the current health situation in Africa. On the second day Caroline Jehu-Appiah, from the African Development Bank, zoomed in on the fast changing environment on the continent with, among others, projected economic growth for the coming decades, an improving health situation (see MDG progress), demographic shifts (which might allow for reaping a ‘demographic dividend’, but will also require the creation of many, many jobs for the young population if the continent is to avoid ‘Arab Springs’), the ICT revolution, the rising demand for accountability, … She also listed the huge challenges, like climate change, fragile states, the enormous infrastructure gap; the substantial youth unemployment, the still low MDG indicators, in spite of progress made, the high disease burden, the corruption and the huge income inequality, which was sadly all too visible in Dakar, the impact of urbanization, the changing international health financing situation… She ended her presentation with an unequivocal message, though: “Yes Africa can!”
A WHO Afro expert then dwelled on the implications of the epidemiological transition (aging, NCDs, …) for the local health systems, and Bruno Meessen, as you might have expected, discussed the importance of paying attention to institutional arrangements when embarking upon this updating exercise of local health systems. Institutions remove uncertainty and solve coordination challenges.
On the last day framing presentations elaborated on patient centered care (with a conceptual presentation on Belgium by Katrien Bombeke, an example of the universal challenges we face, and thus the opportunities for reverse innovation, with the North learning from the South as well as the other way around), referral hospitals (by Dominique Colas, from the International Federation of Hospitals) and the possibility of an international/domestic‘partnership’ to strengthen local health systems (by Hyppolite Kalambay, from the MoH of the DRC) – Hyppolite stressed the importance of increasing domestic revenue, though. By the way, the moderator, René Adzodo (WHO Afro), quite a character, I have to say, put up a marvelous show. If WHO Afro is ever abolished, he can no doubt continue his career in the entertainment sector.
Presentations in parallel sessions focused, among others, on intersectoral coordination, community participation, with JL Lamboray emphasizing, in a very effective presentation, the importance of facilitating a local response and local ownership, and Basile Keugong arguing for the need to go from targeted-oriented to empowerment oriented community participation; other speakers focused on the potential of individuals, households and the community as co-producers of their own health, the impact of decentralization, medicalization of first line services, the need to align the for-profit private sector on public goals; the urban health situation, the need for new institutional arrangements (with Serge Mayaka for example stressing the fact that PBF can complement/reinvigorate health districts, rather than substitute for them), new (mainly coaching?) roles for technical and financial partners, ICT’s contribution to the coordination of health systems, the evolving nature and variability of local health districts … and much more.
The aim was to come to a synthesis on the last day, as well as to list action points and recommendations for stakeholders at different levels. However, that turned out to be too ambitious. The wrap-up session was quite chaotic or, as we would say in Belgium, slightly “surrealistic”, no doubt because the organizers, who did a great job, were also very tired by then. But it’s obviously not easy to combine a participatory and collaborative approach (the hallmark of the CoPs) with deliverables and deadlines – the agencies involved in the organization of this event obviously would have liked to see a clear output, already. In the end, participants agreed on a more effective way forward. A core group was set up to draft an update of the Harare declaration, which will then be shared with the CoP for feedback. In a few weeks from now, people around the world will see whether it is possible to reach some consensus on an updated vision for the Harare Declaration. That won’t be easy, as discussions were fierce, and participants, although all sharing the vision and values of the Harare declaration, sometimes have a very different paradigm/lens to look at the local health district and assess its future relevance and likely disruptive effects in different ways. The discussions on PBF were just one example, with some people arguing for injecting ‘humanism’ in the approach which is very much using a ‘homo economicus’ lens. But most people in the room were convinced at least some consensus on a number of issues is possible, when revisiting Harare.
As I came to learn and observe, mostly, and more importantly, the final document still has to be produced and blogs will appear in the coming weeks on some of the sessions, I will not make an attempt to come up with my own synthesis of the three days.
Let me nevertheless end with a few personal reflections, though. The situation is changing very fast, these days, in Africa just like anywhere else in the world, and different scenarios can materialize, in the coming decades, as the future has never been so uncertain. So it’s probably impossible to come up with an updated Harare declaration for the next 25 years (with a view on Harare +50), in this age of information and uncertainty, instead there will be a need for continuous updates.
The other observation is linked to this: I did not hear much about the new – post-2015 – paradigm, ‘sustainable development’. Of course, the dire impact of climate change was acknowledged, but I still came away with a feeling that African countries are expected to grow, and will thus have a lot more domestic revenue in the coming decades, which will, at least in principle, be available for the health (and other social) sectors. The other, more pessimistic, scenario was not really considered – that we enter an era of uncertainty, crises and shocks, and that – perhaps not now, but definitely in ten years from now, it will be even more obvious the world has to switch to a low carbon path. This might, among others, increase the pressure on countries to leave fossil fuels in the ground. In other words, economic growth is perhaps not ensured in the coming decades, and even if it does materialize for some years, it might not be sustainable. In the latter scenario, an update of Harare will probably need to build resilience, and will require – at the global level – financing mechanisms to fight global ‘public bads’ and ensure global public goods, by taxing the winners of globalization (the financial sector, multinationals, football players, etc).
If anything, James Bond is resilient, though, and so are African experts. They now have the knowhow and the tools to decide on their own future. So yes, Africa can!