District health in Africa: Progress and Prospects 25 years after the Harare Declaration. Regional conference – Dakar 21-23 October 2013

1. District health in Africa: Progress
and Prospects 25 years after the
Harare Declaration
Regional conference – Dakar
21-23 October 2013
REPUBLIQUE DU
SENEGAL
Ministère de la
Santé et
de l’Action
sociale

2. Objectives & content of the
conference
The Harare Declaration & health
districts in Africa : time for an
updated vision
Organising Committee

3. Background
• 3-7 August 1987: WHO interregional meeting
in Harare, on strategies to strengthen district
health systems.
• Extension of the “Health for All” movement of
Alma Ata (1978)
• Key meeting for the adoption of a strategy
allowing to realize primary health care.

4. Many changes in Africa since 1987
• Much greater demand for accountability and
results. How to respond to new expectations?
• Session 6

5. Changes in the health sector
• How to adapt the district system?
• Across sessions.

6. New knowledge and new platforms

8. A diagnosis still valid?

9. A definition
• Is this definition still satisfactory or is it
misleading?

10. 12 points of action
• Have we implemented these 12 points of
action?
• Were they right ? (or guided by a wrong
assessment)
• Still relevant?
• Should we add new ones?

11. National policy
• Implemented… but maybe too much as a blue
print? (health pyramid)
• Shortcomings:
– A too rigid and administrative view.
– No satisfactory answer for cities.
– How to engage with private actors.
• Sessions 2, 3B & 7A

12. Decentralisation
•
•
•
•
•
Partial implementation, varying across countries.
New context: administrative decentralisation.
New - sharper - propositions.
Key question: decentralisation of what, to whom?
Sessions 7B & 8A

13. Planning, (targeting) & information
• Done (yet, without targeting and not with an
intensive use of health information system).
• Too much faith in the planning process? Who
should set priorities?
• Sessions 4B and 9C

14. Community participation
• Bamako Initiative, community health workers.
• “Self-reliance” - still relevant?
• Have we found the appropriate mechanisms? Or
contradiction in the terms?
• Session 4A

15. Intersectoral action
• Probably one of our weakest achievements!
Very health sector–inward looking so far.
• Question: how can we do that?
• Session 3A

16. District management team
• Why so few great leaders at district level?
• Wrong approach or an unrealistic assumption?
• What are the alternative approaches for coordination
of actors? How to steward a pluralistic health sector?
• Session 2 (keynote), 8B

17. Resource mobilisation
• Bamako Initiative, a few weeks later!
• A lot has been tried… with mixed results
• UHC = Health for All + Protection from
catastrophic health care expenditure
• Not the focus of this conference.

18. Integration of vertical programs
• Worse than in 1987?
• Not taken as a theme per se. But present in
the program.

19. Referral hospital
• The always forgotten component!
• Keynote speaker session 11.

20. Action-research
• Could one formulate more precise
recommendations?
• Heavy presence of scientists at this
conference!

21. Equity
•
•
•
•
•
Much higher on the agenda in 2013 than in 1987!
Better formulated today.
Some innovations.
How to do more?
Keynote speaker 1, session 2.

22. Coordination with technical and
financial partners
• Strong momentum in the early nineties… a bit
lost with GHI… back with HHA and CoPs?
• New instruments: SWAp, PBF…
• Session 9A + Philosophy of this conference.

23. Need for an updated vision – first line
services
• More flexibility at Health Centre level (expansion
of the minimum package of activities).
• Return of the community health worker strategy.
• Patient-centered care.
• Session 9B, session 11 (keynote 1)

24. Key objectives
1.
2.
3.
4.
5.
Assess the health district strategy.
An updated vision.
Action points & recommendations.
A strong and shining CoP.
A knowledge agenda.

25. A conference manifesto
There will be no Universal Health Coverage without
strong local health systems: it’s time to update the
health district strategy in Africa
We look for the action points.
→ Your job!

26. Thank you
• Follow us on our
online platforms!
(p2 program)