public health in africa

04/19/2304/19/23 11PHC IN AFRICAPHC IN AFRICA

PUBLIC HEALTH IN AFRICAPUBLIC HEALTH IN AFRICA

THE CONTEXT, THE GAIN THE LOSS THE CONTEXT, THE GAIN THE LOSS AND THE WAY FORWARDAND THE WAY FORWARD

(PH: ability of HH, Community, State System (PH: ability of HH, Community, State System to take care of own health &meet daily needs to take care of own health &meet daily needs

and challenges: env., lifestyle, livelihood)and challenges: env., lifestyle, livelihood)

04/19/2304/19/23 PHC IN AFRICAPHC IN AFRICA 22

THE CONTEXT:THE CONTEXT:THE STATUS OF DEVELOPMENT (GLOBAL)THE STATUS OF DEVELOPMENT (GLOBAL)

• More advance is made in the last 50 years than in 500 years before the 20th Century

• Public health interventions and socioeconomic development reduced mortality and raised life expectancy

• But disparity widened, with a third of the global population wallowing in absolute poverty

• We still lose more than 11 million children to preventable diseases• The absolute number of illiterate women is rising

• Those favored by trends insulated from reality as they take

decisions & others consequences


THE CONTEXT: THE CONTEXT: THE STATUS OF DEVELOPMENT (AFRICA)THE STATUS OF DEVELOPMENT (AFRICA)

• If the 1960s were characterized by the great hope of seeing an irreversible process of development launched throughout Africa, the present age is one of disillusionmentDevelopment has broken down, its theory is in crisis, its ideology the subject of doubtAgreement on failure of devt. in Africa is sadly universal


THE CONTEXT THE CONTEXT THE STATUS OF HUMAN DEVELOPMENTTHE STATUS OF HUMAN DEVELOPMENT

In Africa • Basic human development indicators are declining since

early 80s• Except a few countries the figure on population with

access to basic social services has been static or sluggish at best, complicated by transition(rapid growth)

• Africa carries more than its fair share the global pervasive poverty, disease and death with appalling gap

• 1.2 billion without adequate shelter, overcrowded, no access to safe water, sanitation, recreation, safety & cannot meet PH needs (who is responsible to ensure PH for ALL)



Attenuation of human capital base• The labor force participation is going down with

growing population to feed, aggravated by decimation and/or diversion of productive force by HIV/AIDS and conflicts

• Rising school dropouts• Brain drain, both internal and external by ‘green

pastures’• Inappropriate tooling of human resource –

‘Training for export’



•Man-made and/or natural disasters & degradation of the environment

•Draught and famine•Overuse of agrochemicals•Squandering of resources leading to conflicts•Africa as a dumping ground (sometimes guised as “donations”)•Corruption and looting



Unjust World Order

• Unbalanced global trade

• Imposed reforms, restructuring and adjustment

• Debt burden (relentless and huge servicing)



ILL HEALTHILL HEALTHTRAPPED TRAPPED HOUSEHOLDSHOUSEHOLDSPOVERTYPOVERTY

THE VICIOUS CYCLETHE VICIOUS CYCLE


FACTORS DETERMINING PUBLIC HEALTH FACTORS DETERMINING PUBLIC HEALTH INTERVENTIONINTERVENTION

DIFFERENTIAL

VULNERABILITY

INCOME, CULTURE,ENVIRONMENT, GENDER,EDUCATION, POLICY,RACE, AGE, DISABILITY

ACHIEVEMENTS ANDMIX IN ABILITY,AUTHORITY,RESPONSIBILITY ANDRESOURCE

RISK/PROBABILITY OFEXPOSURE TO HIV/AIDSDUE TO ONE'S RELATIVESOCIAL CONTEXT

SOCIAL AND CLINICALOUTCOMES RESULTINGFROM EXPOSUREDEPENDING ONRELATIVEVULNERABILITY ORCAPACITY

DIFFERENTIALCONSEQUENCES

DIFFERENTIAL EXPOSURE

SOCIAL STRATIFICATION

DIFFERENTIAL CAPACITY


PH: PH: THEGAINS (limited)THEGAINS (limited)

• Reduced child and maternal mortality

Increased coverage

Increased allocation of resources for health

Growing recognition the health-development interplay


PHPHTHEGAINS (limited)THEGAINS (limited)

• Affordable public health inventions

Enhanced integration of health actors

Patchy spots of excellence observed


PHPHTHE LOSSESTHE LOSSES

• Worsening situation among the poorest (The neglected pool)

Millions still die from ‘preventables’

Poor preparedness for emerging scenario leading to reversal of gains


PH: WHY LOSSESPH: WHY LOSSES (4Ps) (4Ps)

The The PeoplePeople viewed as viewed as

Vulnerable, powerless, sick, at risk (The needs-focused approach) instead of partners and resources

The The ProblemProblem conceived as conceived as

Disease, malnutrition, poor sanitation instead of poverty, inequity, ignorance and marginalization


PH: PH: THE DISTORTIONSTHE DISTORTIONS

The Main The Main PackagePackage (service) (service)

Drugs, vaccination, latrine, health talk (neglect of the social context) instead of income and food security, equity in access to services and empowerment

The The ProfessionalProfessional mainly shaped to mainly shaped to

Give, prescribe, inject, educate, help, save, ask instead of facilitate, mobilize, dialogue, partner, feedback to people.


PH: PH: THE DISTORTIONSTHE DISTORTIONS

CapacityCapacity limited to limited to

Skills and knowledge instead of Ability, Resource, Authority and Responsibility


PH PACKAGE TO INCLUDEPH PACKAGE TO INCLUDE

Increased productivityIncreased education performanceFairer/accountable global and national systemsIncreased savings and investments (human, social, economic, environmental)Planned Human Capital: more investment in fewer childrenGreater (redistributive) equity, social and political trust and stabilityGreater social capital, greater accountability, greater effectiveness and equityInvestment in health will reduce deaths, lower population growth and provide 6 fold economic return by the year 2015. USD 66 billion new investment by the yea 2015 will save 8 millions lives per year. Reduce differentials (social status, capacity, exposure, outcome and consequences)


PH: THE WAY FORWARD – THE WORKING TOOLSPH: THE WAY FORWARD – THE WORKING TOOLS

CONCEPTUAL FRAMEWORKCONCEPTUAL FRAMEWORKINCOME, CULTURE, ENVIRONMENT, GENDER, EDUCATION, POLICY, RACE, AGE, DISABILITY

ACHIEVEMENTS AND MIX IN ABILITY, AUTHORITY, RESPONSIBILITY AND RESOURCE

RISK/PROBABILITY OF EXPOSURE TO HIV/AIDS DUE TO ONE'S RELATIVE SOCIAL CONTEXT

SOCIAL AND CLINICAL OUTCOMES RESULTING FROM EXPOSURE DEPENDING ON RELATIVE VULNERABILITY OR CAPACITY

SOCIAL STRATIFICATION

DIFFERENTIAL CAPACITY

DIFFERENTIAL EXPOSURE

DIFFERENTIAL CONSEQUENCES

DIFFERENTIAL

VULNERABILITY


PH: THE WAY FORWARD – THE WORKING PH: THE WAY FORWARD – THE WORKING TOOLSTOOLS

PRIVATE SECTORSNGOs

PUBLIC SERVICE

TRAINING INSTITUTIONS

COMMUNITY

TRAPPEDHouseholds

Poverty

Ill health

FRAMEWORK FOR PARTNERSHIPFRAMEWORK FOR PARTNERSHIP


The Spiral of Continuous DialogueThe Spiral of Continuous Dialogue

ASSESSMENT-2

ACTION & MONITORING

ASSESSMENT-1

ACTIONPLANNING ANALYSIS

DECISION REFLECTION

Fig.1: The Dialogue Spiral Fig.2: One cycle of the Spiral withStages


STEP 1 Listen and learn about their priority concerns and gaps and how they are affected by them/it. (WHAT ARE THE CONCERNS AND CURRENT, often hidden,

ALTERNATIVES)

STEP 2 Listen and learn about their current practices to solve / cope with the problem/s, gaps etc (WHY THE CURRENT SITUATION / CURRENT ACTION / BEHAVIOUR)

STEP 3 Listen and learn about their preferred future situation and suggested actions to achieve it (HOW CAN THE PREFERRED FUTURE BE ACHIEVED), give input including the recommended practice (if not yet mentioned or summarise from

their contributions).

STEP 4 Select together with them the most effective, feasible, appropriate options, (WHICH OPTIONS ARE BEST), based on existing capacity and

opportunities. Summarise agreement and reflect on possible results if implemented (this provides a basis for commitment as well as monitoring and evaluation)

STEP 5 Plan action, including monitoring and evaluation (WHEN DO WE TAKE ACTION AND WHO IS RESPONSIBLE)

STEP 6 Follow up, assess implementation of the joint action plan, based on information (note modifications, compliance or rejection), feedback, celebrate results and re- plan, making necessary adjustments.

Steps in Organised DialogueSteps in Organised Dialogue


Framework for PH AssessmentFramework for PH Assessment

1. Structures and institutions for participatory action (micro to macro): Capacity, representative-ness, inclusiveness, transparency and accountability

2. Participatory program management: Stakeholder involvement in program processes and decisions such as situation analysis, planning, action, monitoring and evaluation

3. Management information system: Design and selection of measurable indicators, data collection, analysis, recording, reporting and local consumption

4. Human resource development and management: re-orienting, and retooling, training, supervision, motivation and control to mainstream participatory approaches.

5. Participatory resource mobilization and management: Mobilization, allocation, expenditure tracking to enhance transparency, accountability and efficacy.

6. Comprehensive communication strategy: Comprehensiveness of the message, appropriateness and diversity of the channels, demystifying content and language to fit the audience, and the interactive-ness of the communication process including documentation, dissemination and feedback.

7. The minimum public service package: Service package definition, its effectiveness, policy relevance, accessibility and affordability.

8. Sustainable linkages and partnerships: Nature of linkage, partner capacity, relevance and effectiveness of partner investment, sustainability of either the linkage or the investment.


CAPACITY BUILDING FOR SUSTAINABLE SERVICECAPACITY BUILDING FOR SUSTAINABLE SERVICE

RESPONSIBIL

ITY

AUTHORITYABILITY

RESOURCE

DONOR/STATE-DRIVENTRANSITIONAL SERVICE DELIVERY& CAPACITY BUILDING

FROM NEED TO

EFFECTIVE DEMAND

EFFECTIVE SUPPLY

REGULATEDMARKET


AFRICA STILL ASKS DR MAHLER’S QUESTIONS OF 1978, ALMA-ATA

Are we ready Are we ready • To address the gap between the haves and the have-nots?• For partnership-participatory and intersectoral action?• For equitable and just health?• To make preferential allocation of resources to the marginalized?• Put people at the center of our action, to recognize them for their

capacities and contributions as partners and not for their needs?• To introduce radical but relevant structural changes in our

systems?• To fight political and technical battle to overcome social, economic

and professional obstacles to PHC?• To mobilize global solidarity for ‘Health For All’?


AFRICA STILL ASKS DR MAHLER’S QUESTIONS OF 1978, ALMA-ATA

• To mobilize global solidarity for ‘Health For All’?

T he risks associated with disease transmission are common features of poverty. T he poor do not have access to information that could have provided the basis for appropriate decision and behaviour.

Early diagnosis and treatment is much easier for the better-off than the destitute. C ontrol over once destiny, even in sexual matters, is associated with one's social context (culture, education, sex, age, race, income, etc.). C ounseling and testing, family planning, antenatal care, condom distribution and many other services favor the richer section of the community.

W hat is more important is that all these factors tend to act in synergy on the poor.T his explains the disparity between the rich and the poor among and within countries regarding the distribution of H IV/AID S. T his inequity extends beyond risk of exposure to medical and social consequences; the poor being more likely to suffer from infections, malnutrition and stigmatization.

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