The sustainability of widespread district health management in Sub-Saharan Africa is difficult to assess. Sustainability is often reported as offset by regressive social trends, cutbacks in public services and a widening income disparity between rich and poor. District health management is not a magic bullet. The initial euphoria has to be replaced by a more balanced and cautious approach focussed on a more equitable social order conductive to health.
The district health system provides a comprehensive packet of health services for a given catchment area. Community involvement is aimed to be a cornerstone of the system. The rationale for the organisation of health services in a district format are based on the minimisation of the loss of individual and collective autonomy through socially acceptable solutions. The self-confidence of individuals and community are to be valued and strengthened. Solutions should be in harmony with the socio-economic context.
In theory, the district health management partly challenges technological solutions to social problems. In practice, due to fragmented implementation and project cycles, underlying socio-economic and political causes of health problems are almost entirely ignored. The comprehensive health strategy of Primary Health Care remains often shortly lived and the disease is not put in the social context. District health management often leaves effective local community empowerment isolated.
More than ever, the need for a unified effort from the bottom up is needed. The concept of a Health district system in rural settings in Sub-Saharan Africa must not be abandoned but the implementation strategies should learn from frequent implementation weaknesses.
Although we are critical of the way district health management is implemented, we recognize that this spearheaded management concept has contributed in saving millions of lives, at least temporarily. Its conceptualization is based on the comprehensive Primary Health Care approach which is a great step forward in terms of meeting the needs of all people through participatory and equity-building action.
Many of the goals set for district health management have not been realized. The earlier, more ambitious goals now appear more distant than ever especially in the poorest nations and communities of Sub-Saharan Africa. We must go beyond alternatives such as Selective Primary Health Care and quick-fix technologies.
A comprehensive strategy is needed. Not only concepts and word on poverty alleviation but an effective strategy that extends beyond the health sector and combats the structural causes of poverty, malnutrition and poor health.
The health sector must work closely with other social and economic sectors, to assure that the needs and the rights of women, children and other vulnerable groups are put first. Social and political causes of poor health should no longer be described as constraints in the health district logical framework planning. Relevant and empowering schooling and awareness-raising must be encouraged and enabled. Sustained demand from an informed and organized population is needed towards a health promoting society enabling managerial approaches such as district management to stand a chance of sustainable success.
*Paper by Ignacio Packer, health economist working at Terre des hommes, following a presentation at the H.A.S. Haiti Alumni Association Europe Reunion, July 7th-9th 2000 in Quarten, Switzerland. Contact: ipa@tdh.ch.
