Private governance of health centres and fragility - call for testimonies

Bruno Meessen and Mohamed Ali Ag Ahmed 

The security situation continues to deteriorate in several parts of Africa. The delivery of primary health care is in jeopardy. This critical situation raises the question of the resilience of health services. The Francophone Africa and Fragility network (AFRAFRA) looks for your testimonies and reflections. You can react under this blog or directly on our online forum. 

In several African countries, the disengagement of the State in the organization of health services is not new. Often, communities have organized themselves and taken their fate into their own hands. They have built a health centre, recruited a nurse, etc..
​
In some countries, this community potential has been turned into policies. Mali remains the best example of such an approach. In this country, it is quite a while that various actors have recognized the structural weaknesses of the State and the need to  entrust the management and organization of health services to communities. This has led to the establishment of the CSCom (Community Health Centre) model: health centres are owned by local communities. The local community health association (ASACO) leads the construction of the health centre, owns the stock of medicines, recruits staff and manages the health centre as an independent economic entity. This model has its drawbacks, but at least, parties have acknowledged the deadlock, dared to reconfigure the role of the State (with a concentration on certain key functions) and formalized this new role with specific institutional arrangements (the ASACOs are non-profit associations).

At the same time, in Mali as elsewhere, the same structural weaknesses of the state have favoured the development of the private sector. The regulation of the latter is still quite problematic, but private providers provide a significant share of health services to the population. Those private providers are often from the local community.

A new perspective?

Let's stay in Mali to continue our reflection. In 2012, when the armed conflict started in the North, many government officials working in the health system  fled to the safer south. At the time, however, this departure did not lead to the collapse of the health system. As communities were already in charge of health facilities reorganized very quickly. This may have facilitated the intervention of international organizations that took over from the state in several areas. Similarly, private providers in the three northern regions continued to offer health services to the population.
This resilience, which stems from the fact that the people in charge of the health centres are from the community (and not representatives of the central State), seems to us to deserve more attention. The case of Mali is certainly not unique. Elsewhere in Africa, in other contexts where the state has not been able to duly perform its mission, , communities and private actors (including faith-based organizations) have also, to some extent, taken over .

Shouldn't this private initiative and its sustainability be reappreciated?

The growing fragility in the Sahel region, but also in Central Africa, now affects areas that were not confronted with insecurity in the past. We are therefore now facing with at least two configurations: areas where communities have long been confronted with the need to take their fate into their own hands, and areas where this investment in autonomy did not take place because the State fulfilled key functions. It cannot be excluded that in a context of more widespread security deterioration, the former are now better off.

We would be interested to hear testimonies, possibly supported by data, to appreciate whether this hypothesis has any value. When insecurity increases (1), does a past history of (deliberate or endogenous) delegation of health services to community actors become an asset or not (because in the meantime, a certain resilience has been built up)?  If it is an asset, is the benefit visible for all services or is it limited to some (e.g., curative care) and not observed for others (e.g., immunization)? (2). We are also interested in learning more about the current situation in areas that tend to correspond more to the second case (previous reliance on the central state). Under this scenario, how easy is it to maintain a health worker presence? Does the community react? Can it otherwise reorganize itself quickly?

The purpose of this discussion is of course not to encourage the state to disengage. It goes without saying that a well-functioning health system requires a strong investment by the State, including effective regulation. Our purpose is rather to circumscribe, with pragmatism, what community mobilization at the level of health centre governance and private sector development can bring in terms of resilience. On a theoretical level, the idea has its appeal, but the priority is to generate and review the evidence.

If you are based in the areas concerned, if you have some routine data, if as a researcher you are currently exploring the relationship between security and health service provision, if you have concrete experience to share, we are interested in your contributions.

Notes:
(1) Here we consider situations where minimal security persists. We do not consider the situation where the community also decides to flee insecurity.
(2) We are well aware that there is currently a major measles outbreak in DRC. This reminds us that health cannot be managed in autarky!