Decentralised health systems will improve services

Dr Yvan Butera European colonisation was a terrible one-way relationship where one party, the coloniser, constantly dug resources - whether it is workforce or raw material-without instilling any sustainable profit towards the opposite party, Africa. One marked heritage from the colonial mindset, inherited by many previously colonised African countries, is the fact that health facilities are solely concentrated in urban areas. This was designed to fit economic interests of colonisers by focusing service delivery in important ports and urban centers in order to keep their workforce healthy. This, in turn, resulted in a quasi-vacancy of health facilities in rural areas that is still noticed todate. Colonial medicine was marked by a centralized health system tainted by racism in the sense that they assumed that, apart from its direct workforce, the rest of the population was not eligible or important enough to benefit from health services. This was a violation of one of the fundamental human rights: The right to health. The selective access to health installed by colonizers aimed at maximising the increase in local crops production for exportation, minerals extraction and wealth creation. The economy of certain African countries is still suffering from this system. This can be illustrated with the case of Zambia where even after colonisation the economy remains largely dependent on tax money from copper exportation. Consequently, when commodity prices fell on the global scale, there was a significant reduction in profit retrieved from taxes. This is how Zambia was pushed to borrow money from the World Bank and the International Monetary Fund in order to keep its wheels going. However, these institutions obliged a series of structural adjustment programs guided by a neo-liberal philosophy (I won’t go into details here – this might be a topic for another day) that ultimately led to further underinvestment in health and social infrastructure. This did not help ease the already existing scarcity of health facilities in rural Zambian areas. Following the same colonial mindset, colonisers only delivered to its workforce information they judged beneficial for the coloniser’s development. The aim wasn’t to educate the whole population in order to develop a given country. The coloniser’s mindset could be simplified into one question: What do we need to teach them in order to be able to extract all the raw material we need? This furthered the gap between the western and African civilization and helped feed horrendous and racist beliefs discriminating against Africans’ intellectual abilities. For example, in 1925, the French anthropologist Lucien Lévy-Bruhl publicised the outrageous theory of “primitive mentality” that postulated structural differences between the “primitive” and “western” mind. The continuation of this belief is still seen in this century - In 2001, the head of the U.S. Agency for International Development (USAID) openly stated that antiretroviral therapy would fail in Africa because Africans “don’t know what Western time is.” He asserted that certain Africans would be unable to adhere to their medication courses, noting, “You say, take it at ten o’clock, they say, what do you mean, ten o’clock?” He iterated that only prevention was possible, and rejected the idea of having prevention and treatment go hand in hand. One can only imagine how many lives got lost as a consequence of not having access to anti-retroviral therapy, as a result of the socially constructed notion of “primitive” versus “western minds”. Thanks to the ever- growing fields of technology that are permitting the rapid globalization of information, education is no longer bounded by geographical location. We are able to get exposed to different ideas, see the world from different perspectives and be able to gather all that info, and mold it in a way that will permit us to implement things like health delivery models that fit each African country’s social and geographical context. Great minds from different locations can easily connect to work on more efficient and equity-bound health systems. The current approach to global health looks promising for addressing and reversing legacies left behind by colonial medicine. Africa could learn a thing or two from what Rwanda is doing. Based on the most recent Demographic and Health Survey, more than 92 per cent of Rwandan infants are vaccinated against ten different diseases. In the same optic, Rwanda has registered the world’s record of steepest decline in children under five mortality rates in a period as short as 2010-2015. This was done through investment in health systems strengthening where health facilities at all levels have sufficient trained workers, materials and medicines, and infrastructure coupled with government designed policies, implementation plans, and support from different stakeholders. Another critical point for success was the decentralisation of health care provision, aiming for an integrated delivery of quality health care to the lowest level in the community. Rwanda is building on community health workers as one of the solutions in breaking, among other things, the access barrier that vulnerable populations (especially the poor) face in reaching clinics. Additionally, in designing health policies, we need to critically self-reflect on how to make “the last mile delivery” possible. Meaning, the people mostly in need of healthcare can actually get it without experiencing financial hardship. We live in a world where, thanks to innovative technologies, great minds are able to connect from miles apart. We are flooded by literature and research on different topics that can help each individual country better their social system by learning from practices that have worked in other parts of the world. Once we all understand that the globalisation of information is a powerful tool that can help educate and train millions of local personnel, thus enriching each African country’s human resources, then we can help eradicate obscene theories such as differences in Western and African minds. We can, subsequently, work toward great things such as decentralised health systems across Africa that strive for the human right to health for all regardless of social or geographical context.