The Ouagadougou Declaration on Primary Health Care and Health Systems in Africa: Achieving Better Health for Africa in the New Millennium

Saidou Pathé Barry
Habib Somanje
Joses Muthuri Kirigia
Jennifer Nyoni
Khaled Bessaoud
Jean-Marie Trapsida
Jean Bosco Ndihokubwayo
Edoh William Soumbey-Alley
David Nyamwaya
Prosper Tumusiime
Ossy Kasilo
Alimata J Diarra-Nama
Chris Mwikisa Ngenda
Luis Gomes Sambo

World Health Organization, Regional Offi ce for Africa

Corresponding author: Saidou Pathé Barry
Email: barrys@afro.who.int

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ABSTRACT

The Ouagadougou Declaration on Primary Health Care and Health Systems in Africa focuses on nine major priority areas: 1) leadership and governance for health, 2) health services delivery, 3) human resources for health, 4) health fi nancing, 5) health information systems, 6) health technologies, 7) community ownership and participation, 8) partnerships for health development, and 9) research for health. This paper describes a framework constructed for implementing the necessary activities in each of these priority areas, and proposes recommendations for consideration by Member States in the development of their own country frameworks. The framework for implementing activities related to health information and research for health which have been taken into account in the Algiers Framework are discussed separately elsewhere in this issue.



RÉSUMÉ

La Déclaration de Ouagadougou sur les soins de santé primaires et les systèmes de santé en Afrique met l'accent sur neuf domaines prioritaires essentiels: 1) le leadership et la gouvernance pour la santé, 2) la prestation de services de santé, 3) les ressources humaines pour la santé, 4) le financement de la santé, 5) les systèmes d'information sanitaire, 6) les technologies sanitaires, 7) l'appropriation et la participation communautaire, 8) les partenariats pour le développement sanitaire 9) et la recherche pour la santé. Le présent document décrit un cadre élaboré afin de mettre œuvre les activités nécessaires dans chacun de ces domaines prioritaires et propose des recommandations - pour examen par les Etats membres - eu égard au développement de leurs propres cadres pays. Le cadre pour la mise en œuvre des activités liées aux informations sanitaires et à la recherche pour la santé, lesquelles ont été prises en compte dans le cadre de mise en œuvre de la Déclaration d'Alger, est traité séparément en d'autres endroits de la présente publication.

SUMÁRIO

A Declaração de Ouagadougou sobre Cuidados de Saúde Primários e Sistemas de Saúde em áfrica concentra-se em nove áreas de importância prioritária: 1) liderança e governação na área da saúde, 2) prestação de serviços de saúde, 3) recursos humanos para a saúde, 4) financiamento da saúde, 5) sistemas de informação de saúde, 6) tecnologias de saúde, 7) apropriação por parte da comunidade e participação, 8) parcerias para o desenvolvimento de saúde e 9) investigação em saúde. Este documento descreve o Quadro Orientador concebido para implementar as actividades necessárias em todas estas áreas prioritárias, e propõe recomendações a serem consideradas pelos Estados Membros na elaboração dos seus próprios quadros nacionais. O quadro orientador para implementação das actividades relativas à informação e à investigação para a saúde, que foram tomadas em consideração no Quadro Orientador de Argel, é apresentado separadamente neste número.


The Ouagadougou Declaration on Primary Health Care and Health Systems in Africa: Achieving Better Health for Africa in the New Millennium was adopted during the International Conference on Primary Health Care and Health Systems in Africa, held in Ouagadougou, Burkina Faso, from 28 to 30 April 2008(1). It was signed by all Member States of the African Region.

The objective of the Conference was to review past experiences on Primary Health Care (PHC) and redefine strategic directions for scaling up essential health interventions to achieve health-related Millennium Development Goals (MDGs) using the PHC approach for strengthening health systems through renewed commitment of all countries in the African Region.

The Conference recommended that WHO develop a framework for the implementation of its Declaration, and this framework is described here.

Background

There is a global movement to renew PHC, a call that has been echoed at international, regional and national conferences, including WHO Regional Committee meetings. The most recent call was by WHO's Executive Board(2).

The calls for a renewal of PHC reaffirm the commitment of Member States to the values of equity, solidarity and social justice, and the principles of multisectoral action, community participation and unconditional enjoyment of health as a human right by all. The calls represent the ambition to deal effectively with current and future challenges to health, mobilizing health professionals and lay people, government institutions and civil society around an agenda of transformation of health-system inequalities, service delivery organization, public policies and health development.

The Ouagadougou Conference was thus a part of this global movement, marking 30 years since the adoption of the Alma-Ata Declaration in 1978. The conference was organized in collaboration with the Government of Burkina Faso, UNICEF, UNFPA, UNAIDS, African Development Bank and the World Bank. Over 600 participants attended from the 46 Member States of the WHO African Region and from other continents.

In order to facilitate concrete actions, Member States requested the development of a generic framework for implementing the Ouagadougou Declaration. This Implementation Framework seeks to meet this request while recognizing that countries have different capacities for implementing the Declaration. In this context, the recommendations herein are generic and are to be adopted and adapted depending on country-specific situations.

Guiding Principles

The following guiding principles were consolidated from the Alma-Ata Declaration on Primary Health Care and other relevant policy documents and declarations, some of which are cited in the Ouagadougou Declaration:

Recommendations by Priority Areas

Since the Alma-Ata Conference on Primary Health Care, progress has been made by countries in the African Region with regard to the eradication of smallpox, control of measles, eradication of poliomyelitis and guinea-worm disease, and elimination of leprosy and river blindness. However, accelerated progress in strengthening health systems using the PHC approach is needed in a number of countries in the African Region in order to achieve nationally and internationally-agreed health goals, including the MDGs.

In this context, countries are encouraged to focus on the following priority areas, as outlined in the Ouagadougou Declaration: 1) leadership and governance for health, 2) health services delivery, 3) human resources for health, 4) health financing, 5) health information, 6) health technologies, 7) community ownership and participation, 8) partnerships for health development; and 9) research for health. As mentioned earlier, items 5 and 9 are covered elsewhere in this issue in the article on the Algiers Declaration framework.

Leadership and Governance for Health

Governance for health is a function of government that requires vision, influence and knowledge management, primarily by the Ministry of Health which must oversee and guide the development and implementation of the nation's health-related activities on the government's behalf. Governance includes the formulation of the national health policy and health strategic plans (including defining a vision and direction) that address governance for health and health equity; exerting influence through regulation and advocacy; collecting and using information; and accountability for equitable health outcomes.(10)

Provision of oversight through collaboration and coordination mechanisms across sectors within and outside government, including the civil society, is essential to influencing action on key health determinants and access to health services, while ensuring accountability. Improving leadership at national and sub-national levels and building capacity will facilitate effective engagement with the private sector to ensure universal coverage.

The Ouagadougou Declaration calls on Member States to update their national health policies and plans according to the Primary Health Care approach, with a view to strengthening health systems in order to achieve the Millennium Development Goals, specifically those related to communicable and non communicable diseases, including HIV/AIDS, tuberculosis and malaria; child health; maternal health; trauma; and the emerging burden of chronic diseases.

In relation to leadership and governance, countries are encouraged to consider the following recommendations for implementing the Ouagadougou Declaration:

Health Service Delivery

The ultimate goal of the health system is to improve people's health by providing comprehensive, integrated, equitable, quality and responsive essential health services. A functional health system ensures the enjoyment of health as a right by those who need it, especially vulnerable populations, when and where they need it as well as the attainment of universal coverage.

Health services delivery needs to be organized and managed in a way that allows effective and affordable health interventions that are people-centred and reach their beneficiary populations regardless of their ethnicity, geographical location, level of education and economic status. It is important to emphasize that consistent community actions towards health promotion and disease prevention are the most efficient and sustainable ways of ensuring better and equitable health outcomes.

The following recommendations for improving the performance of health service delivery are proposed for countries' consideration:

Human Resources for Health

Human resources for health (HRH), or the health workforce, refer to all persons primarily engaged in actions intended to enhance health. Health service providers are the core of every health system and are central to advancing health. Their numbers, quality and distribution correlate with positive outcomes of health service delivery(15). The objective of HRH management is therefore to ensure that the required health workforce is available and functional (effectively planned for, managed and utilized) to deliver effective health services(16).

In relation to human resources for health, the Ouagadougou Declaration calls for strengthening the capacity of training institutions, management, and staff motivation and retention in order to enhance the coverage and quality of care in countries. The following recommendations are proposed for Member States' consideration:

Health Financing

Health financing refers to the collection of funds from various sources (e.g. government, households, businesses and donors) and pooling them to pay for services from public and private health-care providers, thus sharing financial risks across larger population groups. The objectives of health financing are to make funding available, ensure rational selection and purchase of cost effective interventions, give appropriate financial incentives to providers, and ensure that all individuals have access to effective health services.

In relation to health financing, the following recommendations are proposed for consideration by Member States:

Health Technologies

Health technologies includes the application of organized technologies and skills in the form of devices, medicines, vaccines, biological equipment, procedures and systems developed to solve a health problem and improve quality of life. E-health applications (including electronic medical records and tele-medicine applications) and traditional medicines are included within the scope of health technologies. Health technologies are essential when they are evidence-based, cost-effective and meet essential public health needs.

In relation to health technologies, the following recommendations are proposed for Member States' consideration:

Community Ownership and Participation

Community ownership in the context of health development refers to a representative mechanism that allows communities to influence the policy, planning, operation, use and enjoyment of the benefits arising from health services delivery. This results in increased responsiveness to the health needs of the community. It also refers to the community taking ownership of its health and taking actions and adopting behaviors that promote and preserve health. Community organizations, NGOs as well as intersectoral interaction play an important role in facilitating creation of an enabling environment for communities to accept their roles.

In general, community-based activities have been left largely to community-based and nongovernmental organizations, often without appropriate policy on community participation in health development or coordination, guidance and support by public-sector institutions. There exists a proliferation of externally-driven processes that do not promote community ownership. In addition, health services have tended to use vertical approaches rather than building on what already exists in the communities from other sectors, including local authority structures and functions.

In order to improve community ownership and participation, the following recommendations are proposed for Member States' consideration:

Partnerships for Health Development

Partnerships for health are relationships between two or more organizations that jointly carry out interventions for health development. Each partner is expected to make financial, technical and material contributions. An effective partnership requires government stewardship and mutual respect between partners, as well as accountability to ensure coordinated action aimed at strengthening health systems.

Intersectoral action for health among health and non-health sectors is a key strategy to achieve policy coherence and for addressing, more generally, the social determinants of health and health equity.

Global momentum towards the attainment of internationally-determined health goals has led to a growing number of high-profile initiatives. These include the GFATM, GAVI, Stop TB, Roll Back Malaria, PEPFAR, and the Catalytic Initiative, among others.

In order to strengthen partnerships for health development, the following recommendations are proposed for Member States' consideration:

Roles and Responsibilities of Stakeholders

Countries

The Ouagadougou Declaration will be implemented through government commitment and use of the PHC approach countrywide to improve the health status of the people. Country stakeholders include governments, communities and the civil society, including NGOs, professional associations and private health-care providers. Countries should recognize the pivotal role of communities and effectively involve them in health development. Existing coordination mechanisms should be reinforced including strengthening national intersectoral committees taking into account the current context of PHC renewal.

African Union Commission and Regional Economic Communities

Other Stakeholders and Partners

Other stakeholders include UN agencies, bilateral partners, financial institutions, international and global health initiatives and foundations. They could support national and local coordination mechanisms, and provide integrated support to countries to strengthen their national health systems. They could also support countries to build their institutional capacities for coordination.

WHO country teams should incorporate the priority areas of the Ouagadougou Declaration in the development of their updated country cooperation strategies. Other UN agencies, as well as bilateral partners, could also take into account the Declaration in the development of their plans. International funding institutions could increase their financial support to facilitate the implementation of the Declaration by governments. Stakeholders could work towards effective harmonization and alignment to maximize support to countries for the implementation of the Declaration.

Monitoring and Evaluation

The Ouagadougou Declaration requested WHO, in consultation with Member States and other UN Agencies, to establish a regional health observatory and other mechanisms for monitoring the implementation of the Declaration, and to share best practices.

In collaboration with all the relevant partners whose roles are specified in the Declaration, WHO will set up a regional health observatory based on this Implementation Framework. To this end, WHO will develop a monitoring framework for the implementation of the Declaration; identify selected and standardized indicators to show trends in progress made by countries; and promote the sharing of best practices among countries.

Countries therefore are expected to strengthen monitoring and evaluation to measure their progress; improve implementation; and provide relevant and good quality data in a timely manner to allow the processing of indicators at the regional level. To ease the processes of collecting, analysing and reporting data to the WHO Regional Office, the monitoring framework will provide guidance on types of information, possible data sources for each indicator and periodicity of reporting.

Conclusion

In conclusion, countries are expected to use this Framework, adapted to their own specific situations, by taking into account the progress made and the efforts needed for better and more equitable health outcomes. The Regional Committee is requested to endorse the Framework and urge Member States to put in place monitoring frameworks that feed into the national and regional observatories. Partners are expected to support countries in a harmonized and predictable manner that reduces fragmentation during the implementation of the Ouagadougou Declaration.

It is expected that the implementation of the Ouagadougou Declaration by countries will contribute in accelerating progress towards the achievement of the MDGs, and reduce the inequities and social injustices that lead to large segments of the population remaining without access to essential health services.


ACKNOWLEDGEMENTS

PROCESS OF DEVELOPING THE FRAMEWORK

The development of the framework described here was accomplished through exceptional leadership, guidance and coordination provided by Dr Luis Gomes Sambo, the Director for the WHO Regional Office for Africa. In accordance with the nine priority areas identified in the Ouagadougou Declaration, the Division of Health Systems and Services Development shared responsibilities for drafting the Framework among selected staff in the Regional Office and Intercountry Support Teams. A small team comprising the programme managers of health policies and service delivery, health financing and social protection and the Regional Advisor on Human Resources for Health Management participated in a three-day meeting in Pointe Noire, Republic of Congo, to improve the first draft.

The framework was reviewed as a draft by Programme Managers in the Division of Health Systems and Services Development in relation to their areas of work and health promotion in DNC. The draft was then opened to wide consultations at country level. A number of countries made substantive inputs through the WHO Country Offices. All the inputs and the draft were extensively discussed during a regional consultative meeting which was attended by representatives from the ministries of health, academic and research institutions, all levels of WHO, partners (UNICEF, UNFPA, World Bank, UNAIDS) and NGOs. The invaluable contributions made by the individuals representing these stakeholders are highly appreciated. The consolidated draft was submitted to Members of the Programme Sub-Committee, whose inputs were integrated. During the 59th Regional Committee held in Kigali, Rwanda in September 2009, Ministers of Health in the African Region adopted the Framework and requested WHO support for its adaptation and adoption at country level.

The Regional Director, Dr Luis Gomes Sambo recommended expanding the discussions on priority areas of the Framework in future Regional Committee meetings.




PROCESSUS DE DEVELOPPEMENT DU CADRE

Le développement du cadre ici décrit a été exécuté avec brio sous l'autorité, le conseil et la coordination du Dr Luis Gomes Sambo, le Directeur pour le Bureau Régional de l'OMS en Afrique. Conformément aux neuf domaines prioritaires identifiés dans la Déclaration de Ouagadougou, la Division des Systèmes et Services de Santé a partagé les responsabilités, pour préparer le cadre, entre le personnel sélectionné au Bureau Régional et des équipes Inter-pays. Une petite équipe, composée de responsables de programme pour les politiques de santé et la prestation de services, le financement de la santé et protection sociale, ainsi que le Conseiller Régional en ressources humaines pour la santé ont participé à une réunion de trois jours à Pointe Noire, République du Congo, dans le but d'améliorer la version préliminaire.

Dans sa version préliminaire, le cadre a été passé en revue par des responsables de programme de la Division des Systèmes et Services de Santé, en fonction de leurs attributions professionnelles et en lien avec la promotion de la santé à la Division de la Prévention et de la lutte contre les Maladies non Transmissibles (DNC). La version préliminaire a alors été soumise à de larges consultations au niveau des pays. Un certain nombre de pays ont formulé des remarques importantes par le biais des Bureaux de pays de l'OMS. Toutes les remarques et la version préliminaire ont fait l'objet de discussions approfondies durant une réunion de consultation régionale, à laquelle des représentants des ministères de la santé, des institutions universitaires et de recherche, tous les niveaux de l'OMS, des partenaires (UNICEF, UNFPA, Banque mondiale, ONUSIDA) et des ONG ont participé. Les contributions inestimables effectuées par les individus qui représentent ces parties prenantes sont grandement appréciées. La version remaniée a été soumise aux membres du Sous-Comité du Programme, dont les remarques ont été intégrées. Durant le 59e Comité régional qui s'est tenu à Kigali au Rwanda en septembre 2009, les ministres de la santé de la Région Africaine ont adopté le cadre et sollicité le soutien de l'OMS pour son adaptation et son adoption au niveau des pays.

Le Dr Luis Gomes Sambo, Directeur Régional, a recommandé d'étendre les discussions aux domaines prioritaires du cadre durant les futures réunions du Comité régional.

PROCESSO DE DESENVOLVIMENTO DO QUADRO ORIENTADOR

O desenvolvimento do Quadro Orientador descrito neste resumo foi conseguido graças a uma liderança, orientação e coordenação excepcional por parte do Doutor Luis Gomes Sambo, o director do Escritório Regional da OMS para áfrica. De acordo com as nove áreas prioritárias identificadas na Declaração de Ouagadougou, a Divisão de Sistemas de Saúde e Desenvolvimento de Serviços partilhou as responsabilidades do desenvolvimento do quadro orientador com colaboradores selecionados a nível do Escritório Regional e com as Equipas de Apoio Inter-país. Uma pequena equipa composta por gestores dos programas de políticas de saúde e prestação de serviços, financiamento da saúde e protecção social e pelo conselheiro regional dos Recursos Humanos para a Gestão da Saúde participaram num encontro de três dias em Pointe Noire, República do Congo, para melhorar o primeiro projecto de documento.

O quadro orientador foi revisto pelos gestores dos programas da Divisão dos Sistemas de Saúde e Desenvolvimento de Serviços , no que respeita às respectivas áreas de trabalho,e pelo gestor do programa de promoção da saúde na Divisão de Doenças Não Transmissíveis. O projecto de documento revisto foi então submetido a consultas públicas a nível dos países. Diversos países deram contributos substanciais através dos Escritórios Nacionais da OMS. Todas as contribuições e o próprio projecto de documento foram submetidos a uma discussão extensa durante uma reunião regional de consulta em que participaram os representantes dos Ministérios de Saúde, instituições académicas e de investigação, representantes da OMS de todos os níveis, parceiros (UNICEF, UNFPA, o Banco Mundial, UNAIDS) e ONG's. Os contributos valiosos feitos pelas pessoas em representação destas institutições são muito apreciados. O projecto de documento consolidado foi entregue aos membros do Sub-Comité de Programa, cujos contributos foram também integrados. Durante a 59ª sessão do Comité Regional em Kigali, Ruanda, realizado em Setembro de 2009, os Ministros de Saúde da Região Africana adoptaram o Quadro Orientador e pediram à OMS ajuda para a sua adaptação e adopção a nível nacional.

O Director Regional, Doutor Luis Gomes Sambo, recomendou o alargamento da discussão em áreas prioritárias do Quadro Orientador em futuras reuniões do Comité Regional.

REFERENCES