CONFERENCE INTERNATIONALE SUR LES SOINS DE SANTE PRIMAIRES ET SYSTEMES DE SANTE EN AFRIQUE OUAGADOUGOU, BURKINA FASO, 28

1. CONFERENCE INTERNATIONALE SUR LES SOINS DE SANTE PRIMAIRES ET SYSTEMES DE SANTE EN AFRIQUEOUAGADOUGOU, BURKINA FASO, 28-30 AVRIL 2008 «DECENTRALIZATION AND DEVELOPMENT OF THE PRIMARY CARE OF HEALTH IN AFRICA » COMMUNICATION OF MR BAMBA CHEICK DANIEL

2. OBJECT OF PRESENTATION • Contribution in cogitation on: -the revitalization of the primary care of health in the African countries, - the pronunciation reinforced between the processes of political and administrative decentralization and the development of the primary care of health.

3. PLAN OF PRESENTATION I. ILLUMINATION ON THE CONCEPT OF DECENTRALIZATION II. DECENTRALIZATION OF THE SERVICES OF HEALTH AND DEVELOPMENT OF THE PRIMARY CARE OF HEALTH III. OF NECESSARY PRONUNCIATION BETWEEN DECENTRALIZATION AND PRIMARY CARE OF HEALTH IV. PERSPECTIVES AND PROPOSALS V. CONCLUSION

4. I. ILLUMINATION ON THE CONCEPT OF DECENTRALIZATION Re-emergence and amplification of the common advocate of decentralization at the beginning of the eighties. Today more than 90 % of developing countries test a form of decentralization. Terminological ambiguity to be raised on the concept of decentralization: differentiation between the notions of "Decentralization" and "Decentralization".

5. I. ILLUMINATION ON THE CONCEPT OF DECENTRALIZATION • Administrative decentralization: management system where utility hierarchically attached to a central administration from which they are break-up and extension. • Decentralization: management system where clean powers are conferred on an entity distinct from the central administration.

6. I. ILLUMINATION ON THE CONCEPT OF DECENTRALIZATION Two variants of decentralization: • Technical or functional when there is transfer of authority of a particular function, in a local specialized office (case of the Ministry of Health and the regions); • Territorial or geographical when it is decentralized groups. The State transfer and entrusts to organs endowed with the moral personality, with competences and with the powers of decision and with management on a territorial spring.

7. I. ILLUMINATION ON THE CONCEPT OF DECENTRALIZATION Our communication aims to introduce the important lever which can constitute the territorial decentralization to the advantage of the development of the Primary Care of Health.

8. I. ILLUMINATION ON THE CONCEPT OF DECENTRALIZATION • Objectives: - better adapt utility to local priorities and to reinforce the State of right, - transfer powers, competences, property and means of central level at regional and local levels, - reinforce the capacities of the concerned local authorities, - develop near initiatives.

9. I. ILLUMINATION ON THE CONCEPT OF DECENTRALIZATION • Stakes: On political plan - a requirement of democratic process and re-legitimization of public action by the building of a local democratic governance in the fact that it: - favor initiative and popular control, - favor popular participation and contribute to reinforce the process of ongoing democratization, - holder of a lot of hopes for populations, notably for emergence of an active local political life is.

10. I. ILLUMINATION ON THE CONCEPT OF DECENTRALIZATION • Stakes: On administrative plan - contribute to the rapprochement of the administration of the constituents, - and returns it, so, more approachable and in even to react more promptly and efficiently to solicitations of populations, - especially, thanks to the existence of two parallel and supplementary administrations: the decentralized administration which precedes and accompanies the decentralized administration

11. I. ILLUMINATION ON THE CONCEPT OF DECENTRALIZATION • Stakes: On socioeconomic plan • privileged instrument of local development which favors the emergence of basic initiatives, • and, a better draft of local means for impulse the economic development process and social, • contribute to the strengthening of the effectiveness of international help or infranationale in part the prerogatives of programming of actions and management acknowledged in regions with a measure of autonomy.

12. I. ILLUMINATION ON THE CONCEPT OF DECENTRALIZATION • Stakes: On the plan of town and country planning • better sharing out of economic activity and job throughout the national territory, • promotion of the leaders-places of districts in more substantial economic poles of development, • alleviation of the country exodus by thesettlement of the country populations and the promotion of country development.

13. I. ILLUMINATION ON THE CONCEPT OF DECENTRALIZATION Essential problems: • The effective of the transfer of competences by the real transfer of the means of central Power in aid of the decentralized groups. • Absorbency by the regions with a measure of autonomy of transferred competences: deficiencies in local capacities and financial pauperization of these groups make them incapable to take these transferred competences.

14. I. ILLUMINATION ON THE CONCEPT OF DECENTRALIZATION The results: • Impulsion, in the most part of the African countries, of the process of participation of all the actors in definition and implementation of negotiated policies. • At the beginning of a democratic rooting and the effectiveness of public policies. • Strengthening and transformation of the local governance into laboratory of citizenship and development.

15. I. ILLUMINATION ON THE CONCEPT OF DECENTRALIZATION Pressures: • On societal plan, democratic deal still collides with the resistance of certain institutions (kingship and chefferies), stocks and norms of the traditional African societies with which it is still difficult to find a general agreement for the management of local business. • The lack of political will asserted by African powers to get rid really of certain competences, giving support so to the resistance of the ministerial departments.

16. II. DECENTRALIZATION OF THE SERVICES OF HEALTH AND DEVELOPMENT OF THEPRIMARY CARE OF HEALTH • Objectives resulting from the initiative of Bamako (1987): 1.the necessity to create mechanisms of self-financing of SSP at the level of the region, 2.the promotion of social initiative with a view to favoring Community participation as part of policies relating to essential medicaments and to health of the child, 3.the guarantee of regular supply in good quality essential medicaments at lesser expense in favour of SSP.

17. II. DECENTRALIZATION OF THE SERVICES OF HEALTH AND DEVELOPMENT OF THEPRIMARY CARE OF HEALTH • The health region: strategical foundation of development of SSP and Community participation. • Appraisal: pressures and results -Unsatisfactory balance sheet, two decades after the Initiative of Bamako of numerous phenomena still mortgage the development of SSP: -quick urbanization and in no way controlled on health plan;

18. DECENTRALIZATION OF THESERVICES OF HEALTH ANDDEVELOPMENT OF THEPRIMARY CARE OF HEALTH the pitiful national economic performances accompanied with a heavy load of debt and deterioration of the terms of exchange; the deterioration of social situation owing to growing difference for the access to basic social welfare to the populations of urban and country circles; the deterioration of environment sociopolitical: recrudescence of armed conflicts, influx of the refugees and the food scarceness which were translated by well brought up levels

19. II.DECENTRALIZATION OF THESERVICES OF HEALTH AND DEVELOPMENT OF THEPRIMARY CARE OF HEALTH the insufficiency of the manager capacities of basic communities and the well brought up rates of illiteracy: the programs of training and settlement of the health workers at the level of the village disintegrated in numerous countries; the absence of real taking over of the plans of SSP in the profitable countries because of the proper non-involvement of communities in the process of catch of decision.

20. III. OF NECESSARY PRONUNCIATION BETWEENDECENTRALIZATION AND PRIMARY CARE OF HEALTH Toutes les législations africaines semblent concourir à cette fin, avec le vœu affiché d’en accélérer le rythme. Justifications, objectifs et enjeux : • La décentralisation induit un rapprochement substantiel des centres de décisions et ainsi facilite l’expression des besoins, jusque là latents, faute d’interlocuteurs rapprochés. • Les Collectivités décentralisées semblent plus aptes à fournir ou soutenir avec efficience la mise à disposition et l’accessibilité des populations aux soins de santé primaires de la façon la plus viable et la plus pérenne.

21. III. DE LA NECESSAIRE ARTICULATION ENTRE DECENTRALISATION ET SOINS DE SANTE PRIMAIRES • Les SSP suscitent un défi en matière de gestion : comment concilier l’autorité du pouvoir central et un degré considérable de décentralisation et surtout réussir une gestion participative véritable à la base ? • Contraintes : Elles concernent principalement : • La complémentarité insuffisante entre les Collectivités décentralisées (Conseils Généraux, Municipalités) et les services de la santé publique.

22. III. DE LA NECESSAIRE ARTICULATION ENTRE DECENTRALISATION ET SOINS DE SANTE PRIMAIRES • L'aire géographique de compétence des collectivités décentralisées coïncide rarement avec les districts sanitaires : La conséquence en est l'existence de difficultés dans la gestion des fonds de dotation qui sont domiciliés dans les collectivités locales, les communes en particulier. • La décentralisation des responsabilités est rarement accompagnée de la décentralisation des ressources et des pouvoirs décisionnels. • La lenteur dans la mise en œuvre de processus de restructuration des systèmes sanitaires et de développement des capacités.

23. IV. PERSPECTIVES ANDPROPOSALS Perspectives: The main reasons to hope for the emergence of a synergy of the interventions of all actors are: • the free administration of regions with a measure of autonomy, • the fact that the State, of ubiquitous guardian and obliged coordinator, became a partner joining other actors, • legitimacy that decentralization gave in the participation of populations, directly or by the channel of associative movement, • the political commitment asserted to organize the development

24. IV. PERSPECTIVES AND PROPOSALS • Proposals: 1.Conditions of success of pronunciation between decentralization and development of the primary care of health: 2.a strong enough political will at central and local levels to support initiative and process; 3.a total policy of information and sensitization of the actors and development of competences at all levels: Governors, Mayors but also prefectural Authorities and usual Authorities;

25. IV. PERSPECTIVES AND PROPOSALS Conditions of success of pronunciation between decentralization and development of the primary care of health (suite): • an apparently defined plan of implementation; • a lawful administrative frame delimiting the powers of each of the actors; • appropriate means; • the transfer of a management anda financial responsibility more pushed to the health regions.

26. IV. PERSPECTIVES AND PROPOSALS 2. The standardization of the territory of the region with that of a decentralized defined well entity (village or department). 3. The systematic institution of participative budgets in House of Commons and health Regions. The participative budget is a new process of direct participation of a community in the management of its public affairs.

27. IV. PERSPECTIVES AND PROPOSALS 4. Systematization, by lawful texts, of a structure of interface and collaboration or even of popular participation within the decentralized groups and the health regions. 5. Redevelopment at the level of the African public finances of the principle of the uniqueness of case to favor the financing of the primary care of health: this by a direct transfer of means concerning them in regions with a measure of autonomy and concerned health regions.

28. V. CONCLUSION Introduced strategical approach can constitute only one of the levers, among so many others, to contribute to the development of the primary care of health. The increase of the Africans savings remains an inevitable condition: the policy of development of the primary care of health in Africa is taken in the vise of the vicious cycle « economic poverty which procreates the health poverty which supports economic poverty ». Quadrate which can be broken only by the dévelo

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