Africa is under the triple burden of communicable disease, non-communicable disease and socio-behavioral illness exacerbated by illiteracy, poverty and underdevelopment. Considerable efforts have been made by different players to improve the population health in the region. However, to deal with this situation, health systems in the region have placed more emphasis on disease management and not on the “causes of causes" that are the social determinants of health (SDH). Considering seven globally known documents/declarations, we came to the conclusion that African health systems perform interventions as “Ministries of disease” for the greatest part of health expenditures in countries of the African region is meant for disease management. They were not able to reach the Millennium Development Goals (MDGs) in 2015 with that approach. In the perspective of the Sustainable Development Goals (SDGs), there is a need for the paradigm shift in order to effectively improve the population health.

Keywords: social determinants of health, health system strengthening, sustainable development goals, Africa, ouagadougou, malaria, tuberculosis, cholera, acute respiratory infections, ebola, lassa, particular agriculture, animal husbandry, food, industry, education, housing, public works

AAS, action across sectors; BI, bamako initiative; CV, community volunteers; HiAP, health in all policies; MDGs, millennium development goals; PHC, primary health care; SDGs, sustainable development goals; SDH, social determinants of health; WHO, world health organization

Africa is under the triple burden of communicable disease, non-communicable disease and socio-behavioral illness exacerbated by illiteracy, poverty and underdevelopment.¹ Different health players are fully aware of the situation as expressed in the WHO Declaration of Ouagadougou.² However, to deal with this situation, health systems in the region have placed more emphasis on disease management and not on the “causes of causes" that are the social determinants of health (SDH). This was recognized as one of the reasons why it was not possible for countries in the region to reach the Millennium development goals (MDGs) in 2015.³ In the perspective of Sustainable Development Goals (SDGs), is it not time to examine why things must happen that way in this part of the world? As concerned players, we critically consider the situation in view of analyzing some aspects that could explain it before concluding on the need for a paradigm shift and future prospects. For that purpose, we considered seven main documents/declarations selected based on the fact that they are globally adopted documents focusing on the social determinants of health (SDH) and action across sectors (AAS) for effective improvement of population health. Table 1 shows the list of those documents/declarations.

Historical development of health systems in Africa

In Africa, health-related challenges are many including malaria, tuberculosis, cholera and acute respiratory infections. These conditions are preventable, and non-communicable diseases as well as emerging and reemerging diseases such as Ebola, Lassa fever and Marburg fever are significantly adding to the burden.⁴ Despite this somewhat alarming picture, we must recognize that efforts are being made to deal with ill/health in the African region, e.g. the Ouagadougou Declaration.² Although these efforts are strongly supported by all the players in the region, it is clear that health in Africa is still a huge challenge and needs to be reconsidered given that various diseases have never been able to be "rolled back" despite the existence of an effective therapeutic regiment (preventive and curative) and the commitment of many partners in various efforts to control them.^1,4

Health systems in Africa with the challenges of improving population health indicators

Since independence in the early 1960s, Africa has been poorly prepared to take care of itself despite its many natural resources. Poor human resources particularly in the field of health, and significant lack of well-trained and high level professionals have become a great concern for health systems management.⁵ Later on, when PHC was adopted in 1978,⁶ African countries were highly represented and found there an opportunity to revive their health systems that need a new life. In the enthusiasm of the PHC implementation, countries quickly realized the difficulty to fund such care. Hence the Bamako Initiative (BI) was adopted in 1987. Implementation of the BI has been most successful in respect of costs recovery but not in the rehabilitation of health indicators.⁷ Experts in the field have unanimously recognized that PHC and BI had failed in Africa, mainly due to the health systems weakness.^2,5 In order to provide a solution to the situation of poor health indicators in the region, countries adopted the MDGs which have not been achieved by the vast majority of them.¹

Health systems and concepts in Africa

Health professionals in Africa are doing their best, working with great enthusiasm. However, there is a problem related to the use of some concepts/approaches/strategies.⁷ Most of the strategies, approaches, and declarations that are adopted and implemented at the international level with great success outside Africa, have not always had this effect on that continent. In regard to PHC and the MDGs as examples of approaches that failed in the African context, let’s have a closer look. The failure of primary health care in Africa is confirmed by the Ouagadougou Declaration² and the WHO through the World Health Report 2008.⁵ Among the reasons of this failure, there is partial implementation of the PHC approach as noted through issues like research which was supposed to support the PHC process [6, p2]. Contrary to what is suggested in regard to research, PHC practice in African countries was merely accompanied with research as it is for most of the strategic orientations of the health systems in the region.^7,8 PHC encourages addressing the main health problems in the community, providing primitive, preventive, curative and rehabilitative services accordingly [6, p2]. Dealing with health problems must be then conducted in a holistic manner, and not with the major emphasis on curative services as it has been the case in the African region up to now.⁹ PHC includes at least eight components: education concerning prevailing health problems and the methods of preventing and controlling them; promotion of food supply and proper nutrition; adequate supply of safe water and basic sanitation; maternal and child health care, including family planning; immunization against major infectious diseases; prevention and control of locally endemic diseases; appropriate treatment of common diseases and injuries; and provision of essential drugs [6, p2]. It is known that health systems in the African region haven’t taken into account entirely these components.^7,8 According to PHC, Health is not only the health sector’s concern⁹ for it involves, in addition to the health sector, all related sectors and aspects of national and community development, in particular agriculture, animal husbandry, food, industry, education, housing, public works, communications and other sectors; and demands the coordinated efforts of all those sectors [6, p2]. Up to date, in the African region there is no clear collaboration mechanism in an integrative way with other non-health sectors.⁹ Participation that empowers (self-reliance) is said to be key for the success of PHC [6, p2]. Instead, African health systems have practiced the “health committees” for the management of health facilities as well as a section devoted to community volunteers (CV) which have been proven unproductive.¹⁰ Therefore, as shown by Kalinichenko and colleagues⁸ PCH strategy was not genuinely implemented in the African region. That is why WHO stated:⁵ "Primary health care now more than ever."

MDGs have failed in Africa according to WHO.⁴ Health systems in Africa selected three MDGs related to disease to improve health (Goal 4: reduce child mortality; Goal 5: Improve maternal health; Goal 6: Fight HIV/AIDS, malaria, tuberculosis and other endemic diseases).⁴ While all MDGs were pointing out the different necessary levers for the development of health and wellbeing, how can one understand this choice? From the concept of the determinants of health,⁹ illness is the product of a number of fundamental factors such as: poverty, illiteracy (especially on the part of women), the living environment and inequality in international relations, in other words the living conditions of populations.⁴ Those three so-called “health MDGs” cannot be effectively achieved without the other five which are the major determinants of health. Can we reduce maternal mortality (MDG5) without poverty reduction (MDG1), with uneducated women (MDG 2 & 3) and without empowering women (MDG3)? Can we reverse the trend of tuberculosis (MDG6c) without the reduction of poverty (MDG1)? Is child mortality (MDG4) not highly correlated with the mother's education (MDG2 & 3)?.⁹

What do health systems have in Africa: ministries of health or ministries of disease?

Discussions above clearly show that most of the health systems’ actions in Africa are disease-oriented, with no efforts aiming at their root causes. As shown in the "ill-health continuum" in Figure 1 below, when almost the entire expenditure and health action are channeled toward preventive, curative, re-adaptive and rehabilitative care, the current system is a disease-oriented. By extension, let’s understand that we are dealing with ministries of disease and not ministries of health. In such a condition, it is not possible to overcome successfully any disease; it persists according to the WHO Commission on SDH.⁹ Through the example of malaria, authors^4,12 have shown that the approaches used so far in sub-Saharan Africa were inadequate and couldn’t curb the disease prevalence sustainably. The dominant vision of health in this kind of orientation is biomedical³ and there’s need to go beyond by integrating health and non-health sectors resulting from a bio-psychosocial vision of health which would provide an opportunity for the health sector to take great advantage of the action on the SDH in these other non-health sectors (Figure 1).¹¹

Figure 1 Ministry of disease
Legend: HS: Health System; HP: Health Promotion; SDH: Social Determinants of Health; P: Prevention

It is important to make changes in view of achieving this purpose, and this calls for a priority action on SDH.^3,9 It will be necessary to redefine the role of the health sector in the African region to actively enhance the action of non-health sectors in health development. Among others, this implies a reform of health professionals training process at all levels, allowing the health sector to keep its name of health system and therefore “Ministry of health” as shown Figure 2 with an important coordinating role.^11,13 The United Nations understood this as illustrated through the MDGs. Indeed, MDGs target both key health priorities and the socio-economic situation of poor countries.¹⁴ While the action on the SDH is recognized as a more effective approach in the fight against the disease and local development,⁹ this picture of the health situation in Africa suggests a pressing need for the region to move toward its adoption.

Figure 2 Ministry of Health
Legend: HS: Health System; HP: Health Promotion; SDH: Social Determinants of Health; P: Prevention

For whoever seeks to know whether in Africa we have ministries of health or disease, the answer lays in the status of population health indicators. On one hand, when it is a Ministry of disease, health indicators disagree on health status improvement, because the "causes of the causes" are not addressed within the various programs to fight the disease. The vision of health in that kind of health system is biomedical. On the other hand, when it is a Ministry of health, the vision of health would be bio-psychosocial; actions that would be carried out would fall within the logic of SDH/HiAP (health in all policies) with health professionals playing a backing role. In light of this picture, some actions are needed to promote the strategy of addressing SDH/HiAP which includes in our opinion:

1. Finding appropriate mechanisms to reinforce advocacy for action on SDH through the HiAP approach,
2. Strengthening partnerships for health development in particular and the development in general with involvement of other non-health sectors on a trans-sectoral manner,
3. Reorganizing health systems, giving among others, priority to research as it allows the adaptation of actions to the characteristics of populations,
4. Organizing health professionals training that includes important content in connection with the action on SDH through HiAP.

We are grateful to Dr. Fatiou Akambi RAIMI and Mr. Sévérin Agossounon for their support in reviewing the English version of this paper.

Author declares that there is no conflict of interest.

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