Sharing knowhow and joining forces towards Health for All

MMI: Our tune varied along those 40 years...

In the epoch of community development, decolonisation and selfdetermination, all sectors of development, health care included, made a move from professionally defined actions towards activities resulting from an interaction between users and providers.

In Congo, already in 1958, Jacques Meert stated that “a technical error is less detrimental then an error that jeopardizes the selfconfidence of the local people”. So, even in the colonial period, to be an European was not necessarily an obstacle to catch the spirit of that epoch.

The professors Janssens from Belgium, Jentgens from Germany and Oomen from Holland, belonged to those “catchers” and the document they submitted in London in 1962 to the International Association of Catholic doctors was a catalyst for the foundation of MMI: a group of public-spirited health professionals, grasping the spirit of the epoch, and realizing that their insights into the health system, gained by the reflection on their own experience in health care in developing countries, could contribute to a balanced development of the envisaged rapid change of the health system during the last decades of the 20th century.

From the very beginning it was obvious that the organisation should be professional, international, non-denominational and non-governmental. This definition has made it possible to create channels of communication at all relevant levels.

In order to remain professional, channels for continuous interaction with scientific institutions (Amsterdam, Antwerp, Basel, Barcelona, Nijmegen) were developed.

In order to keep in touch with the reality, encounters on the field and exchanges with local governmental and non-governmental authorities as well as with field workers were organised.

In order to keep pace with the worldwide health policies, channels for exchanges with international decision makers (WHO, European Union, Worldbank, UNICEF, Pontifical Council) were developed.

Since 1978 MMI is even acknowledged as an organisation in official relation with the WHO (resolution 63 r.27). This recognition procures the branches of MMI an official status for collaboration with their own governments, with Third World governments and with international organisations such as the European Union. In 1991 also the Spanish government recognised the merits of MMI, by awarding the Price of the Prince of Asturias.

The contacts at different levels inspired the publications and meetings, realised by MMI, often in collaboration with scientific institutions or with WHO. During the years that the general assembly of the WHO, where we are officially invited, lasted two weeks, MMI organised its own general assembly on the Saturday of the first WHO week. It was an opportunity to invite, together with the national branches of MMI, official representatives of the countries where MMI members where active and confront each others view on experiences which were considered to be relevant in that stage of the evolution. Gradually these international colloquia were organised by the national branches. Since the duration of the general assembly of the WHO has been shortened, official representatives do not have the time anymore to join a simultaneous MMI general assembly but, organised at an other period of the year, the colloquia with our members and guests from governments, churches and scientific institutions go on.

Our tune varied along those 40 years

MMI’s concern was and is to keep rationalisation and participation in balance in the continuously changing health system. Themes and melody were chosen in order to draw the attention of the branches and the local partners to variables of the system which had gained too much or not enough importance for the harmonious development of sustainable health projects.

During the sixties, the dramatic absence of local staff was the main matter of concern of MMI. We had to respond to the local requests for expatriate human resources, requests made as well by governmental as by non-governmental institutions. Great efforts were made to recruit medical and paramedical personnel able to keep the health facilities in the run and to organise the activities according to locally felt needs. In order to respond adequately to these requests the training of motivated candidates was entrusted to scientific institutions which offered a relevant curriculum.

The reflection on our own experiences and on those of similar organisations (e.g. by the Christian Medical Commission) and on publications such as Maurice King’s ’Health Care in developing Countries’, oriented the projects more and more to the emerging “Primary Health Care” approach.

In 1968, the publication by MMI of “Concepts 1” reflected this evolution. It was edited by professor Oomen and translated in French, Spanish, German and Portuguese. While it showed to be an excellent tool for exchanges of the MMI concepts with other governmental and non-governmental organisations and with fieldworkers, it was followed in 1975 by a complementary “Concepts 2” and in 1985 and by “North-South Dialogue and Health”, an overview of 25 years experience on the field. Moreover, up to now 70 newsletters have informed our readers not only on the activities of MMI and its branches but also on our concept of an adequate health care system, which remains congruent with the PHC concept.

Allow me therefore to recall that, according to that concept, the adequacy of a health care system implies the preservation of a fair equilibrium between the following inseparable components:

  • access to relevant care
  • sustainability in an existing and evolving social, economic and cultural context
  • scientific analysis and readjustment of effectiveness and efficiency
  • dialogue as a basis for people’s participation
  • promotion of selfhelp and selfdetermination

The international office of Medicus Mundi conducted only one comprehensive field project. In 1972, the Ministry of Health of Niger, in order to strengthen the stateowned health care system, requested, trough the diocese of Niamey, international assistance. A project to assign physicians to several districts as advisers of the nursepractitioners in charge of these districts, was set up. It was financed by Misereor and the technical aspects were entrusted to MMI. In 1974 a change of regime went along with a more realistic health policy. The new government made a very bright analysis of the undesired consequences the well-intentioned initial project brought along in that stage of development: it depreciated the esteem of the nurse-practitioner in the mind of local inhabitants and authorities; it created needs which exceeded the resources available at that level; it was not realistic to foresee in less then a decade the assignment of local doctors at that level. It was a lesson in how to initiate, in a given context, a long term sustainable health project and related training. Consequently the project has been renegotiated, appointing these doctors as team members at a higher level, in the “direction départementale”. In that position, the MMI doctors, respecting the national health policy and master-plan, contributed several years to the organisation of complementing levels of care and to the supervision and continuous training of the staff at district level. At the end of the eighties it became realistic to appoint local doctors at the district level and the experienced MMI doctors, jointly with senior local doctors, were asked to set up a practical training of district medical officers. It was a very instructive experience on the importance of the component “sustainability in an existing and evolving social, economic and cultural context”.

Hundreds of other Medicus Mundi field projects, with governmental or non-governmental counterparts in Africa, Asia and Latin America, were conducted by the national branches. Since 1974 the approaches, observations, analyses and lessons learned are discussed in annual colloquia. Linked with the general assembly it is an opportunity to adjust the PHC inspired policy of the organisation.

So we come back to the tunes and melodies of MMI in the choir.

From ’74 to ’76 the absolute priority to develop correctly functioning health centres and referral levels was stressed. It covered adjusted training; the way to show the re-levance of these concepts to local health personnel; the delegation of tasks to less qualified but correctly supervised personnel; the participation of the population, based on dialogue with individuals, families and genuine representatives of the communities to be served; the respect for the traditional health care based on the local health culture.

In 1977 it was deemed necessary to highlight the role of the hospitals in the strengthening of the first line health services. This essential dimension of what later was called the health district would remain an important topic in the correlation with the WHO and scientific institutions. Testimonies to this are: in 1985, in collaboration with WHO, the spreading of guidelines for annual reports of hospitals committed to the strengthening of a two tiers system; the publication in 1990, in collaboration with the institute for tropical medicine in Antwerp, of the result of a mail survey in 25 sub- Sahara countries, addressed by MMI in 1988 to 173 hospitals, linked with national branches of Medicus Mundi. The booklet, entitled “District and first referral Hospitals in sub-Saharan Africa, an empirical Typology” contributed to the publication, also in 1990, of a WHO paper “The Role of the Hospital in the District: delivering or supporting Primary Health Care?” Later on this question on the role of the hospital forced itself to the African Brothers of Saint John of God. On their demand, MMI organised for the Brothers in 1994, in Asafo (Ghana), a workshop on this theme.

The Alma-Ata declaration on Primary Health Care has taken place in 1978. Being in official relation with the WHO and as member of the NGO-group for PHC, MMI has participated in may of that year, in Halifax, in a workshop, charged to produce a document on the role of non-governmental organisations in the realisation of Primary Health Care. In September the document has been submitted to the Alma-Ata conference where MMI was also invited. In 1981, based on this idea, MMI organised in Yaounde, in collaboration with the ministry of health of Cameroon, a workshop on “NGO Support for the Strengthening of PHC”. This initiative met with a wide response, not only in Cameroon: the workshop document was further used via the WHO and via the Institute for Tropical Medicine in Basel.

In 1979 MMI made a plea for the financial support of European governments to NGO’s who adapt their activities to existing master plans for the implementation of the national PHC policy. The theme was also elaborated in an article published in 1985 in the WHO magazine “World Health”. It was drafted by MMI as member of the NGO-group for PHC and entitled: ”Guiding Principles for external Financing of Health Services”.

More specific topics have also been developed:

When in 1980 action medeor organised the annual colloquium, the possibilities to realise the indispensable access to essential drugs was the theme. While the procurement of reliable essential drugs became more problematic, the topic was put again on the agenda in 1994 and in 2000. The problem of counterfeited drugs and the dilemma between the economic and the social goals of the pharmaceutical industry has then been analysed.

During these two decades other specific aspects, important for the harmonious development of the health care system, have been debated: culturally different concepts of health and ethical choices; the resistance to change as well from the side of the population as from the side of the administration and the professionals; the structural difficulties of doctors from developing countries to commit themselves to PHC; interference of emergency with the development of sustainable general health services; mass media and the South; how to face the HIV problem; how to integrate mental health care in general health services.

But efforts converge more and more to essential conditions for successful Primary Health Care

During the WHO conference in Harare in 1987, the realisation of health districts was considered to be an essential condition for successful Primary Health Care. Gradually MMI as well as its member organisations focussed their efforts more and more on the development of adequate health districts where state owned and non-for-profit private health institutions coordinate their activities in order to function as an integrated system.

The proposed model was indeed very inspiring for the implementation of Primary Health Care. In that challenging model four components are considered to be essential:

  • traditional and modern home care and community care
  • first line health care facilities, technically and culturally acceptable, interacting with the individual users, their families and representative groups of the population
  • district hospitals, acting as referral level and technical support for the first line
  • a district management team, able to conciliate top-down and bottom-up planning

During the colloquia of 1989, 1990 and 1993 the MMI members, joined by guests from developing countries, compared the proposed model with the health districts they were familiar with. Special attention was given to the training requirements for the staff. Invited by WHO, MMI participated in 1995 in a study group preparing a report on “Improving the Performance of Health Centres in the District”.

In course of time the inevitable role of non-governmental health care facilities for the normal functioning of health districts was accepted by all parties. But, local NGO’s needed a responsible common spokesman in order to negotiate with the national authorities. Therefore, more attention was given to the strengthening of national coordinating agencies of church-related NGO’s, able to identify and support reliable local partners. In most of the African countries those coordinating agencies became the interface between local NGO’s and the members of MMI. In 1999 the Anglophone agencies have been invited to a MMI partner consultation on “Updating Health Care Co-operation” in Dar-Es-Salaam, the francophone ones in Conakry.

The consequences of real partnership and the successes and failures in the implementation were analysed. The need to involve the concerned non-governmental partners in all stages of policy development and in all stages of the organisation of the district emerged. But good intentions alone do not suffice to succeed.

Without clear contracts between the official authorities and the private partners the result of the coordination was too hazardous. During the WHO General Assembly of 1998 MMI was authorized to organise, in the Palais des Nations in Geneva, a round table on “Contracting in Health Care”. Great efforts were made to consult and to brief during and after the assembly, representatives of governments who manifested interest for the topic. One year later the delegation of Tchad drafted a proposal for a WHO resolution recommending governments the contracting with reliable private partners. The resolution was finally accepted by the general assembly of the WHO in 2003. In the meantime MMI had informed African church related coordinating agencies on this matter. In 2000, during the colloquium organised by the Dutch branch on the occasion of the 75th anniversary of Memisa, a workshop with African bishops dealt with “The Church and its Involvement with Health: The healing Ministry”. The statement and the commitments formulated by the participants at the end of the workshop pave the way for transparent contracting with national and local authorities.

An even more compelling problem, due to the living conditions in many countries in Central Africa, is the threat on the quality and quantity of well performing health personnel. For the coming years MMI will focus its efforts mainly on these two issues: contracting and human resources development.

Harrie van Balen, Medicus Mundi Belgium, member of the MMI board, addressing the conference "40 years of fighting global poverty by promoting health", Berlin, 24 October 2003.

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