HEALTHLEADERSHIP IN AFRICA

Professor  Monnekosso

Regional Director

WHO (AFRO)

c/o WHO Assembly,

Geneva

May 1994

Your Excellency

Re: AFRO'S TOWARDS HEALTH FOR ALL REPORT: A CONFIDENTIAL ASSESSMENT.

On behalf of the Zambian delegation to the 47th World Health Assembly I wish to officially acknowledge receipt of your report on your Office's work over the past ten years presented  to Afro Region  delegates during a briefing session on 3rd of May, 1994 at the Palais des Nations  Salle VII.

I wish first, to express my delegation's appreciation of the verbal presentation in which you personally highlighted, in impressive graphics, the tremendous amount of work being undertaken by AFRO under your leadership. May I in the same breath register, as I did verbally during my intervention on your presentation, my disappointment at the time allocated to a discussion by AFRO Ministers on this very important matter. While conceding that Afro Health Ministers will  hopefully be given ample time to study this report during region-specific meetings, it is nonetheless  disturbing, that an opportunity offered by your office to Ministers during the World Health Assembly was scheduled in such a way that ample time was only available to receive the presentation and not to fully react to its substance there and then.

As you personally acknowledged in response to my very brief remarks (constrained as I was by  the time allocated), a decision to present such an important document to AFRO Ministers who were delegates to the World Health Assembly required that your office secured  adequate time during the session for sincere and informed discussion. Of course, I am assuming  that your primary intention of scheduling that session was  consistent with your current role as Regional Director and hence your mandate to inform Regional delegates on your Office's activities! My fear is that starved of time as the session was, we as Afro Ministers and delegates  were merely treated as recipients of a product we were not allowed to critically and constructively  engage you sir, in a healthy dialogue, on our concerns regarding the key elements of your Office's activities.

I would be insincere to your Excellency, if I did not state, on behalf of my Zambian delegation as a whole, that the substance (saying nothing about the format) of the presentation raised more questions than it answered. Even more confusing for anyone who understood your presentation  were  your  verbal responses to questions posed by delegates during that session (which I had opportunity to electronically record and attempt to appreciate after the session...a practice I find better than writing notes) . Specifically, I refer to your  response to my interventions.  Please recall that in unison with remarks by previous speakers from Swaziland and Kenya who expressed  concern on inter-agency collaboration on health programmes, particularly contradictory instructions from AFRO on initiatives by other developmental agencies, I wanted to know at least three things:

1. What has been the specific role of AFRO in influencing the process of consensus-building in the case of the UN-joint programme on AIDS? I elaborated by specifying  Zambia's role in this during the 11-14th March meeting of UN programme Directors in Lusaka, ( A meeting I chaired) and I expressed concern that AFRO's role could have been significantly represented at such a meeting given the priority nature of the problem of AIDS in Africa and the potential impact the Joint program may have on existing programmes in the region.

YOUR SUBSTANTIVE RESPONSE

As I said there is a problem in joint programmes. Each one wants to protect his territory, this or that mandate. I agree there is more to be done on this...you and me can discuss this in detail sometime...

MY FOLLOW-UP REMARKS

It is precisely because of the knowledge that there are problems in inter-agency  collaboration that more proactive leadership is necessary...leadership who will help build consensus where none exists. Leaders who will act beyond agency turf-politics and provide a vision of the common purpose. That is why the Lusaka meeting was called. It was an opportunity to reconcile differences. Inter-agency networks which act beyond the unproductive restrictions of their  'mandates' are needed in an African regional health strategy. They will not emerge  by accident, they must be deliberately constructed. That requires a shift in leadership styles among those whose responsibility it is to act in the service of health development in the region. It is the only way partnership for health in Afro can be enhanced.

2. The Dakar Declaration by African Heads of State represented in my judgement, one of the most significant events on the AIDS calendar in Africa. For once, Heads of State were unanimous on an Agenda for Action on AIDS. As a person who ( with the OAU, ADB and GPA) has had to  work on that agenda following the declaration , to give it more concrete operational meaning, I wanted to know why AFRO has not taken further initiatives to actualise the implementation of that Declaration. I cited the Government of Tunisia which, with the direct support of GPA (Geneva) has gone further in elaborating on specific issues such as AIDS and the African Child which  I had the opportunity to contribute to among other fellow Ministers?

YOUR RESPONSE

On the Dakar Declaration, this is why I say that some Declarations are not worth the attention of African Heads of State. Often, there are products of people outside the health field, like Foreign Ministers...leaving out those in charge of the health field...Heads of State are dragged into making declarations on this and that.... This is one issue delegates may wish to discuss in detail sometime as we have run short of time....

MY FOLLOW-UP QUESTIONS

If this is the official status of the Dakar Declaration on the Agenda for Action on AIDS in Africa my questions now are: (a) how come during its discussion in May 1992 in Geneva by African Health Ministers, you personally talked about your involvement in that initiative ? (b) Why does it appear in your report presented to Afro delegates to the 47th World Health Assembly briefing as part  of your Office's contributions in 1992 to 'Shaping African Health Policies'?  (c) Is it accurate that health experts or sectors were not involved when the initiative was lively debated in Geneva in May 1992, and further, the then Health Minister of Nigeria Professor Ransome-Kuti and a select number of Health Ministers were in fact the political engineers of the initiative?

(c) Specifically, what makes that Declaration and follow-up operational strategies not worth the attention of either African Heads of State or your Office for follow-up?  If future declarations won't suffer the same fate, this is an important question!

3. The Third point I raised is the question of resources. The world is facing dwindling resources. The 'Health Package' concept that appears in your District strategy, and as you stated in your earlier remarks, that is derived from the World Bank Initiative, is not a cheap one. I must state that I have also contributed conceptually to the ‘package’ idea through my reform work in Zambia and critically in my participation on the Bank-sponsored Expert panel on Better Health Reforms for Africa. For those of us who are working with this concept on the ground will admit that it calls for considerable resource mobilization for capacity-building and package implementation at the District level. What substantive initiatives or rather what capacity exists at AFRO for aiding member countries in resource mobilisation in support of this initiative? You sir, as Regional Director, did not give me any response to these questions.

MY OUTSTANDING CONCERN

1.                   As the package concept is central to the Regional Director's current strategy as discussed recently in Yaounde by various country representatives of AFRO and WRs in the AFRO region ( a meeting I had some opportunity to witness); and  noting your earlier remark to a similar concern on 'Better Health package' as a World Bank Initiative to which you have rendered conceptual clarity, I have  the following remarks on the compatibility problem in the AFRO strategies. First, I wish to remind your Excellency that during the Paris meeting of the Bank-sponsored panel, your representative Dr. Elias Lambo ( who came as an observer), expressed and I shared in his concern during the debate, that the Bank concept of 'package' was designed in some substantive respects using the device of “cost-effective catchment population”, to reduce the  number of layers or levels of health interventions. This would in turn, eliminate certain  interventions at the community or health centre level. This measure, when applied to maternal issues, could prove retrogressive as referrals from health centres to the District hospitals let alone from the community to the health centre in the region have real constraints. The point is, what degree of flexibility exists in such packaging technology ? What is the cost assessment of packages? How can packaging reflect not only the cost factors but the epidemiological peculiarities of each country, regions within countries or indeed special vulnerable populations within each region of a country? In other words , what is the Regional Strategy for Better Health in Afro?

2.                   Your Excellency , I have many more questions specific to your report but I would  be unfair to register them publicly if I have not given you prior opportunity to reflect on them as I did in the case of the above.  I wish to remind you of my closing remarks during my intervention that my questions or comments were directed at three main issues pertinent to the work of Afro: What leadership must be provided at this level as we enter the threshold of the twenty-first century bearing in mind Africa's  poor prognosis on major health and economic indicators ? What systems of accountability must be institutionalised at AFRO to afford confidence building among member countries and other interested partners in initiatives taken by AFRO such as the Africa Health Fund which you and me had opportunity to briefly discuss in Yaounde? And lastly, what capacity exists at AFRO region Office now to construct sustainable partnership for 'Better Health' in the Region today?

My sincere hope, your Excellency, is that you will afford member countries more  opportunity to provide you with feedback on your efforts in less contested times and circumstances than you afforded us during the session in question. I am ready and  able to engage you in a systematic dialogue on Health Strategy based both on the conceptual and practical experiences  of a member country such as Zambia where we are seriously reconstructing our health field in the interest of our future generations. I wish to state on behalf of my delegation, that our interests are to see greater capacity  at Afro that will bring out the best out of a cadre of staff that Africa can boast about.  My belief in the potential that exists at Afro is derived from a comparative assessment  of similar resources in other regions of WHO that I have opportunity to interact with. They is no doubt in my mind that our experts at Afro and within member countries across various health sector disciplines, can  excel and compete in their quality of products with any other from the rest of the world if a will exists to bring this potential out by those in positions such as you hold.

Your Excellency, I wish once more, to thank you sincerely for the time you took to brief us and hope that my delegation's reactions are consistent with the intentions that underpinned your presentation to delegates on the performance of AFRO.

Yours sincerely

Dr Katele Kalumba, MP, Leader

Zambian Delegation to the 47th World Health Assembly

Deputy Minister of  Health,

Government of the Republic of Zambia.