Burkina Faso: Community Health Revolution 2.0?

Ouagadougou is burning, and it looks like the end of Blaise Campaoré’s 27 year rule. Forget Ebola on its border, Burkina Faso is experiencing ‘Revolution 2.0,’ a nod to Thomas Sankara’s revolution in 1983 and the bold social programs that followed. 

While Sankara’s rule was brief (he was killed in a coup led by his best friend, Blaise Campaoré – yes, that Blaise), he created a legacy of community health care that exists to this day. Sankara introduced a policy of «un village, un PSP» [one village, one primary health care post]. This was in the early 80s, post Alma-Ata, when populist rulers were beginning to stand up in Africa and elsewhere and recognize the importance of primary health care, on one hand, and community empowerment, on the other. Sankara’s revolution was supported by the people – as seems to be the case today – and people need health care. A small health hut was built in each village and the community nominated a lay health worker to work there. She (normally, but sometimes he) received small supplies to treat wounds, provide paracetemol for fever, and perhaps refer the sick to health facilities further afield. Their work was voluntary.

In the years since Sankara’s death, the government paid little attention to sustaining or expanding community health care programs. In some cases the community health workers continued their work without external support. In other cases, NGOs intervened and used the CHWs to deliver their health programs. As a country hit hard by malaria, CHWs soon became essential human resources for preventing and treating malaria in communities, and were rolled into the country’s Home Management of Malaria program in the late 1990s. 

More often than not, the fate of CHWs followed the trends set by global policy elites. The Bamako Initiative, decentralization, and user fees? Sure, let the CHWs charge patients a fee. A shift towards facility-based care? Sure, tell CHWs to refer all sick kids to health centers for IMCI; make birth attendants illegal. The rise of public private partnerships? Yes, CHWs can dispense chloroquine for Roll Back Malaria and the Global Fund. What, user-fees aren’t working? IMCI isn’t working? Chloroquine is no longer effective?

When I interviewed health policy-makers, health bureaucrats, politicians and civil society actors in 2011, it was common for respondents to become nostalgic at the mention of community health care. “Un village, un PSP,” they would whisper. Many had started off as junior civil servants or medical officers in rural districts, responsible for implementation of the policy. No one forgot the slogan. Ideas live, even if their creators do not. 

Despite the roller-coaster of policies involving CHWs, the fact is, they remain in communities and they remain a viable policy instrument. Recent efforts to retrain them (or recruit younger, more educated workers) for integrated community case management have been partly successful, but I found a consensus amongst actors that greater emphasis and resources needed to be directed towards the implementation of the country’s revamped community health policy. 

The community health policy and related community health programs are more than nostalgia. The effective implementation of such program are necessary to address the persistent high rates of under-five mortality, with major causes of malaria, diarrhea and pneumonia. Local and international NGOs have had success with community-based treatment of severe acute malnutrition – the leading risk factor for child morbidity and mortality – but resources and political will are needed. 

This week’s Revolution marks a crossroads. There will be a new leader, and they could throw their political will behind community health strategies as did the President of Niger to tremendous success. Let’s hope so.

And because this is a network blog, a word about networks and social movements in Burkina. One respondent told me that policy change required a «masse critique» [critical mass]. The idea of networks resonated with everyone I spoke to, who acknowledged the role of relationships in every day life. Civil society actors, particularly, wanted to know how to use their networks to achieve social change. Today #lwili is trending on Twitter, faster than CNN can find Burkina on a map.

Here is the network of policy actors involved in the development of the community integrated management of childhood illness (C-IMCI) policy in Burkina in 2011. Note that the most influential actor, as measured by a combination of betweenness and degree centrality and interview and documentary data, was not the most central, not the highest ranking, but a mid-level technical bureaucrat in the Ministry of Health. Anyone can start a revolution.