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Analytical summary - Service delivery

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Despite clear policies on decentralization in most countries, the ability to provide comprehensive, equitable, continuous and people-centred health services at district level continues to be limited.[1] Most countries in the WHO African Region organize health service delivery in accordance with the level and size of health facilities.

These are normally categorized as primary, secondary and tertiary health facilities. Nomenclature of the health facilities in each category may differ from country to country, depending on organizational method and historical influences.

Packages of services in health care interventions are seen as the most effective method of delivering basic services to poor populations. However, most of these packages do not specify time limits for mitigating the diseases or health conditions they target. Nor are they always adequately funded. Filling the gap, the private sector constitutes over 30% of the health facilities in some countries, with contractual arrangements through public and private health care providers being common. These frequently target communicable diseases as well as maternal and child health services such as immunization, antenatal care and delivery.

The concept of creating primary care hubs to coordinate health services for well-defined populations is just starting to gain momentum. However, universal access to a complete package of essential health services is a goal yet to be realized in the Region. Owing to long waiting times for patients, shortage of medical supplies and an often inadequately motivated health workforce, shadow practices still exist within public health facilities whereby patients are required to pay health workers directly in order to get rapid attention.

There is insufficient use of routine data, including vital statistics, to measure progress towards attainment of long-term targets such as the Millennium Development Goals on health.

All these aspects of poor governance compromise the quality, equity and coverage of essential health services. Greater challenges to health service delivery occur in conditions of war, internal strife, and population displacement due to natural or man-made disaster and its aftermath.

Essential health interventions remain unavailable to large segments of African populations. It is estimated that less than half of those with common illnesses obtain the treatment they need. For example, only 38% of those needing treatment for pneumonia and diarrhoea obtain treatment.

Only 40% of those with malaria obtain treatment and, on average, only 3% of these use the recommended artemisinin-based combination therapy, with rates ranging from <1% to 13%.[2] Only 29.5% of mothers exclusively breastfeed their babies for the first 6 months of life.[3]

In addition, resource allocation favours high-cost curative services, with smaller budgets allocated to primary prevention and health promotion measures that could prevent up to 70% of the disease burden in many African countries.


  1. Health systems strengthening: improving district health service delivery, and community ownership and participation (pdf 229.52kb). Brazzaville, World Health Organization Regional Office for Africa, 2010 (AFR/RC60/7)
  2. Countdown to 2015. Tracking progress in maternal, newborn & child survival. The 2008 report (pdf 8.94Mb). New York, United Nations Children’s Fund, 2008
  3. World health statistics 2009 (pdf 5.77Mb). Geneva, World Health Organization, 2009