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Kinship Structure and Health-Care Improvement in Sub-Saharan Africa

The following was originally published in The Lancet, Volume 363, Number 9427, as a letter to the editor. Reprinted with permission from Elsevier.

In sub-Saharan Africa, inadequate resources, poor planning and management, and high poverty levels are so pervasive that apathy is almost the order of the day. Public-health indices from Africa attest to this.1,2 Even where success has been achieved, its sustainability has not been assured.

Our experience shows that the traditional kinship system can be instrumental in involving both men and women in caring for vulnerable groups such as children, teenagers, the elderly, and the disabled. It provides a mechanism for receiving, retaining, and acting on health education messages; for insuring its members; for preventing risky behaviour; for involving all its members in collective decision-making; and for taking responsibility for their own health and security. This provision ensures trust, equity, and quality of health-care delivery at the community level.3

The onchocerciasis control programme in Uganda has used the kinship system to stunning success. This approach helped to eliminate the demand for monetary incentives by community-directed health workers.4 Health education levels have been raised and maintained at more than 67% of the total population. For at least 6 years, the programme has achieved annual treatment coverage of at least 90% of eligible individuals. This success was achieved by getting a large number of community members to select as many community-directed health workers as practical through their own kinships. Government-employed health workers then trained them to educate and treat their own relatives and neighbours. The communities were able to assess their own success and weakness, and make adjustments in their health-care programme. The communities at the kinship level used community-directed health workers to bring more health and development programmes to their communities. Where government health workers were few and unable to handle as many community-directed health workers, communities selected their own supervisors, who were themselves trained by health workers to train and supervise community-directed health workers.

In addition to onchocerciasis control, the kinships have also embraced programmes for HIV/AIDS control and prevention, malaria control, tuberculosis control, reproductive health, immunisation, and other development challenges. The gap between the health-care system and the communities has been filled, and community knowledge on how government systems work increased. This success has motivated communities to pose the right questions to the right people when they have specific needs. This community participation has precipitated a large-scale lobby for quality health-care delivery, which health-care decision-makers, programme directors, politicians, and administrators can no longer ignore. It is what the Alma Ata conference set out to achieve more than 25 years ago.5

This model could be adapted in other sub-Saharan countries. Where kinship systems are weak or non-existent - eg, in urban areas - neighbourhood zones might provide a better option.

*Moses N Katabarwa, Frank O Richards Jr, Lindsay Rakers

The Carter Centre, 1149 Ponce de Leon, Atlanta, GA 30306, USA (

1 WHO. World Health Report, shaping the future. Geneva: World Health Organization, 2003.

2 World Bank. World Development Report 2004: making services work for poor people. Washington, DC: World Bank, 2004.

3 Katabarwa NM, Richards FO, Ndyomugyenyi R. In rural Ugandan communities the traditional kinship/ clan system is vital to the success and sustainment of the African Programme for Onchocerciasis Control. Ann Trop Med Parasitol 2000; 94: 485-95. [PubMed]

4 Katabarwa NM, Richards FO. Community-directed health (CDH) workers enhance the performance and sustainability of CDH programmes: experience from ivermectin distribution in Uganda. Ann Trop Med Parasitol 2001; 95: 275-86. [PubMed]

5 WHO. Declaration of Alma-Ata. International Conference on Primary Health Care, Alma-Ata, USSR, Sept 6-12, 1978.

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