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Organization and management of health services

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Despite clear policies on decentralization in most countries, districts have limited capacity to provide comprehensive, equitable, continuous and people-centred health services.[1]

Health service provision needs to be organized and managed in ways that optimize the availability and continuity of services. Health service organization takes into account the need to ensure smooth referral of patients, and complementary measures to promote, restore and maintain health. Most countries of the WHO African Region organize their health service delivery in relation to the level and size of health facilities – normally categorized as primary, secondary and tertiary health facilities. Nomenclature may differ from country to country depending on the organizational method used. In some countries, the primary care level is divided into two categories, namely health posts and health centres.

In most countries, primary health services include a wide range of preventive health care, basic curative care and health promotion. Most health promotion activities take the form of community-managed interventions, supported by community health workers. Some primary care services require the involvement of highly qualified health personnel that are not available within the community. Ambulatory and outreach services for peripheral communities are therefore commonly managed from health centres and district hospitals.

In most countries, the district hospitals comprise the secondary level health services. Some health facilities supported by the private sector or faith-based organizations may be as large or larger than government-funded district hospitals. They may also be in a position to provide more advanced health services, creating a situation where the district hospital may not serve as the highest level of referral for secondary level health services in that district.

The organization of services by level may fail to recognize that different entry points to primary care services are required according to sex and age group. For example, the primary care service most needed for a child aged under 5 years may be immunization; elderly persons may require hypertension and diabetes treatment; while primary care for women needs to include screening for cervical cancers. Strong ambulatory and outreach services are therefore needed to ensure provision of primary health care to all, as close as possible to where they live.

Tertiary health services are provided through highly specialized hospitals. Many countries of the Region define these as one central and several regional or provincial hospitals. At tertiary level, hospitals are expected to provide sophisticated diagnostic, surgical, medical, paediatric, obstetric, gynaecological, ophthalmic, dermatological and rehabilitative services. This service level should be in a position to ensure an equitable distribution of specialized services, and their management must ensure cross referral and co-management of patients requiring more than one service at a time.

The sophistication of services offered at tertiary level depends on the overall level of development within a country. Those with more advanced tertiary services may find themselves treating patients from neighbouring countries with lesser capacities. These cross-border referrals drain foreign exchange earnings from the receiving country and may generate a vicious circle whereby the less-developed countries continue to trail behind in respect of the quality of their own tertiary care.

With respect to the HIV/AIDS pandemic, tertiary care for this disease is now being provided through home-based care. Family and community members participate in the management of AIDS patients by directly observing the intake of antiretroviral medicines and providing moral and social support.


  1. WHO. Health systems strengthening: improving district health service delivery, and community ownership and participation. Brazzaville, World Health Organization, Regional Office for Africa, 2010 (AFR/RC60/7)