A 1986 issue of the journal Social Science and Medicine examined why health and development has plateaued, or is declining, in many African countries. Concerns and obstacles raised in the introduction entitled "Health Revolution in Africa?" were that:

1. Decentralization and community involvement have been too slow;

2. Improvements are piecemeal without coherent integration;

3. Vested interests in status quo protects vertical programs;

4. Policy decisions are often suggested from outside the health system;

5. Conflict exists between top-down and bottom-up approaches;

6. Women and communities have not been empowered to make decisions;

7. Universities seldom play an innovative role in primary health care;

8. There is a lack of monitoring and adequate information system;

9. Conflict between high vs. appropriate technology;

10. Training is seldom used as a development tool;

11. Incentives to work are often inadequate;

12. Few successes exist in high level intersectoral coordination;

13. A preoccupation exists with recurrent emergencies and not new approaches; and

14. High population growth rates are accepted with complacency.

Almost all of these obstacles are encountered by any health project. The "art" of successful project implementation and management is finding ways to resolve (or detour) these problems. Click one of the above problems for more information about their relationship to improving health systems and program sustainability.