Chapter 1 Introduction and Background
PART ONE: THEORY AND POLICY
Chapter 2 International Perspectives
2.2 International experiences with Community Involvement in Health (CIH)
2.3 What lessons to these international experiences hold for South Africa?
Chapter 3South African Policies
3.1 Government CIH policies before 1994
3.2 Government CIH policies after 1994
3.3 The Department of Health's policies on CIH
3.4 National policy for district health system development
Chapter 4 Evaluating Community Involvement
PART TWO: COMPARING TWO APPROACHES TO CIH
Chapter 5 Mpumalanga Province
5.1 Description of the district development process
5.2 PHC in Mpumalanga: a guide to district-based action
5.3 Perceptions of policymakers
5.4 Perceptions of communities
5.5 Summary of findings
Chapter 6 Western Cape Province
6.1 Description of the district development process
6.2 The Western Cape Provincial Health Plan
6.3 Perceptions of policymakers
6.4 Perceptions of communities
6.5 Summary of findings
Chapter 7 Some Lessons Learned
7.1 Have the preconditions for CIH been met in the two
7.2 Some comparisons between Western Cape and Mpumalanga
7.3 What lessons can be learned?
Chapter 8 Policy Recommendations
8.1 Meeting the preconditions for CIH
8.2 Further practical recommendations
List of Tables, Figures, and Case Studies
Table 1: A continuum of community participation
Table 2: Contrasting approaches to community health and development
Table 3: A summary of district health authority options
Table 4: A summary of district governance structures
Case Study 1: Democratising hospital boards in Quebec, Canada
Case Study 2: Community involvement in Cuba
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1.1 Original research proposal
Community involvement is one essential aspect of poverty alleviation and the attainment of health. The active involvement of community members in health care decisions was formally endorsed as a principle in the Alma-Ata Declaration on Primary Health Care (PHC) in 1978. This Declaration reflected the belief that health could not be attained only through improvements in formal health service delivery. A holistic approach to health was needed that addressed the root causes of poor health and empowered communities to actively participate in the improvement of their health.
The National Department of Health has adopted the PHC approach
as the guiding principle of the transformation of the health
system in South Africa. One of the pillars of the pillars of the
PHC is the empowerment of communities to participate. The
Department of Health has adopted the district health system as
the structural mechanism for transformation. This preliminary
qualitative research was undertaken to describe the first
attempts to involve communities in the conceptualisation and
development of the district health system in two provinces,
Mpumalanga and Western Cape.
At the time of this research, the transformation of the South African health system was still in its very early stages. Much of the work done in the two and one half years since 1994 the elections had been around planning for the implementation of the district health system. Thus, this research was limited to evaluating the participation of communities in the planning, organisation and control of district health system development. It is acknowledged that this project is only the first step in a much longer process of evaluation and feedback needed to refine and improve the process of meaningfully involving communities.
To briefly compare the different approaches to community involvement in health before and after the 1994 elections.
To conduct participatory research among policymakers and community leaders to understand their perceptions of community involvement in district health system development process in the provinces.
To compare the actual experiences of community involvement at the community level with the written policies of the national and provincial departments of health.
1.2 About the National Progressive Primary Health Care Network
The National Progressive Primary Health Care Network (NPPHCN) is a national non-government organisation (NGO) founded in 1987 to advocate for the implementation of a national health system for South Africa based on the principles of the Primary Health Care (PHC) approach. NPPHCN has a membership of more than 1,100 health and development programmes, projects and individuals. The Network has offices in eight of the nine provinces and its national office is based in Johannesburg.
NPPHCN has a strong interest in researching and supporting the involvement of communities in the health system. NPPHCN strongly supports the full, active involvement of communities in all aspects of health and health care. The Network's mission is to advocate for the implementation of the PHC approach; therefore, this research did not reexamine whether or not community involvement was important. Instead, the research looked at ways to improve and support the translation of community involvement principles into concrete actions.
NPPHCN is well positioned to carry out this type of applied, participatory research on CIH because of its extensive experience and credibility in underserved communities. CIH was one of two primary focus areas for the Network in 1996. As such, NPPHCN has a wealth of experience conducting research, analysing policies, and working to implement community involvement.
In 1996, NPPHCN was commissioned by the Hospital Strategy Project to conduct participatory research on the selection, role, function, training and support of community members on Hospital Boards.
Additionally, NPPHCN has substantial knowledge of the district development processes in both provinces under review. For the past year, NPPHCN has been providing technical assistance to the Provincial Department of Health, Welfare, and Gender Affairs in Mpumalanga as it establishes the district health system. NPPHCN members have been involved from the outset of the district development process in the Western Cape, but on a less formal basis. NPPHCN's Western Cape office and its CHW Training Centre have been actively involved in the community curriculum development group in the Western Cape. This intimate experience has provided tremendous insights into the motivation and perceptions behind many of the policy decisions taken in these provinces. This close relationship, however, also presents a challenge to the researchers to maintain their objectivity. It is up to the reader to decide whether we have met this challenge.
1.3 About the Poverty Reduction Monitoring Service
The Poverty Reduction Monitoring Service (PRMS) is one project within the Institute for Democracy in South Africa's Public Information Centre (IDASA-PIC). The PRMS aims to make a strategic contribution to the national poverty alleviation effort by making the best possible use of existing information and by commissioning research on new areas. The project focuses on raising public awareness about poverty issues; influencing policy-making that impacts on the poor; and monitoring the formulation, implementation and actual impact of policies and programme affecting the poor, with particular reference to the Reconstruction and Development Programme (RDP).
NPPHCN would like to acknowledge the contributions of the numerous community members in the Western Cape and Mpumalanga who sacrificed their time to participate in this research project. NPPHCN would also like to thank the various policymakers who shared their candid thoughts on community involvement. Their contributions have enriched the quality of the final report. We want to pay tribute to Mr Clyde Morgan, Chair of the Health Portfolio Committee in Mpumalanga, who died shortly after meeting with the researchers. His presence and boundless energy will be sorely missed.
Finally, we would like to thank the delegates who participated in the workshop on Community Involvement in Health held in Cape Town on 30 November 1996. The discussion and recommendations from that workshop have enriched the final report. The authors accept responsibility for all omissions and mistakes that remain.
NPPHCN's PHILA programme is funded by grants
Henry J.Kaiser Family Foundation,
Menlo Park, California, USA
Health Systems Trust
The active involvement of community members in the health
sector was formally endorsed as a goal of the Alma-Ata
Declaration on Primary Health Care(PHC) in 1978. This Declaration
reflected the belief that good health was not achieved simply by
improvements in formal health service delivery. A holistic
approach to health was envisaged that addressed the root causes
of poor health and empowered communities in the process.
Community participation in decision making was endorsed as one of
the five pillars of PHC Approach for nearly twenty years. The
five pillars of PHC are:
Community participation in decision making;
Focus on preventive and promotive health services;
Appropriate (not necessarily low-cost) technology; and
The Alma-Ata Declaration "requires and promotes maximum community and individual self-reliance and participation in the planning, organisation, operation and control of primary health care, making full use of local, national and other available resources; and to this end develops through appropriate education the ability of communities to participate;"
Further, the Declaration contained a series of twenty-two recommendations to implement the PHC approach. One recommendation stated "that governments encourage and ensure full community participation through the effective propagation of relevant information, increased literacy, and the development of the necessary institutional arrangements through which individuals, families, and communities can assume responsibility for their health and well being."
Before discussing further international experiences in
implementing CIH, it is essential to consider the different
terminologies used to describe this process. Although it may not
be possible or even desirable to develop a universally acceptable
definition for community involvement, it is important to get
clarity of the usage of various terms. According to a World
Health Organisation Study Group Report, there are various
interpretations of community participation. Community
participation can be seen as:
appropriate organisational structures; or
participation as empowerment of communities to manage health matters, enabling them to decide and take action that they believe is essential to their health.
"Community involvement in health" describes a process where people express their right to be active in the development of appropriate health services. It is a partnership between individuals, groups, organisations, and health professionals in which all parties examine the root causes of health issues and together agree on approaches to address these issues. Thus, community participation is a broader concept that can include many different types and levels of involvement while community involvement refers to a particular type of partnership. This research focused on examples of community involvement in the South African health system in the two years following the first democratic elections.
It is important to recognise the radical nature of the concept of CIH at the time of its issue and even today. During the 1950s and 1960s, international trends in the health sector moved toward the introduction of high technology, modernisation of health facilities, and the importance of large hospital complexes. Communities were viewed as passive groups of individual recipients of health care services planned and provided by health care professionals. There was little scope for self determination or community empowerment in the health care system. Interactions at a community level occurred only in the epidemiological context. Thus, acceptance of the PHC approach would force countries to totally reorient their health system and implementation would require nothing short of complete transformation.
Given this background, it is easy to understand why there has been widespread agreement on the theoretical importance of community involvement, but there has been little success in implementing this vision on a large scale. To date, it has been largely church groups and NGOs that have tried to implement this concept. Thus, the government of South Africa's publicly stated commitment to community involvement is an important international landmark for this issue. Political commitment, however, represents only one precondition to the successful involvement of communities.
Once there has been a political commitment to meaningfully involve communities in the health system, the next question is to what degree and at what level people are asked to participate. Table one highlights the continuum of community participation from absolutely no participation to communities having complete control over all key decisions. Research by the World Health Organisation has found many examples of passive participation where communities use health service and contribute money, materials, or labour to a project conceived and controlled by government. Active community participation, in terms of planning and managing health services, however, is very uncommon. The majority of efforts at community involvement fall at the low end of the continuum where policymakers look for the community to advise, consult or receive information about their plans.
Table 1: A continuum of community participation
|High||Has control||Organisation asks community to identify the problem and make all key decisions on goals and means. Willing to help community at each step to accomplish goals.|
|Has delegated power||Organisation identifies and presents a problem to the community, defines the limits and asks community to make a series of decisions which can be embodied in a plan which it will accept.|
|Plans jointly||Organisation presents a tentative plan subject to change and open to change from those affected. Expect to change plan at least slightly and perhaps more significantly.|
|Advises||Organisation presents plan and invites questions. Prepared to modify only if absolutely necessary.|
|Is consulted||Organisation tries to promote plan. Seeks to develop support to facilitate acceptance or give sufficient sanction to plan so that administrative compliance can be expected.|
|Receives information||Organisation makes a plan and announces it. Community is convened for informational purposes. Compliance is expected.|
|Low||None||Community told nothing.|
Source: Community participation for all.
London, Community Participation Group of the United Kingdom
Health For All Network, 1991
Community involvement cannot be established in the same way that a new health service or clinic is built in an area. CIH is a complex, organic process that needs the clear understanding from policymakers and appropriate support structures in order to take root. Thus, the manner in which communities are invited to participate in the policy process is critically important to its success or failure. In this area, health workers and policymakers can learn from the community development movement. Table two compares different elements of the community supportive and the community oppressive approaches to community development.
Table 2: Contrasting approaches to community health and development
Open-ended and flexible
Closed and pre-defined
Method of encouraging community participation
With time, patience and genuine concern
With money and free gifts so that participation is bought
Sharing of knowledge and skills
From doctor to community health worker to local person
Knowledge jealously guarded at each level
Openness and growth of programme
New approaches and improvements encouraged
"Don't rock the boat"
Source: Community Involvement in Health
Development: Challenging Health Services. World Health
Organisation. Geneva. 1991.
2.2 International experiences with CIH
In the first global evaluation of strategies of health for all conducted by the WHO, more than 70 percent of its member states reported the existence of some mechanisms for CIH development. However, despite these positive trends, the researchers found that much work remained to be done.
An 1988 WHO report found that CIH is still a relatively new strategy in health development and the theory of CIH was ahead of the practice. There have a been a few examples of community involvement on massive scales in all policy matters, including health, but these examples have tended to be the exception rather than the rule and have dissipated after a relatively brief revolutionary period. As a fundamental principle of formal health service practice, CIH, is still largely underdeveloped. There have, however, been some small-scale efforts to involve communities in the health system of developing countries that could contain important lessons for South Africa.
2.2.1 Small Scale Efforts
Kenya is often cited as an example of successful CIH implementation. An assessment of community-based health care (CBHC) in Kenya found that "despite a rich experiential base of CBHC initiated by NGOs, there is little evidence that these experiences have influenced government policy on community involvement in health." The researchers also found that community involvement even on a small-scale is a long-term proposition. They found that it took up to two years before basic understanding of the district health system and appropriate support systems were established.
The researchers determined that health professionals may not be the most appropriate motivators for community involvement. There was a real danger that using health workers to initiate the process would institutionalise differentials in power and knowledge, making an equal partnership unlikely. Manipulation by health workers was more likely than cooperation using this approach. Additionally, research showed that the level of community involvement varied from year to year and season to season. Finally it was inevitable that there was a high drop out rate for any initiative. The researchers concluded that the variation and high drop out were natural occurrences that should be expected and not necessarily signs of failure.
The Indonesian experience of using posyandu or integrated service posts that allow for communication, the transfer of technology, and the delivery of health services by and for the community could provide useful information for South Africa.
The process of community involvement usually occurs in the
The community with support from the health centre staff conduct a community level survey identifying health problems and increasing awareness.
The results are presented to the community where priority problems are identified and solutions are developed.
Meetings are held before and after the post to determine its effectiveness and record the events. The success of this programme can be attributed to the inclusion of communities in every phase of the project from needs assessment, to planning, implementation and evaluation. The community is an equal partner with the health services. This strategy was still evolving to create greater intersectoral linkages in areas like adult literacy.
In many other developing countries, community involvement in
health and community development have been spearheaded by
community health workers (CHWs). The activities of CHWs include
raising communities' awareness about health issues, mobilising
the community from poverty alleviation projects and for better
health services, and encouraging intersectoral collaboration.
CHWs often fulfill two separate functions in the PHC context:
they provide basic health care services and they stimulate
2.2.2 Large Scale Efforts
Internationally, one important mechanism used to increase
communities' involvement in the health system on a large scale
has the democratisation of health governance structures. Two case
studies are presented based on experiences in Quebec, Canada and
The first study reflects the difficulties arising from simply nominating community members to sit on the management of the health system without proper preparation and training. The experiences of the Quebec Province in Canada in their efforts to democratise its Hospital Boards have particular relevance for South Africa.
Case Study 1: Democratising hospital boards in Quebec,Canada
In 1971, the Quebec Province passed legislation to restructure the provincial health and social service system. One major goal of these reforms was to increase community participation in the health system. Within the restructuring process, Quebec sought to replace the existing elite Hospital Boards with "democratic" Hospital Boards representing each of the hospital's major interest groups. Many hospitals in the province had been founded and managed by groups of wealthy citizens. These people continue to control the hospitals through their role on the Board. Board members would invite their business colleagues, friends, and relatives to replace outgoing members thereby maintaining control. Although the government subsequently assumed full financial responsibility for the hospitals, the composition of the Boards did not change.
The legislative reforms were implemented in 1973. Hospitals in the province were ordered to dissolve their Boards and to select more representative structures. Under the new selection process, two representatives had to be users of the hospital elected at a constituent meeting, two representatives from the major socioeconomic groups of the community were nominated by civics and appointed by government, and four representatives of the Hospital Corporation were selected at an annual general meeting. Additionally, one hospital professional, one physician, one nonprofessional staff member, and one resident each were selected by their colleagues. Finally, one representative from a local referring clinic was appointed by that clinic. Each Board member was elected for a two-year term.
Hospital management played a central role in the reconstitution of Boards effectively controlling the selection process. They held most of the information about the process and attempted to use it to reelect upper income members. The composition of Hospital Boards did change significantly with the percentage of business and financial representatives declining dramatically. In 1972, 56 percent of Board members came from the financial sector, but they represented only 17 percent after reforms were implemented. Despite the numeric changes, however, Board members came from the same socio-economic backgrounds as previous members.
In spite of changes in the composition of the Boards, new members were effectively limited by their lack of experience, their lack of confidence, and their lack of understanding about how they were supposed to contribute. No formal training programme was established after the changes took place. In the absence of a formal training programme, hospital administrators assumed responsibility for much of the "training" of new members. New Board members were instructed by management as to which issues were appropriate for Board consideration, the need for confidentially of Board discussions, and the impropriety of representing special interests on the Board. In addition, the small number of community members on the Boards according to the formula established in the law made it very difficult for community members to achieve a majority of votes in opposition to management proposals.
Finally, hospital management controlled the flow of important information to the Board. The lack of clarity about the role of the new Board caused strain in their relationship with hospital administrators. Hospital management perceived that the new Boards slowed down the decision making process because they were not familiar with hospital policies. Management also felt very threatened by the presence of their employees on the Board. As a result, hospital management and the old "elite" Board members moved much Board business outside of formal meetings.
In summary, legislation to "democratise" Hospital Boards in Quebec led to the institutionalisation of community members on Boards, but did not empower communities. It is interesting to note that a Commission of Inquiry, convened at that time, suggested many participatory mechanisms to involve communities that were rejected during political discussions. Instead, the final law established that a certain number of seats were earmarked for community members on each health governance structure (four out of 14 on Hospital Boards).
Upon later analysis, the Quebec government admitted that public participation in the health system has not worked as intended. With regard to Hospital Boards, the inclusion of more community members actually decreased their authority, concentrated power for hospital management, and ultimately made hospital governance less democratic. Instead of increasing the influence of community members on hospital management, one researcher found that the reforms actually weakened the authority of Boards over physicians within hospitals.
There are many important lessons to be learned from experiences in Quebec where community participation in hospitals did not take hold. One important lesson for South Africa is that the "top-down" approach to community involvement is not effective. It appeared that government determined their agenda and asked people to participate in their preset plans. As noted above, community members represented a small minority on the Boards even after reform. Researchers found that many people were not interested in participating in a minority position in the highly technical issues related to running a hospital. One researcher found that community advocates were able to develop much stronger power bases outside Hospital Boards that influenced policy through Parliament and the media.
Additionally, there appeared to be no training programme in place to empower new Board members about their vital role in ensuring accountability to communities. In this void, hospital administrators provided "education" that served their narrow interests. It is important to recognise that people will be "trained" to serve on Boards. The question is whether they will be trained in an organised and empowering manner or not. Finally, this attempt at community participation was not rooted in communities. No mechanisms were put in place to link Board members with the broader community or other community initiatives. This appears to have been an isolated attempt to increase community representation in health system management.
In the last several years, Quebec has again restructured community participation in the health system, placing a greater emphasis on community empowerment. They have identified four factors necessary to maximise community input on Boards: 1) providing them with adequate information, 2) creating a strong mandate in the community to support their positions, 3) finding individuals with strong personalities to stand up to administrators, and 4) creating mechanisms for Board members to easily access their constituencies. It is not yet known whether these new reforms have produced better results, but the lessons learned from Quebec's twenty years of experience with CIH are important for South Africa to consider.
Alternatively, Cuba has attempted a complete transformation of the health system where doctors and nurses are completely reoriented to become community development agents in addition to providing preventive, promotive, and curative services.
Case Study 2: Community involvement in Cuba
In some ways, experiences in Cuba reflect the successful implementation of community
participation in civic issues. Cuba has more than 30 years experience in attempting to integrate its mass democratic movement into formalised governance structures in all sectors, including health. Despite general agreement on the democratic nature of this country immediately after the revolution, not all researchers are convinced that communities are empowered to take control of their health or the health system.
Cuba developed institutional structures to involve communities in decision making and policy processes. At one point, more than 4.8 million Cubans participated in one capacity or another on a Committee for the Defence of the Revolution (CDR). Eight out of every ten Cubans were voluntary members. CDRs were originally created to protect neighbourhoods against acts of terrorism or sabotage. Each CDR also had different sectors of involvement (similar to RDP forums in South Africa) including: health, education, social services, police, housing and others. These structures were responsible for stimulating neighbourhood participation and mobilization for the discussion of all policy and legal documents, implementation of mass campaigns, and coordination of voluntary service.
Public officials were elected to People Power Assemblies at the provincial and national level to represent community interests. Within the Cuban Constitution, one principle stated that all authority comes from the people and all accountability comes from the state to the people. Each People Power assembly at each level of government appointed the personnel of the administrative agencies assigned to it.
According to the Constitution, the functions of each hospital were determined under norms set by the Ministry of Health. Politically and administratively, hospitals answer to the municipal or provincial authority depending on their size. Provinces are responsible for tertiary and secondary level facilities while municipalities are responsible for municipal hospitals and health centres. In addition, each facility has an advisory committee consisting of representatives or mass organisations. Hospital management must consult with the advisory committee on issues that affect or require participation from the community. Community residents have the power to request the removal of health workers although this is rarely done.
Additionally, Cuba has developed a unique Family Doctor programme that attaches a family doctor and a nurse to every 120-140 families. This programme has engendered a sense of cooperation between health professionals and community members. The family doctor and nurse are responsible for all of the health needs of the community. In addition to curative services, doctors carry out health education and health promotion in their communities. One study found that "these programmes have been successful in educating the population at large in health matters, and have served as means of training individuals, civil organisations and communities as a whole in topics related to individual and collective health. By elevating individuals' and communities' understanding of health matters, and promoting collective discussion and solution of health problems, the family doctor programme has also strengthened Cuban families' and communities' participatory skills."
Another researcher found that not everyone agrees that the Family Doctor Programme is empowering for communities because of the tremendous surplus of doctors in Cuba, communities had become too dependent on medical interventions to improve their health. The abundance of doctors had also actually reduced the demand for community-based health workers, who could address health issues in the broader socio--economic context. Finally, this researcher found that the messages of health education in Cuba were actually disempowering communities to take responsibility for their health and encouraging them to rely on medical professionals.
In terms of community involvement, Cuba offers a different paradigm from the Canadian model of simply placing community members on governance structures. Cuba has created space for communities in the governance of the system, but they have also refocused the role of their health professionals from curative service providers at a clinic to public health officer for the community. As stated above, there is still debate about whether this model empowers communities or actually increases their dependency on health professionals.
It is clear from these two case studies that community involvement is difficult to establish and sustain. Even well-intentioned efforts can become derailed or stagnant over time. Both of these countries have engaged in processes to review and evaluate CIH efforts to ensure that they were still relevant to the original objectives. Thus, CIH is clearly an iterative process that needs to be refined if it is to succeed.
2.3 What lessons do these international experiences hold for South Africa?
International experiences has suggested four preconditions
that need to be met before community involvement in health can
take hold. These preconditions include:
reorientation of health professionals to community involvement;
development of self-management capabilities of local communities;and
socioeconomic situation in the country conducive to development.
The international literature reflects the many potential
benefits to be gained from actively involving the community in
their health and the health system. These benefits underscore the
value of this process. Experience from other countries reveals
that community involvement is beneficial because it:
ensures the appropriateness of health services for a community's needs;
develops a relationship of trust and empathy between providersand consumers;
encourages a sense of ownership through participatory decision making;
creates political awareness; and
ensures accountability of health care workers and managers to communities that they serve.
But despite its tremendous potential, community involvement is
not a "magic bullet" that simply works without
tremendous nurturing and commitment from both policymakers and
communities. The international literature is full of many failed
attempts to meaningfully involve community members. It is
important for South Africa to learn from these failures. Broadly
speaking, these failures occurred because:
people were asked to contribute their time and energy, but had no sense of ownership because they were not involved in the planning or implementation of the programme.
health development strategies have failed to encourage communities to think and act for themselves.
it was very difficult to measure whether community involvement was been successful or not, causing premature abandonment of the effort.
communities' expectations often outstripped available resources, which caused conflict undermining community involvement.
real structural and political problems and tensions existed within communities which were increased as community involvement attempted to change the prevailing power relationships in a community.
conventional public health planning was not conducive to community participation. It tended to be top-down and centralised which effectively precluded meaningful participation.
economic crises in many developing countries has led to an increase reliance on external funders who have demanded short-term tangible results and were less interested in long-term processes like CIH.
a lack of vibrant community-based structures created difficulty in sustaining community participation.
the paternalistic and patronising attitude of health workers did not value the input of communities, particularly if health workers started the process.
community participation represented a threat to governments, even democratically elected ones, who lost their political will when they understood the full implications.
The next chapter will examine how these international lessons have been applied in the South African policy context. Specifically, it will examine health policy changes impacting on CIH from apartheid era to the post-apartheid government. It will also examine how the international CIH theory has been translated into an implementation framework in South Africa.
3.1 Government CIH policies before 1994
Community activism and community empowerment are not new concepts in South Africa. Many black communities have been working to improve the health of their communities for many years. These efforts largely took the shape of political activism fighting against the apartheid government. It is misconception, however, to assume that the government before the 1994 elections had not formulated any plans for CIH. In fact, the government drafted many policies on paper. For many reasons, however, these policies, were never implemented on a large scale.
Long before the 1994 elections, the Department of Health and Population Development expressed a commitment to involve communities in the health system, but it put few mechanisms in place to make these commitments a reality. In 1990, the Department formally endorsed the Primary Health Care (PHC) approach. In one of its official policy documents, the Department listed ten principles for the health system, which included the involvement of communities.
Upon closer examination, many NGOs and other members of civil society challenged whether the government was committed to the principles of PHC as outlined at Alma-Ata. Some groups contended that the government was attempting to co-opt progressive language to justify second class treatment and deprivation for the majority of its citizens. In addition, the gross inequities of the apartheid system effectively made decisions about the health of the population. The socio--economic conditions inflicted on the majority of South African citizens had a far greater impact on their health then relatively minor proposed changes to the health system would have.
In the absence of democratic freedoms and extremely limited access to health services, there was little community control of public sector health services. Many black communities refused to "collaborate" with the government structures because they felt that it is impossible for the interest of their communities to be adequately represented and when representations were made they were routinely disregarded.
Some independent efforts at community involvement during this period were fostered by NGO's. They established community health committees and other structures. These committees were typically created to provide support to CHW programmes. In South Africa, there is a long history of suppression of political and community organisations which have attempted to express the aspirations of the majority of the population. In certain limited circumstances, communities were able to move beyond the political oppression and form links with certain local health care providers working in the public sector. This was, however, the exception rather than the norm.
The Department of Health and Welfare Population developed a policy advocating the introduction of a national CHW programme in 1990. The policy appeared to meet many of the demands of progressive NGOs at that time. The national CHW programme was not envisaged as an extension and supplementation of the formal health system, but rather as a low-cost alternative for poor communities. A national CHW programme was never implemented.
3.2 Government CIH policies after 1994
Since the 1994 elections, national policymakers have expressed a strong ideological commitment to community involvement in health and development. The Reconstruction and Development Programme (RDP), formally endorsed by the Government of National Unity, emphasized the need for community involvement. The RDP stated that "the way to real development is through democracy which allows everyone the opportunity to shape their own lives and to make a contribution to development. The RDP is based on democracy. It says that people who are affected by decisions must take part in making those decisions." In addition, financial resources made available through the RDP, the Transitional National Development Trust (TNDT) and National Development Agency (NDA) reflected a commitment by the government to development in general. Given the difficulties in implementing community involvement internationally, South Africa's strong political commitment at the highest levels is very significant.
The RDP aimed to achieve the involvement of communities as full partners in their own development.The RDP strongly supported community involvement in its policy documents. After the elections, the presence of the RDP and the financial commitment of the GNU to support development reflected a healthy environment for development. As such, South Africa had met the first and last preconditions at the national level.
The closure of the RDP Office in March 1996, however, could have serious long-term implications for CIH. Beginning in 1994, civil society had responded to Minister Without Portfolio Jay Naidoo's challenge to create RDP structures at the national, provincial, and local level to develop partnerships with government. These structures were envisaged to be the foundation for community involvement in development issues. Each sectors would have their own particular structures but all would be accountable to these representative, intersectoral forums. The RDP forum was envisaged as the most representative and inclusive structure in each community. As such, it was envisaged as the foundation for CIH.
Communities have also expressed a strong desire to become more involved in the health system. In 1995, a national household survey conducted by Community Agency for Social Enquiry for the Henry J Kaiser Family Foundation found a large majority of South Africans (86 percent) believed that CHW's would either probably or definitely improve health services.
Additionally, people wanted to have a say in the way in which their clinic was run. Eighty-two percent thought that communities should have a say when the clinic is open. Nearly three-quarters (72 percent) wanted to have a say in how health workers deal with patients. Two-thirds (67 percent) wanted communities to have a say in what people should pay for services. Almost one half (48 percent) of all respondents felt that communities should be involved in the appointing of staff members.
3.3 The Department of Health's Policy on CIH
The Department of Health has also endorsed the idea of CIH in its official policy documents. One of the Department's goals for transformation of the health system is "to foster community participation across the health sector, to involve communities in the planning, management, delivery, monitoring, and evaluation of health services, to establish mechanisms to improve public accountability, dialogue and feedback between public and health providers, and to encourage communities to take greater responsibility for their own health promotion and health care."
In the Restructuring the National Health System for Universal Primary Health Care, there are many statements asserting the importance of CIH and the necessary decentralisation of the authority. The National Health System should emphasize the needs and rights of users of the system, and should empower users and their communities to participate in governance of the health care system. The National Health System should be congruent with, and should strengthen the emerging district-based health care system. "The organisation and functioning of the National Health System should be based on the principle of decentralised management, which will aim to create the maximum possible management autonomy at health facility level within the framework of national public service guidelines."
Despite these strong statements, there are some omissions in the National Department's approach to CIH that could create obstacles at the provincial level. For example, no strategies have been provided nor are any concrete mechanisms identified to realise the principle of community involvement at the national level. The Department envisaged maximum community involvement at the district level, but it has not yet provided a clear vision on how this involvement will be carried forward at the national level. The draft National Health Bill envisaged a National Consultative Health Forum, comprised of statutory bodies (Medical and Dental Council, etc.) and representatives from non-statutory organisations (Trade unions, NGOs, and professional associations). While this is an important consultation structure, one could hardly argue that it constitutes CIH.
Another important omission in the Department's vision was that it did not see a role for CHWs within the public health sector. "It is recognised that this category of health workers (CHWs) may be able to make an important contribution to the health of communities in some instances, and to provide a link between the formal health services and communities. Furthermore, . . . this category should not be incorporated into the formal health services. This obviously does not preclude NGOs/CBOs and other organisations from continuing with CHW programmes."
As mentioned above, many other developing nations have used CHWs as a catalyst for CIH and community development. Though the Department has been reluctant to endorse CHWs, they have provided space in their policy framework for provinces to make their own decisions on the issue of CHW's.
3.4 National policy for district health system development
As witnessed from international experiences, decentralisation of authority within the health system is one the most important factors in achieving CIH. Within South Africa, decentralisation is primarily taking place within the context of the district health system. A preliminary assessment of the district development process found that significant progress has taken place over a relatively short period of time give massive structural problems. This research project specifically examined how communities have been involved in the initial planning and implementation phases of the district development.
A Policy for the Development of A District Health System for South Africa was adopted as an official policy document of the Department of Health in February 1996. It presented the Department of Health's long-term vision for the development of the new district health system. Chapter Two of this report focuses Governance Structures at the District Level. It was clearly in line with the WHO thinking on the district model and community involvement in governance structures.
Provinces have been given three options for the overall governance of districts. The choice of governance options has profound implications for CIH. Under the provincial option, the provincial office takes responsibility for establishing districts and creating the infrastructure needed for decentralisation. Once these structures are in place, authority and financial control will be decentralised.
The second option is the statutory district health authority model where a new statutory body is created to establish the district. The final option transfers control of district health services to the local government in the area. It is envisaged that all provinces will move to the final option over time. This policy options relate the interim period which may last between five and twenty years. The three options are summarised in table three.
Table 3: A summary of district health authority options
Statutory District Health Authority
Local Government Option
Provincial Health Department is responsible for all district services.
Statutory District Health Authority is responsible of all district health services.
Local Government is responsible for all district health services.
Insufficient independent capacity and infrastructure at the district level.
Capacity to devolve responsibility to district level, but no single local authority with capacity to render comprehensive services and whose boundaries are the same as the health district.
Single local authority with capacity, whose boundaries are the same as the health district.
(Ideally, a single District Authority is responsible for the provision of all services.)
Structure and Process
|A District Health Council (DHC) is established in terms of Provincial legislation with specified powers in relation to the District Health Manager, who is a provincial health department employee at the district level.||A Statutory District Health Authority is established for health district, with a District Health Council have devolved responsibility from the provincial MEC for Health for all district health services.||Responsibility for all
district health services to be devolved by the province
to and designated local government authority, which
establishes a District Health Council.
Where a local government authority's boundaries are larger than those of a health district (such as a Municipal Substructure) that authority will be required to establish separate District Health Councils and to appoint District Health Managers for each health district within its area.
Source: A Policy for the Development of A District Health System for South Africa, Pretoria District Health Systems Committee, Department of Health, 1996.
"In each of these governance options, the District Health Council needs to be structured to ensure meaningful participation of the community and all other stakeholders and role players concerned with the health of the people in the district. It is a fundamental principle of the PHC approach that there is maximal possible community participation in planning, provision, control, and monitoring of health services. For such community participation to be effective, it is not enough that the managers of health services simply are held to be formally accountable to an elected body. Community development and empowerment are essential to the promotion and maintenance of communities, and vibrant community-based organisations must be accommodated within the district health structures if true community participation and involvement is to be realised."
Envisaged structures at the community level are the Community Health Committees and Community Development Forums. At the district level, the District Health Council is the primary governance structure. In addition, each district hospital will have a hospital board.
The responsibilities of District Health Council members are such that many will find them in unfamiliar situations. They will be expected to represent the interests of the people of the whole health district, and not just the constituency or forum from which they have been elected. Thus, it is therefore necessary that the health system as a whole, both provincially and nationally, establish a process for the development of Council members so that their role and expectations as part of a 'corporate' structure are explained and clarified in a consistent manner throughout the country. This would include the rules and codes of conduct. District Health Councils' powers and functions will vary under different options, depending on the accounting authority, so they may be advisory or decision-making powers. The proposed district governance structures are summarized in table four.
In summary, a strong political will to involve communities is reflected at the national level and the National Department of Health policy documents have created a broad framework to meaningfully involve communities. It is not clear with the new macro-economic growth , employment and redistribution strategy (GEAR) and the closure of the RDP national office whether South Africa still has an economy conducive to development.
Thus, while only the first of the four internationally recognised preconditions for community involvement, political commitment, has been satisfied nationally, South Africa has made progress on the other three preconditions. Definite steps have been taken by provinces to include people at the grassroots level in the policy making process and implementation of the new health system. Chapters five and six will review and analyse the CIH implementation processes in Mpumalanga and the Western Cape to evaluate how theory and policy frameworks on community involvement have been put into practice during the district development process.
Table 4: A summary of district governance structures
Community Health Committee
District Health Council
Community Health Committee
Facility manager ex officio
Representatives of Community Health Committees
Political representation from Local Authorities in the district
Chairperson from nominations of Health and Development Forums
Additional members with business/financial expertise
District Health Manager ex officio
Chairperson of the District Hospital Board ex officio
Representation from the Community Health Committees
Representation from the Local Authorities in the health district
Representation from the District Health Council
Representation from private providers working in the health district and using the hospital
Representation from health NGOs working in the health district and using the hospital
Additional Member with business/financial expertise
Hospital Manager, ex-officio
District Health Manager, ex-offocio
District Welfare Manager, ex-officio
Community Selection Process
Elected from the relevant Community Health or Development Forum, but excluding persons employed by the health system in that area or with any line management functions in respect of that area. Members represent the Forum ie. Users of the facility in the community area.
Elected from Community Health Committees. Community representatives represent the Forum, but as Council members must serve the interest of all people in the district. Rules of corporate governance ensure that no vested interests are used to influence decisions.
Elected from the Community Health Committees. As members of Board, these representatives ensure that hospital facilities and services are appropriate for all people in the district.
Roles and Functions
To meet and report back to its forum at least three times per year.
To be part of governance structures of health facilities in the area with either advisory or decision-making control over personnel, finances, facilities, and services.
To participate in needs analysis, planning implementation, and education of PHC in area.
To elect/nominate representative to Hospital Boards and DHC.
To decide on policy issues, set frameworks and oversee resource allocations.
To make decisions or advise on financial matters, provision of pharmaceuticals, revenues, personnel, and services.
To form subcommittees and coopt expertise as required.
To advocate on the behalf of communities, and to participate in management of the hospital.
To raise additional funds for the hospital.
To ensure coordination between the hospital and other facilities in the district.
Either decision making or advisory.
Either decision making or advisory depending on governance options.
Combination of decision making and advisory powers.
Community development forums
MEC and electing structure
District Health Council,
MEC and electing structure
A national programme, administered at the district level, to empower community reps to serve on Community Health Committees
National programme, provincially administered, to ensure that all Council members know and understand their responsibilities and roles as art of a corporate governance structure that serves the whole health district.
A national programme, provincially administered, to ensure that all Board members know and understand their responsibilities and roles with respect to the functions and activities of a District Hospital Board.
Source: Adapted from A Policy for the
Development of A District Health System for South Africa,
Pretoria District Health Systems Committee, Department of Health,
Community involvement is a dynamic process that defies the
conventional health outcome measures used to evaluate other
health activities. Before one can evaluate CIH's effectiveness,
there is a need to define "community involvement." For
the purposes of this research, community is defined as a group of
people with shared needs living in a defined geographic area.
Internationally, there are three interpretations of CIH: 1) contribution to predetermined programmes, 2) representation on organisational structures, and 3) empowerment to make decisions about its own affairs. Although all three components must obviously be present, the highest goal of community involvement is defined as empowerment to make decisions. This "gold standard" has been used as the yardstick to measure CIH.
The theoretical paradigm used in this research was based on the seminal work of Birchman, Rifkin, and Shrestha that was adapted to the South African context by Chetty and Owen. These researchers identified five separate criteria to evaluate community involvement:
Figure one highlights how these five criteria have been converted into more specific indicators to evaluate food and nutrition programmes in Indonesia and Tanzania.
Figure 1: Community involvement in health indicators in Indonesia and Tanzania
CIH indicators in food and nutrition programmes, Indonesia and United Republic of Tanzania
Source: World Health Organisation, Community involvement in
health: challenging health services. Geneva.1991.
Because CIH is process oriented, the use of quantitative or
numeric measurement has not proved useful in previous
evaluations. Many researchers instead have employed qualitative
research techniques to better understand and assess the process.
Because qualitative research is a relatively new and
underutilised discipline, the significant differences between
quantitative and qualitative approaches to evaluation need to be
Qualitative indicators of community involvement are
conceptually different from those normally used in the evaluation
of health services, which focus on productivity, utilisation and
the quality of services. Quantitative research typically attempts
to measure an event in order to judge whether it has been
successful or not. On the other hand, qualitative indicators look
at changes and progress towards an objective over time. It
provides descriptions so that people can interpret the situation
rather than judge its success or failure. As such, the
qualitative indicators chosen must relate to the objectives of
the planning process. Figure two illustrates the conceptual
differences between quantitative and qualitative research.
Figure 2: Comparison of quantitative and qualitative
measurement leads to judgement
description leads to interpretation
Source: World Health Organisation, Community involvement in health: challenging health services. Geneva.1991.
One key research technique used to evaluate CIH is participatory evaluation. Involvement in the evaluation process is a learning experience that can contribute to the empowerment of communities and the strengthening of partnerships with health workers. This process requires a substantial commitment to training and support. Sufficient time and resources must be provided for these methodologies to be successful.
In reality, many attempts are often required to involve communities in PHC projects. Thus evaluation of these iterative processes will often provide insights and lessons which can eventually lead to true participation. Research on community involvement should not be viewed as a static exercise, but must be highly participatory in order to maintain its relevance. The dynamic process of community involvement takes many forms and occurs in different settings. Thus, evaluation instruments must be flexible enough to examine the processes and mechanisms within the community and between the community and health workers.
It is important to restate that the evaluation tools used in
this research were not meant to determine whether community
involvement was a good or bad idea. Further, they were not
intended to judge provincial policymakers on their efforts at
community involvement. Rather, the purpose of this research was
to document changes over time, allow for standardised comparisons
between provinces to allow for interlearning, and ultimately to
help refine and improve the implementation of CIH. Therefore, the
quantification of community involvement was not necessarily
possible or even a desirable outcome. Two essential criteria were
used to create the evaluation measurement instruments :
Can they serve as a feedback mechanism to improve levels of community involvement?
Chetty and Owen expanded on earlier evaluation criteria by looking at both intentions of policymakers and their achievements. Thus, both the intended consequences and the actual outcomes were studied to understand how theory was put into practice. This dual approach allowed researchers to identify specific stress points in the translation of policy into action.