Appendix 1

A.1 Literature Review

The initial literature review, however, did not contain specific information about international experiences with hospital governance and accountability structures (ie, Hospital Boards). An additional literature review was subsequently undertaken which focused on relevant international models of community involvement in the governance and accountability of hospitals. Additional articles on community involvement in health and hospitals were analysed. The review focused on the experience of four countries relevant to South Africa: Great Britain, Quebec (Canada), Cuba, and Zambia. All relevant articles are available from NPPHCN.

A.2 Community Forums

Table A.1: Summary of Community Forums

Forums were designed to solicit the views of a broad range of community stakeholders. NPPHCN invited a mixture of community participants including representatives from: NGOs and CBOs, community health committees, development forums, health professionals, health management, and government. Some individual community members not aligned with any structures were also invited. Figure A.1 reveals that the majority of questionnaire respondents represented community structures.

NPPHCN believed that it was critical for community members to be given the opportunity to express their own views without intimidation from health professionals. Efforts were made to limit the number of health professionals at each workshop. Labour union representatives also were purposely excluded from these discussions. Naledi, a consortium partner, is independently examining personnel and labour issues within hospital decentralisation.

In preparation for these forums, NPPHCN drafted a detailed input on the district health system with particular emphasis on community involvement in health. In our view, it would not have been meaningful to discuss community involvement in hospitals without first ensuring a basic understanding of the Department of Health's overall transformation plans. This view was confirmed by the lack of familiarity of most participants with national health policy documents.

To systematically elicit the views of participants, NPPHCN developed a series of probing questions. The focus of each forum was to develop a national framework with specific policy recommendations; therefore participants were encouraged to move beyond simple identification of problems and restatement of RDP rhetoric. Participants were challenged to present specific, concrete proposals for change.

Each forum consisted of between five and six hours of input and discussion, with the majority of time spent in group discussions. The workshops provided the opportunity to discuss issues in plenary and in small group sessions to ensure greater participation. In addition, all workshops were conducted both in English and in the majority language of the province to accommodate all participants.

There were two primary objectives for the community forums:

• To gain a better understanding of how communities want to involve themselves in the management and administration of hospitals.
• To get feedback from community members on specific issues raised in the Hospital Strategy Project's draft proposal on governance and accountability contained in the Red Book.

To complement the group discussions, NPPHCN also designed a brief written questionnaire for all forum participants to complete. The questions were very similar to those asked in the group discussions. The questionnaire was written in English and translated orally for forum participants.

The questionnaire was intended to gauge the depth of opinions expressed by a few vocal forum participants. Often several participants dominate group discussions thereby giving their own opinion extra influence on the research. Analysis of the questionnaires allowed NPPHCN to find out whether most of the participants agreed with the views expressed by the vocal minority. Secondly, the questionnaire afforded NPPHCN the opportunity to quantify public perceptions about some critical issues raised in the group discussions.

365 written questionnaires were completed and analysed. This analysis has been used to support recommendations made throughout this document. Although, the respondents do not represent the views of all South Africans, they can serve as a barometer to gauge the intensity of a particular constituency's attitudes about community involvement in hospitals.

A.3 Case Studies

NPPHCN conducted two case studies to gain in depth knowledge on two important aspects of community involvement. The first case study examined the potential for an alternate structure to inform communities about hospital policy decisions.

Red Cross Memorial Children's Hospital in Cape Town is attempting to dramatically reduce the number of non-tertiary care patients seen by its outpatient clinic. This plan reflects national pressures to shift money and resources from tertiary level to primary level care. A task force within the hospital drafted a proposal that would turn many patients away from the outpatient clinic and redirect them to neighbouring district hospitals, health centres, and clinics. Recently the hospital presented its proposal to the Cape Metropolitan Health Forum, a voluntary structure representing all the health stakeholders in the area, for debate. NPPHCN has interviewed key stakeholders within the Cape Metropolitan Health Forum and the hospital to gain a better understanding of the benefits and limitations of this consultation process.

The second case study identified some critical issues that may arise as the theory of community involvement is put into practice. To learn from the experiences of a community trying to involve community members in the development of a new hospital, NPPHCN interviewed several community leaders in Khayelitsha.

A new district hospital has recently been built and the community has been actively involved in the planning process of that institution. The Khayelitsha Health and Welfare Forum is attempting to implement the proposals on community involvement contained in the Western Cape Provincial Health Plan. There has been some conflict among health structures in Khayelitsha about who represents the views of community members. To better understand the issues, NPPHCN reviewed the relevant sections of the Western Cape Provincial Health plan and interviewed members of the Khayelitsha Health Co-ordinating Committee, the Khayelitsha Health and Welfare Forum, and the Cape Metropolitan Council.