Chapter 2: Community Involvement in Health

Community Involvement in Hospitals:
Key Findings and Recommendations

2.1 Introduction

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 in 1978. This Declaration reflected the belief that health problems were not caused simply by service delivery issues or solved by service delivery interventions. A holistic approach to health was envisaged that addressed the root causes of poor health and empowered people in the process. Despite endorsement of the Declaration, very few governments have taken up the challenge to involve communities to determine their health priorities and interventions. To date, it has been largely church groups and NGOs that have tried to implement this concept. [3] Thus, the Government of National Unity of South Africa's publicly stated commitment to community involvement is an important landmark. Political commitment, however, represents only one precondition to successful involvement of communities.

Before discussing the potential benefits and limitations of the community's role in the health sector, it is essential to define the terminology. Many people are unaware of the difference between "community participation" and "community involvement." According to a World Health Organisation Study Group Report, there are various interpretations of community participation. Community participation can be seen as:

• the contribution of material or labour;
• 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, on the contrary, is 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. Together they agree on approaches to address these issues. The Reconstruction and Development Programme (RDP) aims to achieve the involvement of communities as full partners in their own development.

2.2 Potential Benefits and Limitations

International experiences suggest four preconditions that need to be met to promote and foster community involvement in health:

• political commitment to community involvement from the government;
• 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 RDP and the Department of Health support community involvement in their policy documents. The presence of the RDP and the financial commitment of the GNU to support development reflect a health environment for development. As such, South Africa has met the first and last preconditions.

There are many potential benefits to be gained from actively involving the community in the health system. Community involvement is beneficial because it:

• realises human rights
• builds self esteem
• and encourages a sense of responsibility;
• ensures the appropriateness of health services for a community's needs;
• develops a relationship of trust and empathy between providers and consumers;
• encourages a sense of ownership through participatory decision making;
• creates political awareness; and
• ensures accountability of health care workers and managers to the communities that they serve.

But despite its tremendous potential, community involvement is not a "magic bullet" that will conquer all health problems. International experience has shown many failed attempts to meaningfully involve community members. It is important for South Africa to learn from these failures. Some reasons behind the failures are listed below.

• Preconditions for community involvement may not be present. This undermines other efforts.
• Medical officers and health teams do not appreciate the importance or value of community involvement
• and they often control important information by using medical jargon to exclude community from discussions.
• People may contribute their time and energy
• but have no sense of ownership because they were not involved in the planning or implementation of the programme.
• Health development strategies have failed to encourage people to think and act for themselves.
• It is very difficult to measure whether community involvement has been successful or not. This may cause premature abandonment of the effort.
• Communities' expectations often outstrip available resources
• which causes conflict undermining community involvement.

2.3 Community Involvement in South Africa

In South Africa, policy makers have expressed a strong ideological commitment to community involvement in health and development. The RDP, endorsed by the Government of National Unity, emphasizes the need for community involvement. "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." [4] In addition, the financial resources made available through the RDP reflect a commitment by the government to development.

The Department of Health has also endorsed the idea in its policy documents. One of the Department's goals for transformation 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." [5]

"It is a fundamental principle of the PHC approach that there is maximal possible community participation in the planning, provision, control, and monitoring of health services. For such community participation to be effective, it is not enough that the managers of the service simply are held formally accountable to an elected body. Community development and empowerment are essential to the promotion and maintenance of the health of communities, and vibrant community-based organisations must be accommodated within the district health structures if true community participation and involvement are to be realised." [6]

While it is acknowledged that "there is an inevitable tension between participation and accountability on the one hand and on the other hand, the need to technically manage the health system on a day-to-day basis,"6 there is an important need to increase accountability of health facilities and management to the communities that they serve.

In summary, a strong political will to involve communities is reflected in all the Department's policy documents. At the National and Provincial levels, more participatory management approaches have been adopted. To date, these approaches have largely included only other elite policy makers and academics in the process. Although two of the four preconditions for community involvement are satisfied, few active steps have been taken to include people at the grassroots level in the policy making process. Hopefully, theory and rhetoric will be put into action with the development of the district health system.

2.4 Objectives for Community Involvement

Clear objectives need to be established for community involvement in hospital management. Based on our research, NPPHCN proposes three objectives that should guide implementation of all community involvement initiatives:

• to ensure that all health services are fully accountable to the people served by them;
• to empower and build the capacity of community members to fully participate in the decision making process; and
• to allow the community to take ownership of the health facilities that they use.

Community participation is a dynamic process; therefore, these objectives should be flexible to adapt to the changing situation. [7]

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