Chapter 3: The Community's Perspective on Community Involvement

Community Involvement in Hospitals:
Key Findings and Recommendations

Internationally, Hospital Boards have been identified as one mechanism to help communities take ownership of these institutions. While Hospital Boards represent powerful structures to involve communities in hospital governance, there are many different ways that South African communities believe that they can contribute to the health system. It is critical that communities' enthusiasm is not stifled by focusing only on the creation of Hospital Boards. This chapter explores some creative suggestions for their involvement in the health sector put forth by community members.

The reader will observe when reading this chapter that communities have high aspirations to get involved in the health system. The suggestions presented here often represent the ideal vision of community involvement in hospitals that could be in place after ten years. Consideration of the feasibility of implementing some of these proposals is included in Chapter 6 which deals with implementation issues.

3.1 Conceptualisation

Based on NPPHCN's consultations, communities definitely want to be involved in the health system. Figure 3.1 reveals that the overwhelming majority of respondents (98 percent) believe that communities should be involved in hospitals, with more than three in four persons strongly supporting community involvement in hospitals. People viewed hospitals as one element of the overall health system. During the forums, communities suggested many ways of getting involved with hospitals.
Figure 2: Involvement in Hospitals

Hospital security is widely recognised as a problem for staff, patients, and community members alike. Communities proposed a series of interventions that they believe can help to create a safer environment. For example, volunteers can patrol the hospital premises to supplement security, similar to neighbourhood watch programmes. Volunteers also could build security fences around hospitals that do not have them. In addition, communities could convene intersectoral meetings through community development forums with the SAPS and other stakeholders to address the situation holistically. Finally, communities could distribute security information to staff and patients to heighten their awareness and reduce risks. Security represents only one issue that was raised at the forums. People's suggestions are included here to stimulate discussion among policy makers about how to harness these untapped resources within communities.

3.2 Hospital Governance

The overwhelming majority of respondents stated that they wanted to be involved in hospital governance. NPPHCN asked community members to list and prioritise specific issues based on the importance of involving communities in governance. For each issue identified as important, specific mechanisms for community involvement are presented. While Hospital Boards figured as prominent answers, they were not the only mechanisms for community involvement. People then identified the training needed to fulfill each function. Finally, methods to evaluate the effectiveness of the interventions were suggested.

A composite summary of regional forum responses is included in Table 3.1. These suggests were made within large group discussions at 11 different forums. Therefore, it is difficult to quantify the results. In the questionnaire, participants were asked to prioritise governance issues based on the importance of involving communities. These results are included in this section to give some indication of the relative importance of each issue to community members.
Table 3.1: Community Involvement in Governance Issues

Issue	Mechanism	Training	Evaluation
Strategic planning	Situational analysis and needs assessment completed by community Joint strategic planning sessions	Planning process Research skills	Number of community members who participate Whether community needs assessment/situational analysis are used by management
Hospital management	Representatives on Hospital Board	Hospital operations	Opinion of Board members Views of electing forum
Finances and budget	Representative on finance committee	Budgeting and accounting skills	Contribution of Board member Budgeting and accounting skills transfer
Labour relations	Oversight of employment practices Intervention channel during dispute	Public sector employment practices Labour Relations Act	Review of crisis management procedures to determine effectiveness

Strategic planning

Across all forums, communities felt that they should be involved in the hospital's strategic planning process. Behind quality assurance, which is discussed under accountability issues, strategic planning was rated as the second most important issue (out of ten) for communities to be involved.
One important contribution to the strategic planning process that people expressed at several different forums was their knowledge of the community's health needs. People on the ground felt that they were in the best position to understand these issues, but they did not have the skills to present the information in a useable format. To document their knowledge, communities expressed a desire to participate in community-based research to develop a situational analysis of the health needs and services available in the community. Using this research, communities and hospital management could then develop a strategic plans to address their needs. Participatory research methodologies are supported by Essential National Health Research (ENHR) policies.

There is evidence within South Africa that successful strategic planning partnerships can be established. The Mpumalanga Department of Health, Welfare, and Gender Affairs has embarked on an ambitious process to assist district facilitating teams in drafting situational analyses and strategic plans for health districts. The district facilitating teams are comprised of health managers, health workers, and community representatives. The process has required substantial time commitment, training, resources, and outside assistance over a six month period. As such, community-based research must be considered a long-term strategy for Hospital Boards. A summary of this process currently is being drafted and will be circulated to other provinces.

Additionally, people mentioned participation on Hospital Boards as a means to influence strategic planning. A more detailed description of the roles and functions of Hospital Boards will be provided in Chapter 4.

Community involvement could be measured by the number of community members who are participating in the research and strategic planning. Additionally, one could assess how much of the community-based research was used by hospital management for planning purposes. Finally, one could survey community members to determine their knowledge and acceptance of the hospital's strategic plan.

Hospital management

Hospital management was characterised as the day-to-day operations that make a hospital run. It is important to note here that day-to-day operations do not imply daily interaction with hospital management, the term was used in contrast to long-term strategic planning.
In all forums, participants felt that Hospital Boards were the most appropriate mechanisms to get involved in basic hospital management issues People felt that some basic training in hospital operations and general principles of organisational management, particularly participatory management, would help them participate effectively on a Board. One could interview Board members and development forum representatives to assess the influence and performance of community representatives on Hospital Boards.

Finance and Budget

Although many community members expressed reluctance to get involved in hospital financial and budgetary matters, with some prompting people acknowledged the importance of their participation. Hospital finances were ranked only as the eighth (out of 10) most important issue for community involvement in governance. These results may reflect respondents' lack of experience with financial matters and consequently a lack of confidence in their ability to make a meaningful contribution.
In several forums, communities suggested that the representation of a properly trained community representative on the finance committee of a Hospital Board would maximize their influence. A clear need for training on basic budgeting and financial issues was expressed so that the representative could make a meaningful contribution.

Labour relations

During the nurses' strike last year, many communities felt caught in the struggle between health management and health workers. Both sides appealed to communities to support their positions, but communities did not feel empowered to make a positive contribution to the situation.
As a result, some people who attended the forums, wanted communities to take a more proactive role in labour relations. Participants in Bisho and Umtata in the Eastern Cape, and kwaZulu/Natal felt particularly strongly about this issue. Specifically, these communities wanted to oversee the employment process to ensure that it is fairly administered. They expressly did not want control over individual hiring and firing decisions. In fact, community involvement in the actual hiring and firing of health personnel was rated as the least important issue in hospital management by questionnaire respondents.

If future disputes arise between hospital management and staff, community members want to serve as mediators to resolve the crisis. To fulfill this role, people will need to be educated about the Public Service Commission's regulation of employment and the new Labour Relations Act. One could review crisis management to determine whether community members had a positive or negative impact. While there may be potential to implement these suggestions on a informal basis, it is not clear that community members could formally serve as mediators under the Labour Relations Act and other laws.

3.3 Accountability of Hospital Management

On the whole, forum participants placed a much stronger emphasis on accountability then on governance. In several forums, groups tasked with listing governance issues focused instead on accountability. Partially, this may be explained by some confusion about the terminology used. Within plenary discussions, it was clear that people first demanded accountability to allow them to participate in the decision-making processes. This sentiment was later echoed during discussion about whether a Hospital Board should advise or make decisions for hospital management.

Community members believed it was essential for hospital management to report back on several important issues. Without information, communities cannot become involved. Participants views on accountability issues are summarised in Table 3.2.

Table 3.2: Community Involvement in Accountability Issues

Issues	Mechanism	Training	Evaluation
Quality of services	Patient surveys Promotion of health rights charter Use of community media	Research skills Advocacy skills	Number of community members participating in research Measure confidence of patients
Planning new services and facilities	Situational analysis of community needs Use of community agents to facilitate debate	Research skills	Number of submissions on new services or facilities
Finances and budget	Presentation of financial audit statement by hospital management to public meeting	Skills to understand an audit statement	Budgeting and accounting skills transfer
Health promotion	Using community radio stations Newsletters Health forums	Re-orientation of management Health promotion skills	Penetration of health promotion messages Number of people participating
Community and patient grievances	Advocacy Public Relations Officer	Advocacy skills	Number of unresolved grievances Home visits to determine level of satisfaction

Quality of services

Ensuring the quality of services delivered in hospitals was rated to be the most important issue for hospital management to report back to communities. Within all of the forum discussions, people felt strongly about the quality of care delivered in the public sector. It seemed that participants could relate to how they were treated by health professionals.
Participants suggested some ambitious and innovative mechanisms to ensure high quality care. Armed with baseline information from their situational analyses, communities can help to develop an ongoing evaluation of health services to ensure that the services provided are meeting their needs. People suggested that could include periodic patient surveys to assess the quality of care provided.

In many forums, communities identified the need for a Health Rights Charter to change the balance of power between patients and providers. Participants suggested that they would actively promote the creation and dissemination of a Health Rights Charter. People believed that changing the current dynamic by empowering patients would improve the quality of care. Here again, participants expressed a need for basic research skills to help them evaluate the quality of services. The number of community members who participate in the evaluation process could serve as one indicator of the level of their involvement.

Finances and budget

As under governance, forum participants reluctantly acknowledged the importance of accountability around hospital financial matters. Some people felt that an independent audit of the hospital's financial statement would help communities to become more informed about financial matters. There was support for the hospital drafting a simplified audit statement of hospital revenues and expenditures with adequate explanations to be widely circulated in the community.
Interested community members then could review the audit statement to ensure that it accurately reflected hospital expenditures. Additionally, hospital management could present its annual budget to the community development forum or an annual general meeting for debate and consideration. A simple mechanism could be established for the community to ratify the hospital budget and strategic plans for the coming year. Even with simplification of the process, people will need basic financial skills training. Acceptance of the hospital budget by community members should indicate the success of the discussion process.

Planning new services and facilities

People at all 11 forums believed that it is the obligation of hospital management to keep the community informed about the establishment of new services and important hospital policy changes. These issues were rated as the third (out of 10) most important for accountability to communities.
Participants viewed this as a communication problem between hospital management and communities. People felt that community agents, such as CBOs, civics, and street committees already serve as communicators on a number of development issues. It was suggested that these organisations could simplify and translate hospital proposals for broader dissemination in the community. They could facilitate workshops and forums to solicit the views of the communities.

Additionally, communities could broadcast on community radio to discuss hospital management proposals and feed back the opinions of the community. Community agents would need timely access to hospital policy information to facilitate this process. The Cape Metropolitan Health Forum, discussed later in this chapter, presents a case study about the dissemination of information to communities about proposed hospital policy changes. Some quantitative indicators of the success of these efforts are the number of public workshops and the number of public comments that hospital management receives about new facilities and services. A difficult, but more meaningful measure would be to test the community's knowledge of hospital proposals.

Health promotion

As mentioned above, hospital management does not have the resources to create effective communication channels with communities; therefore, communities proposed to facilitate the two-way flow of information between communities and hospitals. Community agents can extend health promotion messages beyond the hospital through creative media that is acceptable to their communities. To successfully implement this proposal, hospitals must invest in training people within organisations with basic health promotion skills. One can measure the penetration of health promotion messages and the number of organisations participating in these efforts to assess its effectiveness. It must be noted that currently very little health promotion takes place at the hospital level. Hopefully, this will change with the proposed transformation of the health system.

Patient and community grievances

As stated above, information and communication appear to lie at the heart of many patient and community grievances with hospital staff and management. Without a proper flow of information through relevant communication channels, communities will be excluded from the decision making process.
Community agents can convene workshops and meetings to discuss patient and community grievances. They could consolidate and prioritise the issues and then present them in a systematic way to hospital management. In return, hospitals should provide a dedicated employee (an ombudsperson or public relations officer) with the authority to address patient and community grievances directly or refer them to the Hospital Board for resolution. The number of unresolved grievances and the attitudes of community members could serve as indicators of the success of this initiative.

3.4 A Case Study: The Cape Metropolitan Health Forum

The Cape Metropolitan Health Forum (CMHF) provides one potential model for national, provincial, and regional hospital management to exchange information with the "communities" that they serve. The CMHF is a non-statutory debating forum with representatives from various constituencies in Cape Town: community-based organisations (CBOs), non-governmental organisations (NGOs), community health committees, employee bodies and unions, health service rendering authorities, political structures, training and research institutions, professional associations, and the private sector. The forum is in the process of restructuring to mirror the development of its constituencies.

Red Cross Memorial Children's Hospital serves as a superspecialised referral hospital for all children in South Africa and it supplies specialist paediatricians for the Western Cape. It also provides primary care services for children living in the Cape Town metropolitan area. As a result of restructuring of the national health system, the hospital faces deep budget cuts with the movement of funds from tertiary hospitals to the primary care level. Although the hospital is designated as a superspecialised referral centre, it provides a substantial amount of primary care through its outpatient clinics.

In response to the proposed budget cuts, the hospital has decided to refer children who walk into the hospital to surrounding primary health care clinics for treatment. Their preliminary estimates suggest that two-thirds of their current outpatients would be redirected to other centres. This major shift in policy will impact many families who value the hospital and use it for all of their children's medical care. Because of the reduction in patients, the hospital plans to free some medical staff to work on a sessional basis at the surrounding facilities.

After an extensive internal review process to develop a proposal, hospital management presented their proposal to the CMHF for debate. The CMHF does not have the authority to accept or reject the plan. The hospital was informing this structure about the proposed policy change and asking for their comments on it. Representatives from community health committees in one area voiced concern about the proposal. In response to these concerns, the CMHF has established a subcommittee to workshop the proposal with the communities impacted by the plan to get their opinions. This process is still in progress so it is too early to determine the outcome.

Structures like the CMHF provide an opportunity for hospital management to report directly to a wide range of community structures by giving them an opportunity to debate major policy issues. This forum may relieve pressure on a few Board members to account for all hospital decisions and may address the issue of accountability at larger referral hospitals. The body has no statutory authority and its recommendations are sometimes ignored by hospital management, making it difficult to recommend as a governance structure in its current form.

The CMHF and similar forums need further research to develop their potential to ensure accountability at level two hospitals and above.

Chapter 2

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Chapter 4