• Chapter 4: Community Involvement in Hospital Boards

  Community Involvement in Hospitals:
  Key Findings and Recommendations

  

  This chapter synthesises community opinions about Hospital Boards gathered from the forums and questionnaires. It examines the conceptualisation of Boards, their composition, and the selection process and terms of office for Board members. It concludes with summaries from several international attempts to "democratise" Hospital Boards, drawing some important lessons for South Africa.

  4.1 Conceptualisation

  Within the forums, there was nearly unanimous support for Hospital Boards. Ninety-four percent of respondents believed that Hospital Boards represent important mechanisms to involve communities in the governance of hospitals (Figure 4.1).
  
  

  Almost universally, forum participants felt that it was not acceptable for the provincial government to be solely responsible for overseeing hospital management decisions. People argued that the provincial government is distant from people affected by the local hospital's decisions. Additionally, they felt that the government does not have the capacity to ensure that decisions made by different hospitals are suitable to communities. People affected by such decisions must have a say and Hospital Boards are an effective way to do this. Hospital Boards are not important only at the local level. People thought that it was critically important for communities to be involved at all hospital levels from district to academic health centres.

  In summary, forum participants presented the following goals and objectives for their involvement on Hospital Boards:

  • to advocate for the aspirations of communities:
  • to be involved in the drafting of all polices that directly impact on the community; and
  • to be involved in the implementation and evaluation of these policies.

  In broad terms, people felt that the functions of a Hospital Board should be to:

  • participate in strategic planning process;
  • advocate for communities needs;
  • ensure quality of services;
  • consult with communities on plans under consideration;
  • report back to communities on hospital progress;
  • monitor income and expenditure; and
  • resolve conflict and provide mediation for staff grievances.

  The Hospital Board's role as advisors or decision makers for hospital management proved to be a difficult issue for communities. Instead of being an advisory or decision making body, they believed that the Board should work with hospital management to jointly make decisions. Most participants stressed that the goal of the Board should be to work in collaboration with management rather than in an adversarial manner.

  In the event of a dispute between the Board and hospital management, many different opinions were expressed. The majority of people wanted the province to intervene in that instance (Figure 4.2). Some people, however, expressed distrust in provincial officials, fearing that they would automatically side with hospital management. More than one in four thought that the Board should have final authority to resolve disputes with hospital management. Other individuals suggested that a mediator or the provincial parliament should intervene. The dispute resolution process requires further discussion before definitive recommendations can be made at the provincial level.
  

  
  

  4.2 Composition of Hospital Boards

  Workshop participants suggested that Hospital Boards should contain between 12 and 20 representatives depending on the size of the hospital and community dynamics. Representatives should be selected from the following comprehensive list of potential stakeholders:

  • community-based organisations/non-governmental organisations/civics ;
  • local councillors;
  • legal
  • financial
  • and business experts;
  • religious organisations;
  • youth structures;
  • community health committees;
  • hospital management (ex officio members);
  • hospital employees;
  • disability organisations;
  • users of services; and
  • referral clinic and health centre representatives.

  There was some fluidity in the proportional representation of each sector. People were firm, however, that community representatives need to comprise more than 50 percent of the membership to ensure that their participation is meaningful. The term "community representatives" was not explicitly defined; therefore it is unclear whether local government councillors or NGO/CBO representatives would qualify as community representatives. It was very clear that Board members should not represent the interests of political parties in performing their duties. People would be selected to serve the community's interests.

  In order to be elected to a Board, community members should be a representative of a democratic community structure. Otherwise, the Board will only contain the views of several individuals within the community and accountability will be diminished. To improve the channels of communication between Boards members and the community, people felt that Board members should have to report back to a structure. Often people sit as representatives on structures, but never report back on their activities. It should be noted that the majority of participants at the forums attended as representatives of structures, which could bias this finding.

  Once elected, people anticipated that each Board would draft its own inter alia conditions of service and work plan within the provincial framework. This document could also identify the training and support needs of the Board. It would serve as a "memorandum of agreement" with the MEC, hospital management, the provincial administration, and the community from the Board's perspective. Thus, the suggestions contained in this chapter are meant to serve as guidelines to develop the framework rather than as prescriptive recommendations.

  Most participants felt that there should be a distinction between voting and non-voting members of the Board. Hospital management should be included as non-voting members on the Board. Their reasoning followed that managers will exert tremendous influence over the Board based on their position and their control of vital information. Moreover, they will obviously vote to support their own proposals. Giving them additional voting privileges would shift the balance of power and undermine the influence of community representatives.

  People recognised the need for executive officers. They recommended the creation of Chair, Vice Chair, Secretary, Vice-Secretary and Treasurer. The role and functions of the executive committee vis a vis other Board members should be clearly defined in its inter alia conditions of service. The Chair should be selected from among the community representatives.

  Due to the technical nature of the hospital management and the specialisation required, people felt that the Board may need subcommittees with particular expertise to carry out its functions. Some suggested subcommittees include:

  • research;
  • finance;
  • evaluation; and
  • training and education.

  The creation, composition, terms of reference, and authority of subcommittees, however, should be defined by each Board individually. The regulations governing the creation of subcommittees and the work of the Boards could be based on the Rules of the National Assembly governing Portfolio Committees.

  4.3 Selection Process and Terms of Office

  Participants felt strongly that Board members should be elected by representative structures to ensure accountability. In many areas, this structure exists as the RDP forum or community development forum. Ideally, the health substructure should be responsible for choosing Hospital Board members at the district hospital level. As the case study of Khayelitsha at the end of this chapter reveals, finding a truly representative structure in a community is not always clear cut. In choosing the electing structure, consideration must be given to alternative electing mechanisms if there are conflicting or weak structures in a community. A new Board elected by an undemocratic process will have less credibility than current Boards. It is impossible to prescribe a uniform selection process at the national or provincial level because each community has different power dynamics. The national community audit proposed in Chapter 6 should provide some insight into community power structures and propose alternative selection mechanism models. The selection of locally elected councillors should be carefully considered as an option.

  Much of the discussion at the workshops about the selection process of Hospital Boards focused on district level hospitals. In order to understand the proposed selection process, it is important to understand the community's perception of the governance structures at the district level. The governance model that most forums seemed to adopt at the district level was that Hospital Boards and Community Health Committees ultimately should both be accountable to the District Health Council (DHC). Community Health Committees would be directly accountable to Community Development Forums, which would have representation on the District Health Council. Thus, each facility would have its own Board, but ultimately authority would still rest with the District Health Council. This model is different than the models presented by the HSP.

  Figure 4.3 : Alternative District Governance Model

  

  There are several advantages to this alternative model of governance. First, it provides maximum potential for community involvement at all delivery levels. Second, it assures that hospitals are integrated into the health system at the district level. It will also facilitate information flow between different levels of facilities, mirroring referral patterns of patients. The creation of more governance structures, however, will be difficult to establish and expensive for districts and provinces. Thus, in the short-term, it may not be practical to establish separate Hospital Boards at district level hospitals. The next preferable alterative is to create subcommittees within the DHC to oversee district hospitals.

  As stated above, there was very little discussion in the forums about the selection process for level 2 hospitals and above. It is recognised that for referral hospitals serving large areas and populations it will be even more difficult to convene a representative community-based electing structure. Once restructured along district lines, the Cape Metropolitan Health Forum could serve as an electing forum for regional and referral hospitals serving Cape Town. Another potential option is that provincial RDP councils could elect representatives to provincial level hospitals and the national RDP Council could elect Board members for academic health centres. In these cases, it will be very important to clarify to whom is the Board accountable. Further discussion is obviously needed to make concrete recommendations for each level hospital. It is clear from these discussions, however, that there need to be different selection processes for different level hospitals.

  There was consensus for a 3-year term of office for Board members. People reasoned that it would take time for representatives to become comfortable with their responsibilities; therefore it would be counterproductive to re-elect Board members every year or two. On the other hand, people felt that members should not sit on Boards for too long and become too powerful. Thus, a limit of two consecutive terms should be set. The initials election process could be staggered to ensure that there was some turnover each year.

  The consensus was that Board should meet monthly and whenever necessary in the interim. Based on the functions listed above, people estimated that Board members would spend approximately two to three days each month to fulfill their duties. Upon reflection, this appears to be an unrealistic amount of time to expect. In reality, Board members may sacrifice one evening per month or a Saturday to conduct Board business. People who serve on Hospital Boards most likely will sit on other structures, restricting their actual time commitment to the Board.

  The payment of Hospital Board members proved to be a very contentious issue in many forums. Genuine differences of opinion existed on this issue. Some people argued that Board members should be compensated for their time. They will have significant responsibilities in governing hospitals. Expecting them to make a large commitment without renumeration is not realistic. Among participants who supported payment of Board members, there was a wide range of suggested payment levels ranging from R 20 per day to R 5,000 per annum.

  The opposing view held that payment of Board members would set a dangerous principle for other structures and other departments. People would begin to demand payment for serving on any committee or structure. They also cited the potentially high cost involved in paying every Hospital Board member. They argued that money spent to pay Board members should first be allocated to administrative support, training, and transport costs. Finally, they expressed concerns that people would be motivated to serve on a Board solely for the payment. Paying members would destroy the spirit of voluntarism and democracy in South Africa.

  There was unanimous support that the government should provide money for training, transport, and other administrative expenditures related to the Board's work. These issues are covered in more detail in Chapter 6.

  In all forums, participants felt that here should be a mechanism to dismiss Board members who fail to fulfill their duties. The following deeds were given as examples that would warrant dismissal: gross misconduct, missing three consecutive meetings, mal-administration, and sexual harassment. The province could set down conduct guideline for Board members that would be enforced by individual Boards. People felt that Board members should be responsible for determining whether to dismiss someone based on provincial guidelines. It is critical that the entire Board is accountable to the larger community. Thus, every six months there should be an evaluation of the Board to assess its performance based on the goals and objectives that it has set. Results of the evaluation should be widely distributed to community members and the electing forum for discussion. The Board also could present make a presentation of its work to an annual general meeting of community members.

  4.4 International Experiences with Democratic Hospital Boards

  As with all published literature, there is a definite bias toward documenting and researching the health systems of developed countries like the United States, Great Britain, and Canada. Many other nations have reformed their health systems and tried to involve communities in various governance structures, but there have been few published articles documenting their experiences. Despite this limitation, South Africa can learn some important lessons from the successes and failures of other nations' efforts at community involvement. At the same time, South Africa must document its own health transformation process to contribute an African experience to the international literature.

  Great Britain

  The strong influence of the British National Health System (NHS) on South African health policy development is apparent. It can be seen in the conceptualisation of district health system and the "purchaser-provider split" envisaged as a long-term strategy to promote efficiency. Because the proposed South African model is so similar to Great Britain, it is imperative to examine, but not necessarily adopt, British strategies for engendering community participation in the health system.

  In the NHS, individuals participate in the governance of health services and facilities through several structures. Community Health Councils were introduced in 1974. These bodies are composed of people nominated from local authorities, voluntary organisations, and the regional health authority (RHA). Although they have the right to access public information, the right to visit hospitals, and access to senior management, the councils have few powers in practice. [8]

  An additional mechanism for community involvement is the NHS Board. NHS Boards are comprised of an executive and part-time non-executive Board members. They are required to meet regularly. In addition, Boards must present an annual report to the Ministry of Health, the Audit Commission, and the local community assessing the hospital's performance. Finally, Board members are subject to a strict code of ethical conduct.

  Local NHS Boards are constituted as statutory bodies with a separate legal identity. Laws and regulations prescribe the structure, functions, and selection and responsibility of Boards. NHS Boards are responsible for owning and managing hospitals. The Boards are accountable to the Ministry of Health, who is accountable to Parliament for the delivery of services and the expenditure of state funds.

  The functions of the NHS Boards and their non-executive members have been broadly outlined by central government in the enabling legislation. NHS Boards are responsible for annual and long-term strategic planning; overseeing the delivery of services; monitoring performance against objectives; providing financial stewardship; ensuring high standards of behaviour; appointing, appraising and renumerating senior executives; and ensuring dialogue between the organisation and communities. [9]

  Non-executive Board members are expected to: provide oversight of staff relations with the public and the media; participate in professional conduct and competency inquiries; participate in staff disciplinary appeals; oversee the procurement of information management and technology; comprise the audit committee; and handle non-clinical complaints as lay conciliators or adjudicators. [10]

  Great Britain has developed a series of sophisticated orientation manuals and guidebooks to help educate the public about their role in the health system in general and on NHS Boards specifically. One such document, Taken on Board was written to help develop the role of non-executive local NHS Board members. Interestingly, the primary messages of the report are very consistent with the inputs made by community leaders at the community forums in South Africa. The main messages are listed below:

  • Induction programmes must individually tailored to give people information about national structure and policy
  • their organisation and the local health services.
  • The role and functions of non-executive Board members should be clearly established at the local level.
  • Giving non-executives a specific focus area can increase their involvement as they gain understanding.
  • Non-executive members can build on their knowledge by meeting with providers and other individuals outside the Board.
  • Previous decisions of the Board should be followed up rigorously to determine what progress has been made.
  • Non-executive members should be involved in strategy development and should monitor implementation.
  • Each Board should specify performance reports that it wants to see. These reports should be presented in an accessible format.
  • Non-executive Board members should take the lead on working with communities
  • providing them with information
  • listening to their concerns
  • and ensuring that the Board addresses the issues raised. [11]

  While the technical level of writing of this document makes it inappropriate for South Africa at this time, the idea of drafting a national or provincial briefing manual with background information for new Board members warrants serious consideration. A sample checklist for new NHS Board members is included as Appendix 2.

  Despite government's clearly stated aims, structures and guidelines, many critics question whether significant community involvement has been achieved in the NHS. Some researchers believe that community participation is insufficient within the NHS and subject to party political manipulation because of the lack of local accountability. [12] Another study found that NHS Boards have few black or ethnic minority non-executive members (45 out of 1531). The authors argued that it is very difficult for Board members to address the needs of communities that they do not understand. [13] Further criticism suggests that Boards are dominated by professionals and are not clear about their roles. As a result, NHS Boards manage hospitals effectively, but are not accountable to local needs. [14]

  Great Britain has much to teach South Africa about the drafting of laws and regulations to establish a new system of hospital governance. Their experiences can provide guidance in the drafting of enabling and implementation legislation. Additionally, their educational materials on the health system present a good model to introduce new Board members to the new health system and hospital management. While their conceptualisation of community involvement is strong and Britain may have achieved management efficiency through their NHS Boards, it is clear that they have not effectively engaged communities and particularly disadvantaged communities in this process. South African should be cautious not to simply adopt the British drive for corporate efficiency while forgetting to include people on the ground.

  Quebec, Canada

  The experiences of the Quebec Province in Canada in their efforts to democratise its Hospital Boards have particular relevance for South Africa. Before reform legislation was introduced, wealthy elite citizens formed the core of Hospital Boards. They served as patrons for the hospital rather than representatives of the public's interests. This situation closely resembles the current structure of many Hospital Boards in South Africa. There are, however, limitations to this comparison. In Quebec, the democratisation of Hospital Boards was the primary intervention. Whereas, the decentralisation and transformation of hospital management envisaged in South Africa will most likely put hospital management and Boards on more equal footing.

  In 1971, the Quebec Province in Canada 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. Although the government 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 socio-economic 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. [15] Each Board member was elected for a two year term.

  At that time, there was great apprehension among hospital management, labour unions, and elite Board members who tried to position themselves for the changes. Despite these concerns, 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 re-elect 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, many of the new Board members came from the same socio-economic backgrounds as previous members.

  In spite of changes in the composition of the Board, 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 to the Board. 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. These unstated rules effectively silenced many new members. The statutory composition of the Boards made it very difficult for community members to achieve a majority of votes in opposition to management proposals. Additionally, 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, the plan to "democratise" Boards in Quebec led to the institutionalisation of community members on Boards, but did not empower communities. [16] 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 new law, mentioned above, established that a certain number of seats were earmarked for community members on each health governance structure (four out of 14 on Hospital Boards). [17]

  In the final analysis, the Quebec government has admitted that public participation in the health system has not worked. [18] With regard to Hospital Boards, it actually decreased their authority, concentrated power for hospital management, and ultimately made hospital governance less democratic. [19] 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. The most glaring and most important lesson for South Africa is that the "top-down" approach to community involvement is not effective. It did not appear that the demand for democratisation came from communities. Rather it appeared that government determined their agenda and asked people to participate in it. As noted above, community members represented a small minority on the Boards even after reform. People were not interested in participating in a minority position in the highly technical issues related to running a hospital. [20] One researcher found that community advocates were able to develop much stronger power bases outside Boards that influenced policy through Parliament and the media. [21]

  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 hospital 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) provide them with adequate information, 2) create a strong mandate in the community to support their positions, 3) find individuals with strong personalities to stand up to administrators, and 4) create mechanisms for Board members to easily access their constituencies. It is not yet known whether these new reforms will produce different results, but the lessons learned from Quebec's twenty years of experience are invaluable for South Africa.

  Cuba

  There are strong historic and current links between Cuba and South Africa. The mass democratic movements in both countries lay at the heart of resistance politics and they form the foundation for new democratic societies. Cuba has more than 30 years experience in attempting to integrate the mass democratic movement into formalised governance structures in all sectors, including health. Additionally, the presence of 100 Cuban health professionals throughout the country presents the unique opportunity for South Africa to learn first hand about their experiences.

  In many ways, experiences in Cuba reflect the successful implementation of community participation in civic issues. [22] It has adopted a two prong approach to community involvement that could hold valuable lessons for South Africa. On the one hand, Cuba has developed institutional structures to involve communities in decisionmaking 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 are 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 are 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 comprised 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 communites. One study found that "these programmes have been succesful 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' particpatory skills." [23]

  It is important to remember that these positive results are due to a comprehensive reform initiave that addressed human resource distribution, medical education, and the delivery structure of the health system. South Africa is currently undergoing a similar process and should seriously consider elements of the Cuban health system as it restructures, but these issues are beyond the scope of this paper.

  In terms of community involvement, Cuba offers a different paradigm from the British and Canadian models of simply placing community members on governance structures. Cuba has done that, but they have also refocused the role of their health professionals from curative service provider at a clinic to public health officer for a community. Family doctors are expected to actively particpate in community life. Whether South Africa adopts the Cuban Family Doctor model or not, it should definitely incorporate the concept of active participation in community activities by health professionals. This spirit should permeate the health worker reorientation process, future medical curriculum development, and district health system development.

  Zambia

  After political changes in the early 1990's, the Zambian Government put forward a wide range of proposals to reform their health system. At the centre of these reforms was the reestablishment of fees for health care services and the decentralisation of health administration. [24] In many ways, the principle reforms implemented resonate with the goals of the Hospital Strategy Project. The reforms proposed long-term financial autonomy, organisational restructuring, and the increased use of commercial management principles in the health sector. Additionally, Zambia faces many of the same health problems and the remnants of colonial rule as South Africa does. As such, the Zambian experience could contain some lessons for South Africa.

  At the time of independence in Zambia, the government undertook major efforts to build health facilities and train doctors and nurses to provide access to free health care for all of its citizens. Because of limited government funds, a two-tiered health system developed with private hospitals for the rich and free state hospitals for everyone else. Three levels of hospital were created: district level hospitals, general hospitals at the provincial level, and referral hospitals in Lusaka.

  Declining government revenues forced a 30% decline in real terms in health spending between 1981 and 1991. This financial crisis resulted in the shortage of drugs and equipment and the exodus of staff to the private sector. Civil service restrictions required that managers consult with the Ministry of Health headquarters in Lusaka for most decisions. These poor working conditions led to civil unrest among health workers. In response, major reforms were proposed for the health system.

  The first Hospital Management Board was created for the University Teaching Hospital in Lusaka in 1985. Under the 1992 legislation reforms, this idea was expanded and the creation of health management boards was permitted for all hospitals and districts in Zambia. These Boards would be permitted to set their own fees, determine conditions of service for staff, and engage in any other developments of health services for which they were responsible. At the same time, the role of the national Ministry of Health in day-to-day administration of hospitals was greatly reduced. A Central Board of Health assumed responsibility for broad policy formulation and supervision of individual Boards. It was believed that these governance changes would increase the influence of communities and individuals over the administration of hospitals.

  In the government's reform proposal, Hospital Boards were expected to provide leadership and strategic vision for their institutions. Board members were supposed to be exercised their authority without threat of political interference and their terms of office were to be secured. The selection of Board members was supposed to reflect the communities served by the hospital: those who pay fees and those who would be impacted by changes in health services. In addition, the selection process was to be transparent. Caution was advised to prevent Boards from being dominated by health professionals at the expense of community interests. Along with these changes in governance, medical professionals and managers were supposed to be reoriented and retrained to cope with the decentralisation of authority.

  Unfortunately, because these reforms have so recently been implemented, it is difficult to evaluate their effectiveness and to measure the impact on community involvement in the health system. The vague descriptions of the selection process and the role of Board, however, could make it difficult to implement these reforms. In the end, South Africa should strike a balance between the very specific, detailed language used in Canada and Great Britain and the general principles found in Zambia. It is clear, however, that South Africa should heed Zambia's warning about the politicisation of governance structures and find a way to depoliticise Hospital Boards so that they serve community interests and not political interests in their work. The Department of Health should continue to monitor changes in the Zambian health system to understand the implications for South Africa.

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  4.5 A Case Study: Determining Representative Structures in One Community

  A new district hospital has recently been built in Khayelitsha, a township 20 km outside of Cape Town. The Cape Metropolitan Council has been attempting to work with the community to involve them in the planning and development of the hospital.

  Last year, partially in response to the proposed hospital, a Khayelitsha Health and Welfare Forum was established as a substructure of the Khayelitsha Development Forum. After its formation, the Health and Welfare Forum called for the dissolution of all other community health structures, stating that all decisions about health in Khayelitsha should be considered by the Forum in the future. This organisation based its authority on its status as an RDP structure and the policies on community involvement in the Western Cape Health Plan.

  Another community organisation, the Khayelitsha Co-ordinating Committee, was established in 1992 to facilitate dialogue between community health committees working at the grassroots level. Individual community health committees were elected directly from the community and many were trained by NGOs. They have been active in Khayelitsha for several years and are recognised within their communities. They called into question the legitimacy of the Health and Welfare Forum as a representative of community interests. At the insistence of the Health and Welfare Forum, this structure dissolved and people, who previously had been active in the community, became quiet. The Forum has indicated that they will call for the re-election of all health committees in Khayelitsha to ensure that they are "representative." As a result, much of the groundwork already done will be duplicated in the quest for "representation."

  In trying to be inclusive, the CMC has invited both groups to participate in the hospital development process, but the Co-ordinating Committee has not responded to their invitations. As a result, the CMC has been dealing primarily with the Khayelitsha Health and Welfare Forum. Currently, the CMC is in the process of allocating jobs at the hospital to community members. The Health and Welfare Forum is assisting the CMC in the process. When the hospital is opened, presumably the Forum will assist in the selection of Board members. If in six months time, another structure successfully challenges the Health and Welfare Forum, many of their decisions could be reviewed and reversed.

  This case study illustrates the power struggles that take place within communities. In an area where unemployment is greater than 50 percent, control over job selection gives a structure tremendous influence. Similarly, Hospital Boards will be viewed as powerful institutions. Consequently, there will inevitably be battles to "represent the community."
  

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