Chapter 5: Training and Capacity Building
Community Involvement in Hospitals:
Key Findings and Recommendations
As witnessed from experiences in Quebec, electing representatives to sit on a governance structure is not sufficient unless they have been given the adequate training to contribute to the process. Appropriate training and capacity building are essential to make sure that communities can make a meaningful contribution. Without a serious commitment to training, these proposals will be reduced to tokenism and co-option. It is important to state from the outset that training of communities to participate in governance structures is an expensive, time consuming, and difficult process.
5.1 Community Perspective on Training
After considering the functions identified for a Hospital Board, people clearly expressed the need for some specific skills training to fulfill these tasks adequately. Some potential training topics suggested by community members are listed below. Subjects have been divided by type of training.
Life Skills/Orientation
- PHC orientation/district health system;
- roles
- functions
- and expectations of Hospital Boards;
- communication skills and assertiveness training
- including reading and writing skills;
- problem solving skills; and
- conflict management and mediation skills.
Basic Management Skills
- planning skills;
- management skills; and
- advocacy skills.
Advanced Skill Development
- financial and budgeting skills;
- research skills; and
- human resource development and performance appraisal skills.
The training requested by community members represents a combination of basic life skills and development and management skills. If the training modules coincide with the training needs for community health committees and district health councils, then training programmes for Hospital Board members could be integrated with other training programmes at the district level. Hospital Board members may need several advanced modules specific to hospital management, but the majority of their training should be similar to the other structures at the district level. This will help to integrate the governance structures and create some economy of scale. Providing life skills training will build capacity so that people can participate in many different forums beyond health issues.
At all forums, participants felt strongly that the government, either at the district, provincial, or national level, should be responsible for coordinating, supporting, and funding training of Board members. They argued that training represents an investment in people, documented in the RDP. Logistically, participants expressed support for a series of short courses rather than an extended training programme. Ideally, each training module should last from one day to several weeks with follow-up support provided.
Some community members suggested that NGOs and CBOs should be involved in the training process. They felt comfortable working with these organisations and trusted them. Other people suggested the development of short courses through a School of Public Health. Training institutions should be chosen based on their ability to deliver, their understanding of training methodologies and the PHC approach, and their acceptability to the community.
Whoever provides the training, people felt strongly that they want it to take place within their community. Participants did not want to "go on a course" to learn these skills. People felt that training should be provided for all Board members, not just for community representatives. This will build a team spirit among Board members and prevent the marginalisation of community members.
5.2 Framework for Training
The actual process of training community members is essential to the success of this effort. Training should be mandatory for every Board. There are no short cuts for this process. While there should be national and provincial training frameworks, each community and hospital has unique dynamics, needs, skills, and histories which need to be identified and incorporated into the training modules. Bypassing elements of the training process for the sake of expediency will only serve to undermine community empowerment and interest. NPPHCN proposes the following framework for training. [25] More details about each phase are provided in the implementation strategy in Chapter 6.
Build a partnership with the community.
- For many years, NPPHCN has worked in
under-resource communities. One of the valuable
lessons of this experience is the importance of
building a relationship and partnership with the
community. Building a partnership is not easy and
takes time, but NPPHCN has identified it as a
crucial step prior to implementation of a
training programme. The community's need to take
responsibility for its health must be respected
during the process. The creation of a partnership
with the community lays the foundation for
follow-up support after training has been
completed.
The two public education campaigns and the community audit proposed in Chapter 6 should provide opportunities to develop partnerships with communities. These partnerships will be strengthened after the elections of Hospital Boards.
Start a dialogue with the community.
- This is a consultative process during which the
need to train is discussed. It may take a long
time to establish a Board's training needs,
depending on availability and how much groundwork
has been done previously. Dialogue between people
seeking training and people who possess the
capacity to train is essential to ensure that
training matches a Board's needs.
The national community audit will provide some background information on communities needs. A second public education campaign focusing on decentralisation of management and community involvement in governance will begin this dialogue, which will be continued during and after the election of Board members.
Set a framework for the training programme.
- Depending on the background of the people to be
trained, the programme could be divided into
specific and general modules. The emphasis of the
training should always be to build the capacity
of the Board in the broadest sense possible. At
this point, the relationship between a Hospital
Board and other community structures is
clarified. The logistics of the training
programme, venue, time and length of training are
also agreed upon.
This process should occur between Hospital Boards and the trainer soon after the election. Training should take place as a team in order for the group to provide an opportunity for interlearning. Again, information gathering from the community audit will inform this process.
Implement the training programme.
- It is a challenge to the trainer to design the training programme in such a way that all members of the Board can participate in training activities. The trainer must also be innovative to hold their attention. This necessitates that training is done in the language of the participants.
Provide the necessary support.
- Beyond training, additional support mechanisms will be necessary to help Board members carry out their duties. The prime objective of this capacity building support should be to strengthen community involvement. Support can be rendered through structured follow-up training or through an organisation or institution that will serve a reference role for Hospital Board members. It is important that accountability of Board members remains with their constituency and not with the reference organisation.
5.3 Practical Considerations
Office skills training should be provided. This will empower Board members and reduce their dependence on public sector administrative staff. Available resources such as computers, printers, stationary, and office space also should be made available to Board members to fulfill their duties. In addition to capacity building support, secretarial assistance will be required.
Transport should either be provided for Board related activities or compensated at a fair rate. Attending frequent meetings and conducting Board business represent major sacrifices of time and money. A uniform reimbursement policy needs to be established at the provincial level to ensure that the system is not abused. Because these policies may impact other sectors, they should be discussed and ratified at the Cabinet level.
Meeting the basic administrative and transport requirements of Board members will ensure that people are chosen on the basis of merit and not because of their financial situation or access to transport.
5.4 Specific Recommendations for Training Hospital Boards
Providing formal in-depth training in all of the subject areas indicated above would be a formidable task, and consideration must be given to the fact that Hospital Board members will have other full-time jobs. The principles of participatory training, including learner centredness, flexibility, experiential and problem-based learning should form the basis of all training. The learning process should be as important as the training outcomes. Outcomes will be developed with the development of the curriculum.
Since time availability of participants is a certainly likely to limit the amount of theoretical content that can be covered in separate training sessions. Weekend or one week short courses are likely to be the longest periods of time available for training. These short courses should present a mixture of repetition and new material to allow for the periodic inclusion of new Board members.
NPPHCN proposes that training curriculum should be should be staged to coincide with the devolution of power to Hospital Boards. All Boards should begin with orientation and life skills development modules when they have basic governance powers. As Boards acquire intermediate governance powers, members should receive additional training in management, planning and advocacy skills. Finally, as the Boards move to full governance powers, advanced financial and research skills will be introduced. This example illustrates potential curriculum topics. Actual curriculum will need to reflect the specific functions delegated to Board members.
In order to maximise the inherent capacity of Board members, it is important that the training method builds on their prior knowledge and experiences. Intensive workshops run by facilitators with experience in adult education methods are likely to offer the best method of training. Tasks should be set for Board members to work on between workshops. Convened several times per year, these workshops would expand the skills of all Board members and foster a team spirit. The district management training programme in kwaZulu/Natal convened by CHESS and funded by the Health Systems Trust represents a model of this training methodology.
The training of Board members should be seen as a continuous process of investigation and exploration followed by action. Members would then reflect upon their experience and then learn again after reflection. It must be accepted that the development of a broad range of skills in all participants can only be achieved after many years of continuous training. In the interim, patience, tolerance, and a willingness to share their expertise will be required of professional and highly skilled Board members to engender community involvement. Where possible, Board members should be encouraged to improve their own formal education in areas that are relevant to hospital management.
Recognition of this training under the new National Qualifications Framework is important. The Department of Health should explore ways of gaining appropriate recognition.
 |
|
Please send comments or suggestions about this site.