• Chapter 6: Implementation Framework

  Community Involvement in Hospitals:
  Key Findings and Recommendations

  

  "It has become clear that community involvement for health cannot emerge and develop without the deliberate support of appropriate mechanisms at different levels. The evidence to date suggests that in those countries where community involvement in health has begun to develop, it has done so with the assistance of a range of support mechanisms. In the first instance, however, it is important to establish the preconditions for community involvement, that is the factors that can favourably affect the necessary mechanisms." [26]

  6.1 Preconditions to Community Involvement

  A reorientation of all professional health care workers needs to occur.

  Appropriate curricula should be developed to train staff about the PHC approach and community involvement should be developed. Then, all existing health staff at all levels must be retrained. This process is not unique to hospital decentralisation, but it is an important precondition to effective community involvement and should occur within the next year.

  Provinces must make a firm commitment of political support and financial resources for community involvement to be meaningful.

  To demonstrate their political commitment to this process, Departments of Health at the national, provincial, and district levels must create "community involvement in health" budgets that will include at least: transport costs, administrative support, training, and capacity building.

  Representative community structures need to be put in place.

  Communities need to establish sufficient democratic structures to sustain their involvement over time. This will require a critical mass of people with energy and commitment to the process of establishing these structures.

  The national community audit should document the current situation in communities. Based on this research, the Provincial Administration should develop several democratic models for communities to adopt and implement depending on their particular circumstances. This approach will be based on empirical evidence and attempt to balance between uniformity and flexibility. A uniform, top-down approach will not work.

  6.2 Potential Obstacles

  As evidenced from the international literature, it is very difficult to translate theories from paper into practice. It is critical to anticipate some potential obstacles in the implementation of this new system and recommend potential solutions.

  Community members are largely uninformed and not interested in health issues.

  The majority of people in South Africa have little understanding of basic health policy issues. Participants in the Eastern Cape forums were asked about their knowledge of the district health system. Most community representatives had never heard of the district health system development process and had never seen the discussion document. In many communities, the delivery of health care services is not a priority issue. People are more concerned with food, employment, housing, and clothing. Health professionals and policy makers then artificially try to place health services on the community's agenda. Without basic knowledge of health issues, many community members simply are not interested in participating.

  Thus, a massive orientation on the Primary Health Care approach and the Department of Health's policies is essential. Additionally, wide community involvement will only develop through an intersectoral approach that addresses the full range of community needs. It is artificial to discuss the relationship of community members and hospitals independently. Attempts to develop community involvement must occur within the broader discussion of district development and the RDP.

  Health professionals and communities historically have had a poor relationship.

  It is a common myth that government, health professionals, and communities share the same perspective. In Quebec, community representatives on Hospital Boards were treated with disrespect by both doctors and hospital managers. Their knowledge was believed to be unscientific. According to one hospital administrator in South Africa, "We have often used that horrible word 'ignorance' to describe our underprivileged communities, but as far as this is concerned the greatest ignorance is culpable ignorance associated with many of our medical and administrative folk in hospital administration." [27]

  A re-orientation of health workers and community members must take place. Both sides recognise that their attitudes represent major obstacles to successful community involvement. It is important to realise that past methodologies for re-orienting health workers have not been very effective. Health workers have been trained to repeat the "right words," but their basic attitudes remain unchanged. This needs to be addressed in the curriculum development process.

  Community members are marginalised within governance structures.

  In Quebec, the former Yugoslavia, and Cuba, researchers found that despite the presence of community members within a structure, they were often marginalised by health professionals and managers. They did not have the technical expertise to understand the discussions and remained on the sidelines. Much official business was conducted outside of Board meetings to reduce the influence of communities. These experiences demonstrate that simply voting someone onto a structure does not guarantee influence.

  Extensive training and capacity building, as proposed in Chapter 5, will be necessary to prepare community representatives. In addition, hospital management and professionals must present information in a format that is understandable for all community members. Technical jargon and literacy should not be used to marginalise community members. To minimise this phenomenon, it is critical that the Chair of the Board is a community member. Otherwise, hospital management and the Chair could broker deals outside of meetings and effectively bypass the Board.

  In many communities, conflicting or weak development structures exist.

  It is important to acknowledge that community involvement is political by nature. It involves the election of individuals to represent a constituency. As such, it is attempting to change the power structure within a community. Shifting power relationships in a community will cause conflict. Some communities have addressed this issue and put representative structures in place. Other communities are in the midst of power struggles between different factions claiming to represent community interests. Some areas have not begun to address these issues. The Khayelitsha case study presents a powerful example of the interrelationship between health, community involvement, and politics.

  During the next year, a concerted effort should be made to identify representative community structures during the community audit. Government cannot establish these structures, but it should certainly encourage and facilitate this process. Without a representative structure in place, community involvement will not take hold. Each Hospital Board must be reviewed based on its merit and credibility by the community. While in practice, most existing Boards will be dissolved and re-elected, it is important to assess the previous Board's work in an effort to learn from their experiences.

  Poor people are often excluded from election to structures because of socio-economic factors bias the selection process.

  Within South Africa, there are examples of communities choosing nurses, teachers and other professionals that do not stay in the area as their "community representatives." Meanwhile, other people are elected to structures simply because they have transport or a telephone. Finally, professionals with the most education and skills are usually chosen over less educated persons. The combination of these factors leaves the poorest and most marginalised community members without representation.

  To address these issues, explicit criteria need to be established for the selection of Board members. NPPHCN suggests that they should be based on a person's commitment and activeness in the community. Transport and financial issues should be removed from the selection process if sufficient resources are made available by government. Within the Board, every effort must be made to accommodate people at their current educational level and understanding.

  Table 6.1: Some Obstacles to Implementation

  Potential Obstacles	Possible Solutions
  Community members are largely uniformed and not interested in health issues.	Massive public awareness campaign Intersectoral approach to community involvement
  Health professionals and communities have had a poor relationship.	Re-orientation and re-education programme for both communities and health workers
  Communities are often marginalised within governance structures.	Implementation of training programme Information should be clear and understandable for community members Chair of Hospital Board should be from community
  In many communities, conflicting or weak development structures exist.	Establishment of representative structures in each community as a priority
  Poor people are often excluded from election to structures.	Criteria for selection of members Sufficient resources and support to level the playing field

  6.3 An Implementation Strategy

  Previous international experiences with community participation in health programmes suggest that a different type of action plan from the traditional delivery of health services is needed. [28] The major elements of an implementation plan are sketched out below. Considerable energy needs to be invested to fully develop each of these proposals into an action plan.

  Final policy decisions on the conceptualisation of Hospital Boards need to be made by provinces.

  1. District boundary and governance issues need to be resolved to place these discussions in context. Provinces must determine district health boundaries and their relationship to local authorities. They must also decide among the three governance options presented in the district health system development report.
  2. The relationship between district Hospital Boards and other elected structures at the district level needs to be clarified. Two generic models have been proposed by the Hospital Strategy Project and a third model is presented in this report. Each province needs to resolve which model they will implement in the short-term because this decision has important implications for the selection and training of Boards.
  3. Establishing representative Boards will require a financial investment from the province. Provinces need to decide how and if they will finance community involvement in health initiatives. These decisions should be finalised in the next two months.

  Provinces need to develop community involvement frameworks.

  1. Provincial action plans for community involvement in health need to be developed in the short-term. The action plans will map out the process listed below and integrate other efforts to involve communities in the health sector at the district, regional and provincial level.
  2. Provincial community involvement policy frameworks should be developed. Ideally a national framework would be developed on community involvement to guide the process but this could seriously delay the implementation process at the provincial level.

     The policy framework should clearly define the role of community members within governance structures in the health system. The section on Hospital Boards should clearly define their composition, selection process, functions, accountability, and authority to prevent confusion. Within the policy formulation process, other sectors should be consulted so that all frameworks for community involvement are integrated.

  3. Once policy decisions are finalised, enabling legislation will need to be drafted at the provincial level. The National Department should provide technical assistance in the drafting process when necessary. The Free State province has drafted legislation that should be circulated to other provinces for information.

  Communities need to be prepared for involvement.

  1. A massive orientation programme about health policies is needed. People on the ground are not informed about the changes taking place in the health system. A education campaign should be mounted about district health system development and the new primary health care plan. This is a basic prerequisite to involve communities in any of the reforms proposed nationally.
  2. A national sponsored audit of the representative structures, skills and information channels that already exist within communities should be completed in the short-term. This is a challenging, but vital project for community involvement.

     NPPHCN recommends a three pronged approach to the audit to addressed issues raised in this paper. The audit should research the civil society power structures within communities. (eg. Who represents whose interests? Who are the power brokers?) In addition, the audit should determine the level of skills among community members to feed into the training process. (Are community members literate? What skills do they possess?) Finally, the audit should examine information channels in communities. (How is information disseminated? Who controls access to information? Where do blockages exist?)

  3. After the initial orientation campaign has been complete, communities should be briefed on the decentralisation of health management and the role of community involvement. A set of briefing charts on district development, the hospital decentralisation, and community involvement should be developed to support this effort.

     Based on our experience, NPPHCN proposes the cascade model of information dissemination for both campaigns. A single workshop is held at the national level with representatives attending from each province. These representative then facilitate workshops at the provincial level for district representatives, who facilitate workshops at the district level for community leaders, who distribute it to community members.

     Plan training and capacity building programmes.

     1. The role and functions of Hospital Boards need to be clarified in the short-term to develop specific training modules. Many of the basic skills modules already are being developed as part of the health district development process.
     2. Specific elements of the curricula for community involvement in hospitals also need to be developed. These specialised modules should be developed in collaboration by adult education specialists, health educators, hospital management, community representatives, and provincial personnel. A similar process is occurring for Community Health Committee training in the Western Cape.
     3. Once new Boards have been elected, the trainer should work with Board members to identify their specific training needs. Based on these discussions, training objectives, modules, and time frames should be agreed on.
     4. Long-term training and capacity building (as proposed in Chapter 5) should then begin.

     Evaluation and Monitoring

     1. From the outset, mechanisms need to be put in place to evaluate the success of these efforts. Because community involvement is a dynamic process, alternative process indicators are necessary to evaluate it. Ideally, the curriculum development group should develop evaluation and monitoring measures.

        NPPHCN proposes the following framework developed by Bichmann, Rifkin, and Shrestha to evaluate the effectiveness of community involvement efforts. [29] They have identified five potential evaluation indicators: needs assessment, leadership, organisation, resource mobilisation, and management. For each indicator, a series of supplementary questions can be created to determine the breadth and depth of community involvement. Based on this information a composite score can be assigned for community involvement. Obviously, much research and refinement would be needed to adapt this framework to hospitals in South Africa, but it represents an interesting conceptual model to stimulate debate.

     2. The evaluation mechanisms should be tested and refined over time.

     Implement new Hospital Boards

     1. After the policy and legislative frameworks have been completed, the orientation and education campaigns completed, and training curriculum developed, new Hospital Boards should be elected. Actual training of the Boards should begin soon after election based on the needs of Board members using the framework outlined in Chapter 6. Long-term support and evaluation mechanisms should be put into place as soon as training begins.

     A final word of caution: developing communities for involvement is a challenging process that will require some patience from policy makers. Implementation strategies must be comprehensive and integrated. Simply pushing forward to elect new Hospital Boards before adequate preparations have taken place will not accomplish their objectives and will probably lead to disaster.

Table 6.2: Summary of Implementation Activities

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