Executive Summary

Community Involvement in Hospitals:
Key Findings and Recommendations

Introduction and Background (Chapter 1)

The Hospital Strategy Project (HSP) was established in October 1995 to provide guidance and technical assistance to the National and Provincial Departments of Health on the transformation of hospital services and management. The Project represents a partnership between The Monitor Company, The Centre for Health Policy Research at the University of the Witwatersrand, Naledi, and International Health Partners. It is funded by the European Union. During the strategic planning process around the decentralisation of hospital management, several stakeholders expressed an interest in examining the potential for community involvement.

The Hospital Strategy Project approached the National Progressive Primary Health Care Network (NPPHCN) in late October 1995 to submit a proposal to research the potential role for communities within a decentralised hospital management system. Four focal areas were included in the original briefing:

• role of communities in hospital management;
• accountability of hospital management to communities;
• hospital governance structures; and
• framework for implementation of community involvement.

Research Methodology (Appendix 1)

There were four major elements to NPPHCN's research on community involvement in hospitals: review of international literature, scripted community forums, written questionnaires, and case studies.

During December 1995, NPPHCN reviewed key articles from the international literature on community involvement in health generally, and hospitals specifically. The initial literature review, however, did not contain specific information about international experiences with hospital governance and accountability structures (ie. Hospital Boards). An additional literature review was subsequently undertaken which focused on relevant international models of community involvement in the governance and accountability of hospitals.

To inform community members about the restructuring of hospitals and to provide them with an opportunity to participate in the policy formulation process, NPPHCN convened a series of community forums between 10 February 1996 and 19 March 1996 in all nine provinces. Each of the eleven forums brought together between 30 and 60 community members to discuss issues related to community involvement in hospital management.

To complement the group discussions, NPPHCN also designed a brief written questionnaire for all forum participants to complete. The questionnaire was intended to gauge the depth of opinions expressed by a few vocal forum participants. Analysis of the questionnaires allowed NPPHCN to find out whether most of the participants agreed with the views expressed by the vocal minority. Secondly, the questionnaire afforded NPPHCN the opportunity to quantify public perceptions about some critical issues raised in the group discussions.

NPPHCN conducted two case studies to gain in depth knowledge on two important aspects of community involvement. The first case study examined the potential for an alternate structure to inform communities about hospital policy decisions. The second case study identified some critical issues that may arise as the theory of community involvement is put into practice.

Community Involvement in Health (Chapter 2)

There are many potential benefits to be gained from actively involving the community in the health system. 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.

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.

Thus far, South Africa has met the first and last preconditions.

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 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.

The Community's Perspective on Community Involvement (Chapter 3)

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 management, 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.

Communities clearly want to be involved in the health system. 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.

The overwhelming majority of respondents want to be involved in hospital governance. To facilitate the planning process, 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. Important governance issues included:

• Strategic planning;
• Hospital management;
• Finance and budget; and
• Labour relations.

Beyond participating in the governance of hospitals, community members believed it was essential for hospital management to report back on important issues. Otherwise, the community cannot get involved in the process. Important accountability issues included:

• Quality of services;
• Planning new services and facilities;
• Finances and budget;
• Health promotion; and
• Patient and community grievances.

Community Involvement in Hospital Boards (Chapter 4)

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. 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. 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. 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.

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 a Board, community members should be a member of a democratic community structure. Otherwise, the Board will only contain the views of several individuals within the community and accountability will be diminished. 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.

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 would 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.

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. 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. 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 should provide some insight into community power structures and propose alternative selection mechanism models.

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 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 ulitmately 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, which is different than the models presented by the HSP, is presented in more detail in Chapter 4.

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. The creation of more governance structures, however, will be difficult to establish and expensive for districts and provinces.

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. A limit of two consecutive terms should be set. The initials election process could be staggered to ensure that there was some turnover on the Board 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.

The payment of Hospital Board members proved to be a very contentious issue in many forums. Genuine differences of opinion existed on this issue. 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. 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.

In all forums, participants felt that here should be a mechanism to dismiss Board members who fail to fulfill their duties. The province could set down conduct guideline for Board members that would be enforced by individual Boards.

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. The Board also could present make a presentation of its work to an annual general meeting of community members.

There was unanimous support that the government should provide money for training, transport, and other administrative expenditures related to the Board's work.

Training and Capacity Building (Chapter 5)

The training requested by community members represents a combination of basic life skills development and management skills. Some of the training modules coincide with the training needs for community health committees and district health councils. Thus, training programmes for Hospital Board members should be integrated with other training programmes at the district level.

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. Training represents an investment in people. There was strong support for a series of short courses about each topic rather than an extended training programme.

The actual process of training community members is essential to the success of this effort. 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:

• build a partnership with the community;
• start a dialogue with the community;
• set a framework for the training programme;
• implement the training programme; and
• provide the necessary support.

In addition to capacity building support, secretarial assistance will be required. 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. 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.

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.

Framework for Implementation (Chapter 6)

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. 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.

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. [1] 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 district and 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 provincail 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. As 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.

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 nationally sponsored audit of the representative structures skills and information channels that exist within communities should be initiated 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, 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 would be held at the national level with representatives attending from each province. These representative would then facilitate workshops at the provincial level for district representatives, who facilitate workshops at the district level for community leaders, who then 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.
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 5. 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.


ES-1: Summary of Implemenation Activities

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