5.1 Description of district development process
The Mpumalanga Province Department of Health, Welfare and
Gender Affairs was formally established in March 1995. Among its
first tasks was to formulate its developmental mission which was
"to achieve optimal health for all households in the
Mpumalanga Province." The province adopted the Primary
Health Care (PHC) approach to achieve its aims, it emphasised the
department's concentration on delivering integrated services with
full participation of the local community in health development,
care delivery, and governance of the system.
5.1.1 Departmental structure
The Department underwent extensive restructuring to prepare for the implementation of the district health system. An new organogram was formulated with the Chief Director for the Health Services responsible for the management of the health services. The Chief Director was accountable to the Deputy Director General. Under the Chief Director were three directorates: Primary Health Care; Policy, Planning and Information Services, and Secondary Health Services. This level was supported by a Director of Administration which was shared between Health, Welfare and Gender Affairs. The basic aim of the restructuring has been to decentralize authority, decision making, resource control, and service coordination to the district level and nearer to the community. Thus, a key position is that of the District Health Manager. It has a critical technical, managerial and leadership role in the coordination of the development of the district health plans and health programme implementation. Acting district managers were appointed in July 1996.
The province has been divided into three regions, each headed by regional directors who report directly to the Chief Director. Twenty-one districts were demarcated, each headed by a district manager. The District Health Service were organised according to ten priority programmes: Environmental Health; Health Promotion; Nutrition; Maternal, Child and Women Health; Communicable Diseases Control; Emergency Health Services; Oral Health; Curative and Diagnostic Services; Metal Health; Rehabilitation. Technical support at the district level will come from three units under the District Health Manager: a District Information Unit; Pharmaceutical Services and Human Resource Development. Administration is provided by a Finance and Administration Officer. There is also a Primary Health Care Coordinator who will probably assume the position of deputy district health manager.
5.1.2 Establishing health districts
A programme for the development of a coordinated and comprehensive primary health care plan within a district health system was launched in October 1995. This programme was jointedly developed by the Department and local and international NGOs with expertise in district development. The district development programme outlined five phases of activity to take place over a two year period.
The first phase attempted to inform and reorient senior provincial policymakers to the PHC approach and the concept of a district health system. The objective of this process was to develop a common vision within the senior Managementof the Department. It was envisaged that the health workers would then take on the task of raising public awareness of PHC and establishing mechanisms to promote community involvement.
During November and December 1995, phase two included a series
of public awareness workshops to initiate the public consultation
process on the district health system. Workshops were organised
in each of the six sub-regions for professional health workers,
other Public sector staff, local councillors, NGO's, CBO's and
selected members of the community. These workshops explained the
PHC approach and the health service restructuring process in the
province. At these workshops, district facilitating teams (DFTs)
were chosen from amongst the participants to take the district
development process forward.
DFTs consisted mostly of public sector service providers with several community representatives. These teams were envisaged as the driving forces for phases three and four, drafting situational analyses and district health plans.
The first responsibility of the DFTs was to conduct a
situational analysis of the health needs and priorities in their
subregions. In order to fullfil this role, provincial
policymakers recognised that capacity building was a prerequisite
for all DFT members. Thus, considerable investment was put into
building local capacity for health development planning through
workshops, hands-on training, and supportive guidance to enable
the DFTs to take leadership and responsibility for developing an
appropriate health service in Mpumalanga. All six DFTs completed
their situational analyses in April 1997. Technical support for
the teams was provided by NPPHCN, Health Systems Development
Unit, and African Medical Research and Education Foundation
(AMREF) from Kenya.
After the formulation of the situation analysis the DFTs
turned their attention to drafting three year strategic district
health plans. During the drafting process of district health
plans, the province was further divided from six sub-regions into
twenty-one districts. This significantly increased the task of
the DFTs. Provincial officials believed that twenty-one district
health plans could not be undertaken simultaneously. It was
resolved that one team from each region would formulate a model
district plan that would be copied in the other districts. Some
DFTs also co-opted new members to undertake this task.
An independent task team was established to explore the
feasibility of community health worker programmes. Proposals were
drafted by communities in several districts and presented to the
provincial department for consideration. The Department accepted
the role and function of CHWs and has developed an implementation
framework. (See section 5.2)
The situation as of October 1996 was that in all three
regions, a model district health plan has been completed. The
other districts have completed draft plans and were working
toward finalisation. There was still some need for considerable
support to operationalise these three year strategic plans with
reference to the required resources and developing financial
plans and budgets. Acting district managers have been given some
authority, but further decentralisation of financial authority
was expected to take place during the next budget cycle beginning
in April 1997. The final phase of the district development
process, long-term capacity building for district health
management teams, and community health committees has been
organised and was planned to begin early in 1997.
5.2 PHC in Mpumalanga: a guide to district-based action
To provide written documentation of the district development process and to communicate important provincial policy decisions, an illustrative guide was drafted by the provincial department with the assistance of AMREF. The guide was targeted at district level health workers. PHC in Mpumalanga: a guide to district-based Action was released by the department on 2 December 1996.
Chapter four of the guide examined the role of communities in health development. It presented the motivation for community involvement, some background, and practical information for health workers to begin this process. The guide states that "Community participation is not the sporadic and superficial consultations with 'not-so-representative community forums,' not does it imply the abdication of the Department on its responsibilities to provide health services."
The guide noted that community involvement is a new experience for both health workers and communities in the province. It was envisaged that it would be improved over time as both partners acquired more skills to interact. The province viewed community structures as vital intersectoral linkages that would be essential to improving the health of the community. The province stated that it has identified and was attempting to meet the four preconditions for effective community participation based on internation experience. Specific indicators were presented to assess whether community participation was occurring or not.
Chapter six addressed health district governance issues. The province has chosen the provincial governance option because it did not have the necessary infrastructure in the districts for either of the other alternatives. Thus, the provincial office would be responsible for the administration, the provision of service, and the establishment of districts. Each level of governance would have an advisory structure with some community involvement.
These governance structures would begin as interim, advisory structures and eventually would become permanent and gain more powers. At the community level, each community would form a community health committee. It was not stated how these structures would be formed or accredited, but they would feed into the facility-based governance structures. Each facility would have a committee or board who would participate in its management. The district health council would work with district management team to oversee the district. The chairs of each district council would form the provincial health authority and advise the Minister of Executive Committee (MEC) for Health . This provincial authority would make inputs on resource allocation, equity, and district development.
Policymakers also have adopted the belief that CHWs should form an integral part of the district health system. They motivated for the inclusion of CHWs to serve as a link between heath and its socio--economic causes. They envisaged CHWs fulfilling the dual role of health service provision and community development. CHWs would be governed by community health structures, but they would have direct links to formal health services. In order to implement a CHW programme, the district manager must submit a detailed proposal to the Department for approval. The most needy districts would be prioritised.
5.3 Perceptions of policymakers
5.3.1 Comments on the process
Policymakers reflected a great sense of satisfaction on the district development process and their achievements to date. Overall, they expressed commitment and demonstrated enthusiasm to take the process forward. They, however, recognised that their successes relied on substantial contributions from government and civil society.
They believed that communities were consulted from the beginning about the DHS, and involved throughout the process. A commitment to broaden their PHC knowledge and transfer it to the community exists amongst the interviewees. One senior politician mentioned that he has regular meetings with policymakers and service providers to stay abreast of the issues. He then transferred this information to communities through community committees, community fora and other relevant structures in the community. He was of the opinion that policymakers in the health department were putting in a fair amount of effort to involve the community.
A common assumption among policymakers was that Mpumalanga was ahead of other provinces in terms of district development. Several officials disagreed with this perception because they felt that majority of people at the grassroots level were not aware of the progress. Policymakers were particularly proud of the "PHC in Mpumalanga : a guide to district-based action"
Although the district health service development process has been slower then the original target dates, the process has benefited a large number of both department staff and other partners by involving them in establishing a district health service that they would be responsible for implementing. The DFTs have demonstrated a remarkable sense of responsibility and endurance equally matched by their desire for knowledge and sense of pride in developing a system that was relevant to the needs of the community and with which they can be proudly identified. This was a principal objective of the process and, in this regard, a lot of progress has been made. However, on the practical side of having applicable plans for the various districts, a lot more still remained to be done. It was also acknowledged that the speed and complexity of the process had been too fast for many community members, leaving them behind.
Several policymakers thought that communities did not participate in health related issues because they lacked motivation. They felt that communities were resistant to change because of the practices of the previous government. People were taught to remain quiet and receive what they needed without getting involved. In the past, hospitals were built, but no thought was given to how long queues would be or who should serve on the hospital boards. Now policymakers expected communities to fully participate in these processes. This change in mind set would take some time.
5.3.2 Obstacles to CIH
Despite their general optimism and satisfaction, policymakers acknowledged some obstacles and limitations thus far. There was a general feeling that the magnitude of the task of developing twenty-one districts limited CIH. Support resources were spread very thinly among the districts. In addition, the opportunity to share resources with other sectors was limited by the differences in district boundaries. Health has twenty-one districts while education has ten districts. Members of the facilitating teams were given tasks to provide co-ordination and support to districts. Some of these members are employed by the Department of Health and fulfill different functions.
The geography of the province has limited participation. Mpumalanga is mainly rural and access to farming areas is still restricted. As a result, a vast number of people have been excluded from the process. There have been conflicts between political parties, which have a direct bearing on the progress of district development. Political conflicts impacted most severely at the community level.
Many unanswered questions existed in terms of the role of local government, which would impact on CIH. For example, local government structures in the province have not been finalised and uncertainty existed on local governance issues. It was hoped that the passing of the new Municipality Bill would shed light on this issue. These delays meant that the difficult choices about elected vs participatory democracy have only been delayed is the provinces.
Policymakers found that communities did not take issues well on paper and that direct interaction worked best. Unfortunately, direct interaction was expensive, time consuming, and logistically difficult. The role of community health committees has not been clearly defined. They were seen as a source to assist with the identification and referral of health related problems. It was acknowledged that capacity building programmes for communities were not in place because the Director of Human Resource Development was killed in an auto accident in August and had not been replaced.
5.3.3 Understanding the DHS
It was recognised that there was a very uneven level of understanding of the district health system in the province. The members of the DFTs were very well informed, but most other people were not well informed. Many health professionals did not feel sufficiently informed. A matron, working in Nelspruit, felt that she was not well informed and not involved at all in the process. She had been consulted once. Further, she felt that many of her colleagues were not informed about the DHS.
5.3.4 Way forward
Policymakers felt that, despite the progress thus far, there was still room for improvement and were committed to continue meeting with people on community level. Training programmes for communities were being planned. Efforts were being made to keep the Transitional Rural Council and Transitional Local Council informed about the DHS and future plans. Improving these relationships would be a great step forward in addressing some local conflicts for the province. It was accepted that there was still a great need to build capacity at all levels.
Community health committees were viewed as important structures to take the process forward at the community level. Without the participation of communities through community health committees, service providers might lose out on important information. Better strategies for two-way communication between communities and policymakers needed to be devised and strengthened through regular contact. All stakeholders should be brought on board. The director of human resource development needed to be replaced urgently to resume planning for the community health committee capacity-building process.
5.4 Perceptions of communities
In general, community members felt that policymakers had good intentions to involve them in the transformation process. While they found fault with some of the implementation decisions, they were generally supportive of health policymakers in the province. Some people, however, felt that community involvement was not taken seriously by policymakers.
5.4.1 Consultation
Communities were aware of the process to involve all stakeholders in the development of a district health plan for their province. The Department of Health held consultative workshops in November 1995 to discuss the idea of developing a framework for implementing the DHS. Policymakers, services providers, and some community members were present at these workshops. District Facilitating Teams (DFT's) were elected consisting of representatives of all stakeholders. The role of the DFT's was to take the District Development process forward.
5.4.2 Community's role on District Facilitating Teams (DFTs)
People felt that the elections of the district facilitating team were not very democratic or participatory. Because of the speed of the process, community members, NGOs and other non-public sector employees were co-opted onto the teams. People were chosen at the workshops without mandates. Thus, there was attrition and turnover on the teams over time.
Further, there was no clarity on the role and function of civil society representatives and no mechanisms for them to take the process forward in their communities. Thus, many community members felt useless. Members of the DFTs felt that they gained a wealth of knowledge, but they did know how to use this knowledge. They felt that specific mechanisms were not put in place to report back to communities.
There was also conflict between the conception of the DFTs on paper and the way they operated in practice. In some cases, this caused conflict between professionals and communities. Community members were consciously left behind in the process because the high level at which information was shared by health professionals. At times community members were not informed about meetings. Community members understood that it was the responsibility of the DFT to keep them informed.
5.5 Summary of findings
5.5.1 Understanding the DHS
Policymakers have made some progress in broadening understanding of the district health system. There was high level of understanding among people on DFTs. As a result of the intensive capacity building efforts, these community members were very knowledgeable about the DHS. Outside these teams, understanding of the DHS was quite low. Community representatives on the DFTs were committed to share their knowledge on PHC with their communities, but they did not understand how to do this. Thus, there was still a need to provide support mechanisms to help DFTs disseminate information more widely.
5.5.2 Consultation
Communities and other stakeholders were informed about the process and brought on board from the beginning. The DFTs, who were given significant authority to taken decisions, included representatives from local government, the department of health, NGO's, Reconstruction and Development Councils and community leaders. As mentioned above, there has been confusion about extending consultation beyond the DFTs. Some teams were more successful then others in consulting with communities in the district.
5.5.3 Needs Assessment
Many positive steps have taken place to encourage the participation of communities in assessing the health needs of their communities. Community members were included on the DFTs that developed the situational analyses for the six sub-regions. Much capacity building was done to assist in this process. A standard format and criteria for identifying needs in the community were distributed to all DFTs to help them prioritise issues for their communities. Despite these positive steps, there were conflicts between health workers and communities about what were the priority health needs of their communities. These tensions were eventually resolved, but they underscore the different perceptions of the two partners.
5.5.4 Capacity Development
As mentioned above, a structured programme was established to improve the PHC knowledge and strategic planning skills of the DFTs. Sufficient resources were provided to ensure the participation of communities. Despite these efforts, the capacity-building process to develop the DHS plan for the province was fast and product oriented. These factors excluded many community members.
The Department has expressed a commitment to continue the capacity development process for community health committees. This process has not yet been implemented. Similarly, a plan has been devised to reorient health professional to appreciate and accept to community involvement. Both of these processes have been delayed until a new director of human resource development was appointed.
5.5.5 Organisation
Progressive steps have been put in place to establish health committees. The role of these committees would are to assist health providers to identify community needs and constrains. No long-term mechanisms have been established to keep communities involved in the district. There was the drafting of the plan, but it is not clear how health committees would be established, trained and sustained. This could be a major problem, losing all of the capacity that has been developed during the strategic planning process.
5.5.6 Leadership
Communities were well involved in the development of a district health plan for their province, but the process was then driven by skilled professionals. According to the guide for district-based action, most governance structures would be given only advisory powers initially. Over time, they would be granted more authority. Although this phased approach is understandable, there are no guarantees that health managers will cede control to communities after them become established.
Within the DFTs, too much emphasis and pressure were placed on a few community leaders, who were not sure of the expectations of them. More effort is need to support and recognise vibrant community structures as the foundation for community involvement. Based on the provincial guide, this problem looks like it will be institutionalised. Within the policy framework for community involvement, clear lines of accountability have not been established. Lines of accountability between facility committees and district health councils have not been made explicit. Additionally, it was not clearly stated how any of these structures would be rooted in communities. This proposed governance system will continue to place extreme pressures on a few community members.
Finally, the relationship between elected councillors and
participatory structures has not been adequately addressed. These
discussion should take place before governance structures are
established and people's expectations are raised.
6.1 Description of district development process
In 1994, the MEC for Health and Social Services appointed Strategic Management Teams (SMTs). The SMTs, together with policymakers and key role players, drafted provincial policy documents on a number of topics that together formed the basis of a health plan for the province. The draft provincial health plan was widely circulated for comments over 1995 and presented to the Provincial Cabinet in late 1995 for approval. The final provincial health plan was envisaged as a blue print for restructuring the health system in the province over the next five years.
Many communities were involved in commenting on the draft health plan. It was translated into Xhosa and Afrikaans and widely distributed. A series of workshops was held in different communities to present the draft plan and receive feedback on it.
Within the health plan, the Provincial Department of Health formally adopted the principle of community involvement. The Provincial Cabinet accepted the principle of community participation, but argued that the specific chapter in the health plan dealing with community health committees was too detailed. The Cabinet was not prepared to commit itself to the amount of detail on the role and function of community health committees and suggested that it be included in the health act.
Beginning in 1994, meetings with community structures like civics, churches, community health committees, and health fora were called in potential districts. Efforts were made to form community health committees and community health and welfare committees in areas where they did not previously exist. Existing committees were drawn into the process from the beginning. The primary function of these committees was to give input on the community's health and development needs. Some committees were more successful than others in engaging in this process.
Also in 1994, a district health subcommittee was formed,
chaired by Dr John Frankish, Director of District Development in
the province. Members of this subcommittee travelled extensively
to all major towns in the province to inform communities about
the district development process. Documents on the DHS were
summarised, translated into Afrikaans and Xhosa, and circulated
to communities. The purpose of these meetings was to discuss the
restructuring process in the province. District working groups
were formed in most potential districts to:
take the restructuring process forward; form
Community Health Committees where they did not exist;
organise and hold workshops on the powers
& functions of committees; and
give feedback on the process to communities
on district health concept, role/function of committees,
and governance issues.
Interim district working groups were set up in all twenty-four districts. These groups have been functioning at different levels of effectiveness over the last two years. The province has approximately six hundred health facilities. It was believed that most facilities have health committees attached to them. Community health committees and health fora have been set up at community level, there are an estimated 170 RDP fora in the province at the time of this report. As mentioned above, communities were encouraged to establish their own structures within broad provincial guidelines to ensure inclusivity and representativeness. The province has developed a process to accredit these RDP fora. As of November 1996 a special cabinet committee was scheduled to meet in early December to certify these fora. It was expected that there would be approximately 100 certified RDP fora once the process was complete. This process was essential to district health planning because the RDP health structures were envisaged as the foundations for CIH.
Although there have been indications that the province favoured the local government option, no district governance option has been chosen. Uncertainty existed among local and provincial policymakers on this issue. In addition, district boundaries have not yet been finalised. For example, in the metropolitan area there was continuing debate about whether Athlone should form its own district or not.
Community capacity building has been recognised as important component of CIH. To date, a series of information sharing workshops on the DHS have been held for community health committees. The Provincial Department has made a commitment to train communities for participation. A working group, consisting of health professionals, training institutions, and NGOs, was established in 1995 to develop a curriculum to train communities. A curriculum for the training of trainers has been developed. The province has earmarked European Union funding for this initiative. They have decided to first train health professionals, who would transfer the information and skills to community members. No firm dates have been established for implementation.
6.2 The Western Cape Provincial Health Plan
Chapter four of the plan outlines the process for implementing a District Health Care System in the province. The mechanism for implementation was based on the philosophy of the Department of Health which is based on the primary health care approach with strong emphasis on equity, comprehensiveness, community participation and empowerment, affordability and sustainability. This chapter suggested an approach to implement health service delivery on district level, governance and the role and function of community health committees.
The province would be divided into four health regions. Each region would be divided into health districts. Within each district, health services would be divided into community and district level services. Health centres would be managed by management teams that would be responsible for rendering health services to the people living in the community it serves. This team would be responsible for its satellite clinics, outreach and community service programmes, environmental health officers and community health workers. The management team would work closely with statutorily established community health committees.
The district management team would be accountable to a district health committee consisting of representatives of the people within that district. Each district would have a nonspecialist inpatient hospital. The plan suggests that interim districts be put in place, as no finalisation was reached on the demarcation of districts. As noted above, the plan indicated that no consensus was reach regarding the governance of the district health system. It points out that irrespective which governance option would be taken, statutory health committees would be formed and services would be community-oriented. These community health fora would be statutory bodies consisting of representatives of role-players in health within the defined district. The forum would consist out of two representatives from each community structure within that district. A community health committee would be elected from the forum. The community health committee would be accountable to the forum and report back to the forum at least three times a year.
Community health committees would consist of eight to twelve 8-12 elected members elected by the health forum. Community health manager will serve on the committee in an ex-officio capacity. They will be restricted to serve as representatives from the community, and render advice and support to the committee. Members on the committee would serve in a voluntary capacity and refunded to expenses related to committee work. The Provincial Health department would be responsible for the administrative infrastructure and provide training for committee members. Each community health committee would elect a representative to the district health committee.
It was envisaged that community health committees would
fulfill the following functions:
Community health communities would have the
powers to make recommendations in regard to appointments,
disciplinary and evaluations of health personnel. Committees
would be allowed to make recommendations to district
health budgets, authorise non-personnel expenditure and
generate additional income.
Committees would have a say in how services
are rendered as well as tendering processes.
Committees would be directly involved in the
planning of health services within their areas.
6.3 Perceptions of policymakers
6.3.1 Process
Policymakers believed that they have shown a commitment to involve communities in the transformation process in the Western Cape. They pointed to considerable efforts spent translating documents and consulting with communities about the draft health plan. They viewed communities primary involvement through structures like community health committees and community health fora. They acknowledged that the process has been patchy.
They felt that communities were to a large extent involved in the district development process. Their level of involvement varied depending on the political nature of the community. A belief existed that the department of health's adoption of the principles of community participation as critical to this. It was further stated that community involvement in health should be addressed on two levels. At the community level, community health committees would be central in identifying health needs and services. Mention was made that this level was relatively well established and accepted as a means to take the DHS process forward. The second level would be the governance powers of structures within the province. This was less established and clouded with uncertainty the demarcation of boundaries and governance option. Hope existed, that governance decisions would contribute to greater successes in community involvement.
Some policymakers pointed to conflicts that existed in communities as a source of tension delaying the process. They felt that these conflict were mainly driven by the nature of politics in the province. For example, conflicts existed between welfare committees and community health committees in areas of Khayelitsha. Tension also existed between health committees, health fora, RDP structures, and community service committees of the local government. The Matthew Goniwe informal settlement had an RDP health committee and another NGO-aligned health committee. In the same area, there was conflict between the elected councillors and the RDP structures. Individuals who lost the local government elections were forming committees to challenge the elected councillors. The conflict between local councils and participatory structures was cited as an ongoing problem that had not been adequately addressed.
6.3.2 Obstacles to CIH
Some major obstacles to CIH have arisen because important policy decisions have not been taken. The district governance option had not been finalised, which would have huge implications for CIH. Consequently, the role and function of governance structures had not been finalised. The different perspectives of provincial and local government representatives suggested that these issues would not be resolved in the near future. Some authorities were hesitant to give communities decision-making powers. They saw communities fulfilling an advisory role, while others wanted communities to play an active role in decision-making.
Some communities had more than one health committee, and confusion on the election and composition of health committees existed. Some committees were frustrated with the slow pace of the process and members dropped out. They expected immediate results and formed new committees. If committees set themselves up as part of a political party, then greater confusion arise.
Political rivalries between the National party (NP) and the African National Congress (ANC) in the province had also caused problems. There was a low degree of cooperation between elected councillors and those who lost in the election. Some local councillors were ANC while the province as a whole was governed by the NP. As a result, health committees were being manipulated due to fragmentation in the province due to the provincial and local government conflict. Uncertainty felt by the community was a reflection of the conflicts between provincial and local government around governance issues.
Managers of the different health authorities did not cooperate with each other. Uncertainty on the management role especially among health personnel existed. They were not happy that communities would be given the powers on issues such as employment, income and expenditures. They felt that communities would abuse their role. Questions on the legal position and accountability of committees were still unanswered.
6.3.3 Way forward
All policymakers agreed that clarity on the district governance structures was disparately needed and would create opportunities to improve communities' involvement in health. The capacity of communities also needed to be enhanced. Training should not be directive but should aim to clarify the role of councillors. The cooperation of NGOs, training institutions, and the Department on the training of communities would be important. Each community should only have one committee. In communities where there was more than one structure, authorities must attempt to integrate them into one structure. It was acknowledged that this might be a difficult process, but it was essential to sustain CIH.
In the short-term, the chapter on community involvement in the provincial health plan must be re-drafted and approved by Cabinet. Then, governance powers of committees must be formalised and legislated. These steps would help to clear confusion around communities involvement in health.
Communities also needed to be more involved in health and development programmes that were community-based, outside the clinic walls. This would directly contribute to community empowerment and increase their involvement in health. Community members were not interested in philosophical issues but were more comfortable with tangible community development initiatives.
6.4 Perceptions of communities
6.4.1 Mitchell's Plain
Mitchell's Plain is a former "coloured township" located 15 km southeast of Cape Town with a long history of community activism. The Western Cape community-based partnership project (CBPP) has operated in Mitchell's Plain since 1992. CBPP was initiated by the W K Kellogg Foundation in the United States to form linkages between academic institutions, communities, and service providers. This project has provided the community with some support and capacity building, but it has brought many problems with it as well. Some members of the community felt used by the academics and services providers and were tired of continual efforts to take information from the community for the benefit of outsiders.
The Mitchell's Plain community has well developed community-based structures, including health committees and RDP health structures. In October 1994, the draft provincial health plan was released and a series of meetings in most suburbs were held, this resulted in the establishment of community health committees in Mitchell's Plain. These committees functioned well until the beginning of 1996 when policymakers were questioned about their commitment to involve communities in health.
A strong feeling existed that policymakers underplay their contribution to the conflicts that were present in Mitchell's Plain. Some of the contributing factors to the conflicts were the formation of a District Management Team without consulting existing community-based health structures. The misinterpretation of research findings that communities were responsible for the delays in the district development process. This interpretation sparked anger and frustration within community-based health committees and led to a decision to terminate their relationship with policymakers and the RDP health forum. Despite this decision, community health committees remained committed to develop health services within Mitchell's Plain. They adopted a proactive approach to district development and did not wait for guidance from policymakers. They begun to develop area-based programmes depending on their needs.
6.4.2 Mamre
Mamre is a rural community located 70 km north of Cape Town. It has a vibrant CHW programme established in 1987 by University of Cape Town. This programme receives ongoing support from academics. In 1994, a consultative meeting was held to inform the Mamre community of restructuring process in the Western Cape. At that meeting a District Co-ordinating Team was elected to take the process forward in their district. The primary objective of the group was to involve the community in the district development process. The process came to a stand still due to confusion on the role of the District Coordinating Team, the RDP health committee and the local health committee. Many community workers did not remember the consultative process due to the long space of time without activity.
6.4.3 Brown's Farm
Brown's Farm is relatively new, peri-urban township located 25 km east of Cape Town. There are approximately 48 000 people living in Brown's Farm. Although there are no official records of the area, it is estimated that there are approximately 12 500 shacks, of which 1 600 are serviced with toilets and running water.
In 1995 representatives from Brown's Farm attended two meetings organised by policymakers in the province. The purpose of these meetings was to introduce the idea of developing a district-based health care system for the Western Cape Province. A committee was elected at the first meeting to take the process forward. The committee consisted of representatives from health committees and NGO's. At the meeting policymakers decided in principle to involve community organisations in the process, but this idea was not implemented.
6.5 Summary of Findings
6.5.1 Understanding the DHS
The Province has developed very progressive policies on community involvement on paper.
They have fleshed out international policies and theory down to the provincial level. Efforts were made to increase communities' understanding of the DHP.
6.5.2 Consultation
Extensive consultation and popularisation of the provincial health plans occurred during 1995 and early 1996, but it seems that many people have forgotten this process. According to provincial officials, lots of effort was made to make people aware of the provincial health plan. When asked people seemed to have forgotten about these meetings. Possibly too much time has passed before follow-up or any actions taken. The plan was not connected to any action on the ground. The translation of documents was a beneficial process of consultation.
6.5.3 Capacity development
Very progressive plans to train community health committees, working in collaboration with NGOs and training institutions, have been developed and are waiting to be implemented. As evidenced from the Cuban experience this could be problematic to use professional health workers to initiate community involvement. It could lead to manipulation rather than involvement.
6.5.4 Organisation
The province has not finalised its decision on governance options. It appeared to be leaning towards the local government option wherever possible. This would increase the role of elected local councillors. It would be difficult to structure the relationship between community structures and elected officials. Additionally, the province had not finalised provisions in the health plan on CIH.
6.5.5 Leadership
A "hurry up and wait" syndrome prevails in the
province. Communities like Mitchells Plain have gotten organised
and begun to work, but they were given little authority and no
control of the money. Other communities have shelved their
interest in the district development process and focused on
locally based programmes. People were losing interest. Within
their communities, people were given leadership responsibilities,
but it is not clear that communities takes leadership at a
broader level.
7.1 Have the four preconditions for CIH been met in the two provinces?
Political commitment to community
involvement from the government Mpumalanga has demonstrated solid political support at the highest levels. The MEC for Health, senior management within the Department of Health, and members of the provincial legislature have all publicly stated their commitment to CIH. The province has presented its official policy positions on this topic in its PHC guide released in December. In addition, policymakers have demonstrated their strong commitment by allocating resources for transport and administration needed to involve communities, including community members in all capacity building exercises, and adopting CHWs as an important component of the health sector.
The answer for the Western Cape is much less clear. Provincial health policymakers have included their vision for CIH in the draft provincial health plan. This document provided detailed guidelines on the establishment, powers and functions of community health committees. The Provincial Cabinet, however, did not accepted this chapter of the document so it is currently being redrafted. To further complicate matters, continual fighting between local government and provincial government has undermined commitment to CIH. Finally, communities have complained that the policymakers have not provided resources to give substance to their commitments made on paper.
Re-orientation of health professionals to
community involvement Both provinces acknowledged the importance of this task. They were in the process of a developing plans for the reorientation of health workers to the PHC approach. One element of the reorientation should address issues related to CIH. The reorientation of health workers in the public sector, however, had not yet been implemented in either province. Specific start dates were not available.
The presence of a reorientation programme is important, but
will not guarantee to achieved the desired results. The process
of training, the training methodology, the attitude and
experience of the trainers, and the number of health workers
being reoriented will determine whether or not these initiatives
are successful. Thus, it is important to ask these questions
about any efforts to reorient health workers. It is not enough
for health workers to repeat the right words without changing
their attitudes.
Development of self-management
capabilities of local communities The Western Cape had moved far toward meeting this precondition. The province had a rich organisational history that set the tone for the formation of numerous structures. In addition, policymakers focused their efforts on establishing vibrant community structures in each district. In addition, the RDP certification process adopted by the province should help to ensure that there were sufficient representative structures in each community to anchor the CIH process. Political infighting in some communities posed a serious threat to organisational development and lack of tangible progress on important issues by the province could undermine these structures.
The speed of the district development process in Mpumalanga made it difficult to ensure that the necessary structures were in place. Policymakers acknowledged that the lack of community structures was a problem and we are committed to address it. Communities have been urged to create the appropriate structures, but the province has not yet drafted plans to certify CHCs and other structures. Progress had been uneven, but people have expressed enthusiasm for the changes taking place. It was envisaged that it would take some time to complete the process in each community.
Socio-economic situation in the country
conducive to development In the Western Cape, the Department of Health and Social Services has experienced severe budget cuts over the past two years. These cuts have focused the majority of policymakers' attention to hospital restructuring in order to reduce spending levels. Some community members alleged that policymakers were using limited funds as an excuse to reduce their commitment to CIH. On the other hand, the Western Cape has demonstrated strong capability to raise funds for development. In 1996, it has received the largest share of RDP funds among the provinces.
On the other extreme, Mpumalanga received additional financial resources for health in an attempt to redress previous imbalances. In addition, the provinces did not have the massive hospital infrastructure to maintain as in the Western Cape. Thus, there should be funding available for development projects. Policymakers made a commitment to make these resources available to communities.
7.2 Some comparisons between the Western Cape and Mpumalanga
The demographic and political differences between the two provinces have had significant impact on efforts to implement CIH. The Western Cape has approximately four million people of which the majority are situated in metropolitan areas. In addition, the Western Cape health system has numerous academic health complexes and tertiary hospitals. Consequently, it share of the national health budget was disproportionately large. The Western Cape was the only province governed by the NP while at the local level, there is a mixture of ANC and NP controlled councils.
Mpumalanga, on the other hand, is mainly rural province of roughly three million people. It has many farms and a large mining industry. Towns are far apart and there are very few organs of civil society. Mpumalanga has no tertiary hospitals in the province and was historically disadvantaged in terms of health resources. The ANC controls the majority of seats provincially and many of the local councils.
The district development processes chosen by the provinces have been quite different. The Western Cape developed its provincial health plan during the first phase of restructuring in the province. This document set the framework for the rest of district development. Then the province moved to develop districts and involve communities within that process.
Mpumalanga began by developing a common provincial vision for district development. They then developed a two year operational plan to develop district health plans that would feed into a provincial health plan. They established DFTs as the building block for district development and attempted to build their capacity so that these teams could take the process forward. Attempting to develop 21 districts in the absence of a detailed provincial framework proved quite challenging for the province.
Although Mpumalanga took much longer to start their district development process, they have been working continuously. The Western Cape began moving much sooner, but they have had to wait until important decisions about the district health system were taken. As a result, many people have forgotten much of the preliminary groundwork that was done during the period of inactivity. Thus, there could be some benefit in preparing provincially before engaging communities in this process. The unity of vision presented in Mpumalanga seemed to bring people on board with them. It also diffused some of the anger, frustration and resentment that were evident in the Western Cape.
Speed, however, can be both positive and negative. The faster and more focused the process, the more excitement was generated. Such was the case in Mpumalanga, where community members did not agree with every decision made, but expressed a generally positive attitude toward policymakers. Unfortunately, many people were lost during the process. This was acceptable as long as there was a process to bring these people back on board over time.
The principle benefits of a slower process were that it allowed communities the opportunity to set up structures and to interact with documents at their own pace. The process in the Western Cape realised these benefits. If the pace of change was too slow, however, people will drop out due to boredom and frustration. In the Western Cape, which has been working on district development for more than two years, there should be a focus on tangible short-term results. In addition, the process needs continuous support from policymakers. People begin to feel lost if they are not kept informed of the latest developments and they do not see any change on the ground.
7.3 What lessons can be learned?
7.3.1 Understanding the DHS
While there have been efforts to inform key individuals in communities in both provinces about the process to develop a DHS. Difficult strategic trade-offs had to be made by policymakers about whether to heavily involve a few community members in the process or to equip many people with limited knowledge. In Mpumalanga, policymakers chose to involve a few community members on DFTs, which were involved in completing situational analyses, developing the district health plans, and drafting the PHC handbook. Thus, these individuals were very familiar with the process. Other community members, however, were unsure about the content and implementation process of their provincial plan. This was not surprising considering that the PHC guide was not publicly released until December 1996.
The Western Cape opted for wider dissemination, recognising that the level of understanding would be much more limited. The draft provincial health plan was translated and widely circulated to communities. Despite these efforts, the level of understanding of the DHS in the province, however, appeared to be fairly shallow and uneven. One explanation could be that the province relied heavily on written documents. Even though these documents were translated, the written word created barriers to community understanding. It was also slightly troubling, but not surprising, that policymakers judged communities' levels of understanding of the DHS according to their own efforts rather than asking communities if they understood these issues.
7.3.2 Consultation
Policymakers in both provinces have made conscientious efforts to consult communities during district development. There were many consultative meetings held in both provinces where policymakers provided information and requested feedback from communities about the DHS process.
This included some extraordinary efforts to broaden the consultation process beyond the traditional stakeholders. In Mpumalanga, their commitment for a participatory approach was demonstrated by co-opting community members on the DFTs. In the Western Cape, policymakers attempted to redress urban and rural imbalances by making an extra effort to inform all major towns in the rural areas.
Despite these strong efforts, the reality is that only a small number of community members were consulted. The majority of people in both provinces were left out of the process as it unfolded. In Mpumalanga, the lack of no formal system for reporting beyond the DFTs meant that important information on health district development only reached a few people, thereby limiting consultation. In the Western Cape, the slow pace of progress has led to frustration among some communities, causing some people to withdraw from the process.
7.3.3 Capacity Development
If community members capacities are developed earlier in the process, then the will have greater opportunities to be involved in important strategic decisions. In Mpumalanga, provincial policymakers recognised the need to develop the capacity of both health professionals and community members. The province drew on its internal resources and made good use of external experts on PHC issues to facilitate a series of workshops. As a result, some community members participated in developing their situational analyses and district health plans.
In Western Cape, most of the strategic policy decisions were made before any community capacity building efforts had been implemented. A comprehensive curriculum for community capacity development has been developed in consultation with NGOs and training institutions in the province but it has not yet been implemented. Without these skills, communities found it difficult to participate in the most important policy decisions around district development.
In addition, there does not appear to be a single way to build communities' capacity. The different choices all have advantages and limitations. For example, capacity can be developed jointly for health professionals and communities as in Mpumalanga. While this built team spirit, community members sometimes felt marginalised and intimidated within the groups. Alternatively, health workers can be trained to train community members as is proposed in the Western Cape. While this may be cost effective, it could lead to manipulation of communities and could reinforce the imbalance of power.
7.3.4 Organisation
Policymaker's understanding of the role of communities within governance structures differed from how community members understood their role. Policymakers generally wanted to use communities as a mechanism to extend their control over the health facilities. They viewed communities as "working" to serve their purposes. Community members viewed their involvement in these structures as an opportunity to take ownership of the health services and to develop their capacity. As a result of these differences, policymakers have often "fudged" this issue, trying to satisfy both sets of objectives. The role and function of all governance structures need to be clarified before further community involvement can occur.
It is both an advantage and a disadvantage to have vibrant civil society structures in place. In the Western Cape these structures make entry into the community much easier, but they also introduced the potential for conflict when policymakers attempted to introduce new structures to meet their needs. Without these structures, sustainability becomes a major concern. In Mpumalanga, mechanisms to sustain community involvement were not in place because there were few community structures before this process began.
7.3.5 Leadership
Policymakers have to make a firm political commitment to allow communities to take a leadership role. This decision involves actively relinquishing control to community members if it is to be successful. In Mpumalanga, the capacity building exercise empowered community members to participate in the decision-making process. To make this process meaningful, provincial officials had to agree from the outset to accept the work done by the DFTs as long as it fit with national and provincial guidelines.
In highly motivated, organised, and informed communities,
there was potential to establish terms of engagement that allowed
them to take on leadership roles. For example in the Western
Cape, one community outlined its terms of reference for health
workers and academics working in the community. They used
national and provincial policy documents to hold policymakers to
their promises. Thus, while it was mentioned above that written
documents limit consultation, they also force policymakers to
commit themselves. This commitment can then be used by community
in their advocacy efforts to demand action.
There is no single "right way" to implement CIH. It is an incredibly complex and dynamic process that often eludes both communities and policymakers. It is also an iterative process that must be continually refined over time. When it is working properly, it is a partnership between policymakers and communities that is defined according to the combination of their needs. Thus, the recommendations suggested below are simply meant to stimulate debate in order to move the process of CIH forward in these two provinces.
8.1 Meeting the preconditions to CIH
A re-orientation of all professional
health care workers still needs to occur in both
provinces. Appropriate curricula should be developed to train staff about the PHC approach and community involvement. Then, all existing health staff at all levels must be retrained. This process is an important precondition to effective community involvement and should occur within the next year.
It is important to realise that previous methodologies for reorienting health workers have not been very effective. Health workers have been trained to repeat the "right words," but their basic attitudes remain unchanged. This issue needs to be addressed in the health education curriculum development process.
The Western Cape Province must make a firm
political commitment for community involvement to be
meaningful. The Western Cape needs endorse community involvement at the highest level. The Cabinet needs to approve the chapter on CIH in the provincial health plan. Provincial and local government also need to resolve their difference on the role of communities and present a unified vision for community involvement. Communities acknowledged and valued the commitment from the provincial Department of Health and Social Services. They were concerned that resources have not been made available to them. Thus, it is further recommended that policymakers demonstrate their commitment by making resources directly available to communities.
Representative community structures need
to be put in place. In Mpumalanga, 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. 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.
During the next year, a concerted effort should be made to identify and strengthen representative community structures. 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. The accreditation process undertaken in the Western Cape appears to be a reasonable attempt to achieve these aims and warrants further attention from other provinces.
8.2 Practical Recommendations
As evidenced from this brief research project, it is very
difficult to translate theories from paper into practice. It is
critical to highlight some obstacles experienced in the
implementation of this new system and recommend practical
solutions.
Important district governance decisions
must be finalised. As mentioned above, there are several critical policy
decisions that are impeding progress toward CIH. The Western Cape
must make a final decision on its district governance option in
the short-term. Both provinces need to establish more clarity on
the role, functions and relationship of all governance
structures. There should be wide consultation with communities on
these issues and then positions should be finalised. Without
these issues resolved, capacity development programmes cannot go
forward.
Despite the efforts of policymakers, many
community members are still uninformed about the district
development process. The few members who were contacted directly have knowledge,
but there was little penetration. As a result, the vast majority
of people in South Africa have little understanding of basic
health policy issues. Without the basic knowledge of health
issues, many community members simply are not interested in
participating. Thus, a massive public education campaign on the
Primary Health Care approach and Department of Health policies
will be essential to broaden the support base for CIH. Provinces
could employ the cascade model to relieve the pressure from few
overcommitted community leaders and could make wider use of
community radio to reduce the emphasis on written documents.
Sufficient time, space and support are
required for CIH to develop. Community involvement in service delivery needs to be gradually introduced to communities. There are lots of old habits and practices that need to be unlearned. Due to the extreme speed and sophistication of the DFT process in Mpumalanga, many community members were left out. Future efforts at CIH should provide more time and space to ensure wider participation.
In the Western Cape, while there has been sufficient time and
space given, it is not clear that there has been sufficient
support to communities. Some communities felt forgotten after the
initial round of consultations. Policymakers must maintain
regular contact with all structures.
Community members often become
marginalised within governance structures. Simply voting or coopting someone onto a structure does not
guarantee that they will make inputs meaningful contributions.
Extensive training and capacity building will be necessary to
prepare community representatives. Even with these programmes in
place, some people will be left behind. Technical jargon,
literacy, and speed should not be used by health professionals to
marginalise community members.
Some conditions to redress the imbalance
of power between communities and policymakers need to be
established. The relationship between policymakers and communities is unequal by nature. In order to equalise this power relationship, it is important to establish clear terms of reference from the beginning of an initiative. These terms will open the lines of communication and reduce the potential for conflict.
One community in the Western Cape, has identified a set of
preconditions for health workers and other outsiders. People
coming into the community from the outside must agree to:
recognise existing community structures; be
committed to build on the strengths of community members;
make resources available to communities;
involve the community on all levels including
governance issues;
make effort to build capacity, especially on
policy issues; and
clearly spell out the powers and limitations
of communities from the outset.
CIH will take time, money and effort and people may be tempted
to consider it a failure but it worth the effort at the end of
the day.