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Given these imperatives for—yet limitations to—the community participation structures outlined in the Draft Policy, this analysis identifies five structural obstacles to community participation in the Western Cape:. There is organizational uncertainty as to what the role of the CMHF is or should be. There is complexity in identifying, selecting, or electing those who truly represent the community. Without established processes for determining community representation, it is often difficult to determine if representatives are participating in the best interests of the communities for whom they claim to speak, denying legitimacy to HC structures.

There is little government support for building the capacity of community representatives. The Department of Health has not instituted a structure to build HC capacity to engage with the health system. There is a lack of administrative training for HC members. Once a committee member, there are few substantive training or administrative support structures to carry out required community representation functions. There is unclear commitment to implementing policy for community participation.

In the aftermath of developing the Draft Policy, policymakers have not sought to institutionalize community participation structures in implementing the DHS. From this analysis, it becomes clear that provincial policy holds a crucial role in overcoming these obstacles, facilitating or inhibiting the development of representative institutions conducive to community participation. When the CMHF was formed in , its establishment came about during a time of major restructuring in the Western Cape health system. At the national level, the Department of Health was seeking to bring together fourteen autonomous health authorities; at the local level, the City of Cape Town alone had twenty-seven distinct authorities providing health services.

In this restructuring, the new Provincial Health Department sought to implement national policy by merging various health authorities under the mantle of one DHS. As a forum to discuss these structural reforms with affected communities, the CMHF served an essential, albeit informal, role in bringing together health officials and community members to collaborate and coordinate during the provincial implementation of the national Policy for the Development of the District Health System.

Since the Western Cape has begun to put in place formal institutions for DHS oversight, the CMHF has not been able to collaborate adequately in a process in which it has no legislative standing or defined mandate within the DHS. To alleviate this organizational uncertainty, the Draft Policy was sought as a means to formalize the CMHF pursuant to provincial legislation. As such, many community members fear that health reforms will not adequately allow for community participation, creating a pressing imperative for their efforts to secure implementation of the Draft Policy and thereby formalize the CMHF as a basis for engagement within the DHS.

Not fully addressed in the Draft Policy, there remains complexity in identifying, selecting, or electing community representatives to the HCs. As this problem was identified by a key stakeholder:. Several stakeholders noted that the lack of clearly defined processes for representation creates an environment in which community representatives do not have a clear relationship to the communities for whom they claim to speak. Emblematic of the limitations to true representation, elections for HC members are frequently forgone in place of direct appointment from the committee chair.

In situations in which these members are not elected or selected by standard procedures, engagement with community participation structures may serve only for personal enrichment, with community representation reinforcing existing bases of political and social capital and reflecting nothing more than personal opinion [ 56 ]. Rather than representing or understanding their communities, it is believed that several community representatives were motivated strongly by self-interest, volunteering to participate in health committees merely to gain the qualifications necessary to seek future employment and leaving the committee once employed nominating a family member or friend as a replacement without any additional confirmation.

With such processes undercutting efforts to achieve community participation, a stakeholder criticized:. These non-standard selection processes, allowing personal interests to play a role in joining committees and representing interests, can present potential obstacles to representation, denying HCs the impartiality, public spirit, and effective conflict resolution structures necessary for community participation.

As health officials seek to engage with these community representatives, the government lacks a clear vision of how the DHS can institutionally support community engagement to promote meaningful participation in the health system. And part of that has to deal with the community and having a voice closer to management and informing processes. Despite serving as the main government entity responsible for the provision of health services, the provincial Department of Health has not traditionally held responsibility for building community capacity for participation, with many of these functions undertaken by civil society representatives rather than Department physicians [ 57 ].

The Department has been restructured to emphasize Primary Health Care and rights-based community participation; however, the Department leadership comes primarily from medical backgrounds, and stakeholders within the Department noted the enduring limitations of this medicalized workforce:. As a result of this organizational culture, it was believed—both inside and outside the Department of Health—that many health officials continue to question whether the Department has the obligation or ability to engage in capacity building to support community representatives.

Even with the Draft Policy, there remains ambiguity over how the Department might communicate effectively with its constituents, give voice to community representatives, and relate institutionally to community participation structures. Beyond building capacity for community participation, HC members often noted the need for administrative training — as defined by communities themselves, but including, at a minimum, basic computer skills, administrative committee procedures, and information on prevailing health issues, DHS bureaucratic functions, and HC participation responsibilities.

With this training only just begun, one of the trainers reflected on how training could impact the role of the community representatives in the health system:. Because a lot of the training was around what makes you sick, what makes you better — understand Primary Health Care first before you can understand your role in the Primary Health Care system.

People did want to know. People are smarter than people expect. They can work some things out because they are survivors. Yet among officials within the Department of Health, even among those who were otherwise supportive of community participation, there was criticism of training efforts and concern for achieving training goals.

Such opposing perspectives on the value and impact of training between Department officials and community representatives highlight the divergent ways in which the two groups define training success.

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Because the Department is a large governmental institution that is evaluated on the basis of achieving measureable targets within a limited budget, cost-benefit analysis defines its success or failure; in comparison, community members and trainers may gauge success on factors not amenable to quantifiable measures such as individual empowerment or community engagement [ 55 ]. Further, with this administrative training thought to provide a demonstrable impact only once a threshold number of representatives have been trained, the Department would need to scale-up training to see a measurable association between representative training and community participation.

As the health system is reorganized so that management can be brought closer to communities and communities can have a voice in policy, many question the lack of focus on effective community participation in health system management and lack of commitment to engaging HCs under the new DHS.

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Effectively shifting from a paternalistic medical model to a participation-based model requires a significantly different approach to health and healthcare that has not been addressed in provincial policy. With less attention paid to establishing effective institutions for community participation at the local level, policy reforms have not focused on building and supporting effective HCs.

Since the adoption of the Patients Rights Charter and the White Paper in , over a decade passed before stakeholders developed the Draft Policy to institutionalize HCs; and rather than adopting this Draft Policy, the eventual District Health Council Bill extends this lack of commitment to community participation and excludes HCs altogether.

Supporting HCs through participatory policy would require investment in: how to mobilize communities to select representatives; how to ensure that HCs meet regularly; how to engage health services management; and how to coordinate communities with management at the local clinic level. Where leaders in the health system continue to neglect community voices, there is a need for effective and engaged policymakers who have a clear understanding of what kind of community participation is required and how such participation can be realized in a way that allows community representatives to become more active members in the policymaking process [ 1 ].

Indicative of this lack of policy commitment to community participation, the Department of Health promulgated new legislation in December to institutionalize a District Health Council [ 58 ]. Without requiring formal community representation under this new policy, stakeholders expect that the establishment of a District Health Council will lead to the dissolution of the CMHF, ending longstanding efforts in the Western Cape to foster formal community participation in the health system. As the Department of Health reviews previous community participation structures in preparation for the establishment of the new District Health Councils, government officials are contemplating the prospective loss of the CMHF, explaining that:.

But they are actually not legally legitimate in terms of the structure. In the absence of legislative institutionalization, the CMHF and HCs have evolved over time to serve a quasi-official role for community participation in the health system, and yet their future is unclear. Because of shortcomings in community participation policy, many have come to undervalue the relationship between the government and the community since the hopeful beginnings of community participation in the New South Africa.

While the Western Cape has taken evolving steps to institutionalize these participatory processes, with the development of the Draft Policy and most recently with the legislative adoption of District Health Councils, these transitions may signal the decline, demise, or complete reconfiguration of existing structures for community participation, leaving HCs without direction moving into the future. From the Western Cape experience, many lessons emerge in the context of policy development for community participation in the health system.

To assure institutional frameworks for community participation, this research finds that there must be clearly defined roles and functions of community representatives, codified in legislation, that specifically outline how communities engage with government through effective and accountable channels for participation.

Facilitating this rights-based participation in the health system, ongoing training and policy support must be established to enable communities to communicate with officials. Without legislative authority that articulates participatory structures, community participation is likely to fall into uncertainty, inefficiency, and dissolution. There are abundant benefits of community participation, but these benefits have the potential to be lost in a health system in which community participation is exclusively dependent on power structures, political will, and informal institutions.

Without further research to establish clear and precise roles for participatory institutions, paired with extensive training and capacity building for representatives, community participation will not be able to achieve its full potential in realizing health for all. BMM and LL conceptualized the study. CP carried out documentary research and semi-structured interviews. All three authors participated in the analysis of results and development of this manuscript.

National Center for Biotechnology Information , U. Published online Aug Author information Article notes Copyright and License information Disclaimer. Corresponding author. Benjamin Mason Meier: ude. Received Mar 7; Accepted Jul This article has been cited by other articles in PMC. Methods With the Draft Policy as a frame of analysis, the researchers conducted documentary policy analysis and semi-structured interviews on the evolution of South African community participation policy.

Results Framing institutions for the establishment, appointment, and functioning of community participation, the Draft Policy proposed a formal network of communication — from local HCs to the health system. Conclusions Attempts to realize community participation have not adequately addressed the underlying factors crucial to promoting effective participation, with policy reforms necessary: to codify clearly defined roles and functions of community representation; to outline how communities engage with government through effective and accountable channels for participation; and to ensure extensive training and capacity building of community representatives.

The Legislative Process | PMG

Background Community participation is crucial to realizing a rights-based approach to health, yet many health systems have not enacted policies to enable the institutions necessary for effective participation. Community participation in health systems Community participation in the health system has come to be seen as a key component of any rights-based health policy. South african policy reforms to realize participation South Africa has developed evolving executive and legislative measures to realize the benefits of community participation, establishing HCs as participation structures to promote community involvement in the health system, create sites for health-related rights, and reflect fundamental values of the New South Africa [ 24 , 25 ].

Open in a separate window. Figure 1. Facilitating participation by focusing health care decision making at the district rather than national level, the DHS is intended to increase communication between providers and citizens, and give communities greater opportunity to contribute to policy decisions, with the Policy for the Development of the District Health System outlining that: "The users of these facilities should be an integral part of the health services, and not merely be seen as the passive recipients of services.

Figure 2.

Figure 3. Methods With the Draft Policy as a frame of analysis, the researchers conducted a detailed case study analysis of the evolving policy landscape for community participation in the health system in the Western Cape province of South Africa [ 46 ]. Results and discussion Developing policy that effectively implements rights-based community participation has long faced challenges in defining and addressing the complex realities of the participation process [ 50 ].

Given these imperatives for—yet limitations to—the community participation structures outlined in the Draft Policy, this analysis identifies five structural obstacles to community participation in the Western Cape: 1.

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Organizational uncertainty When the CMHF was formed in , its establishment came about during a time of major restructuring in the Western Cape health system. Open government requires an open executive branch, an open legislature, and an open judiciary. Historically, however, global attention to government transparency and access to information has focused on the executive branch.

But this may finally be changing. In April of this year, 38 civil society organizations from around the world convened in Washington, D. In September, more than 90 civil society organizations from more than 60 countries launched the Declaration on Parliamentary Openness in Rome. Civil society attention on lawmakers and legislatures is critically important—especially in Africa, where parliaments have long worked behind closed doors most legislatures on the continent are parliaments.

Transparency is needed for civil society to hold legislators accountable for their decisions and actions, and to ensure they are responsive to the needs and concerns of their constituents. The report identified a deep disconnect between African lawmakers and their electors.

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For various reasons, most citizens have a limited, often erroneous understanding of the formal lawmaking, executive oversight, and representation responsibilities of legislators. Rural people in particular view lawmakers principally as development agents and press them to bring projects to their districts. In response, many legislators work to find resources to build schools, dispensaries, wells, roads, and other infrastructure and assist their constituents with personal matters. As a result, however, elections are often referendums on how many projects lawmakers brought to their communities—not on which laws they supported or how effectively they shadowed line ministries to ensure effective performance.

Indeed, while many citizens are aware of the development efforts of their legislators, most do not know if they voted on bills or took other actions in parliament that are consistent with their campaign pledges, political party positions, or the priority needs of constituents. Few monitor the performance of their lawmakers in parliament and hold them accountable for their constitutional roles. When voters pay little attention to how legislators act in parliament, lawmakers can be influenced by government leaders, political party officials, and other powerful actors whose interests may diverge from those of their electors.

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