Formation process and composition

In contrast with the NHA, the Western Cape Act makes it clear how health committees are established. The Act embraces a model of ministerial appointments (Western Cape Health Facility Boards and Committees Act, 2016: ss6(1)), where the provincial minister, also referred to as the MEC (Member of Executive Council) or a representative of the MEC, appoints 12 members to each health committee. Appointments will be based on nominations from a body that, in the opinion of the MEC, is sufficiently representative of the interests of the community or communities concerned (ibid: 6(3)(a)). The Act follows the NHA in its composition of health committees as constituted by the head of the primary health care facility, one or more councillors of the municipal council in the area and community members. The head of the primary health care services is often referred to as the facility manager. Furthermore, the Act (ibid: ss6(7)) prescribes that the MEC should pay attention to age, gender, race, and disability issues.

Roles and degree of influence

An equally important part of the legislation is the prescription of health committees’ roles.

In the Act, roles are split into duties defined as roles that health committees must perform, and powers defined as roles that a committee may perform. All roles are related to a primary health care facility. Table 1 outlines duties and powers, respectively.

Table 1. Duties and powers of health committees in the Western Cape health facility boards and committees act 2016

A vital clause concerning health committees’ roles appears in section 14 of the Act, which gives the MEC the power to revoke or extend roles. The clause states that changes to the prescribed roles should be in the public’s interest. Changes are supposed to happen in consultation with the health committee in question and be based on an assessment of the health committee’s capacity to perform a particular duty.

Support and linkages to other structures

Notably, there are some provisions for support in the Western Cape Act. The facility manager must ‘take measures to assist the Board or Committee concerned to perform its duties and exercise its power’ (2016: ss16(3)(a)). Some concrete provisions for support are also mentioned. First, the facility is obliged to provide a venue, and ‘in so far as is possible, secretarial, administrative and financial accounting support required by the Committee’ (ibid: ss18(4)). Second, the Department must provide induction and training for newly appointed members and additional training if considered necessary and appropriate (ibid: ss18(8)). Third, a provision related to offering transport reimbursement is included in the Act (ibid: ss25(3)(b)).

A section worth attention is the linkages to other structures. On this point, the Act states that the facility manager may take measures to ensure a collaborative working relationship between health facility boards, committees, and district health councils (ibid: ss16(1)).

Appointed participation

The appointment model, where health committees are formed through a ministerial appointment process, is similar to practices in those committees where the facility managers initiated their formation in the sense that it is the health services that control membership. Appointed participation is in contrast with community-led formation, which was practised in some communities. The linked paper showed that when facility managers appoint health committees, committees may align themselves with the facility rather than represent community interest. This raises the question of how community representatives appointed by the MEC and the Minister’s representatives, such as facility managers, will represent communities.

According to the Act, communities can nominate people. The nomination process is an opportunity to ensure community input. However, the fact that appointments will be based on nominations from a body that, in the opinion of the MEC, is sufficiently representative of the community’s interests means that the minister has the ultimate say in who can represent communities. Depending on how the word ‘body’ is understood, the process may exclude groups, sections, and individuals who are not part of community structures and unorganized social movements. The minister, in other words, has the discretion to decide who are representative of communities.

The appointment model is not only practised in the Western Cape Province. In seven out of South Africa’s nine provinces, health committees are appointed (Haricharan, Reference Haricharan2015). In the remaining two, community organizations elect committees. In the international literature, there are only a few examples of elected committees. Often there is a lack of clarity on who elects the committees. Elections are said to be practised in Kenya (Sohani, 2009), while participatory structures in Peru have some elected members (Iwami and Petchey, 2002). However, there is limited information on the election process – in particular, who constitutes the electorate. Similarly, when Coelho, Pozzoni and Cifuentes (2005) write about elected health council members in Brazil, they refer to members elected to represent specific sectors (mostly civil society organizations). It is these sectors that elect their representatives. There is a shortage of information on the processes leading to electing these members, note the authors. Of importance is that when the literature talks about elected structures, this does not necessarily imply that the electorate consists of all people residing in a specific area.

Sector representation, where sectors within the community elect their representative to the health committee, is practised in South Africa’s Eastern Cape Province and some areas in Cape Town. While the model seems to allow for more community representation, it is important to consider the rationale behind giving preference to certain categories. For instance, in both the Eastern Cape and the Western Cape, traditional healers are represented, as are local businesses. One might ask why groups such as migrants and the LGBT community – groups known to face barriers when accessing health care – are not considered (Human Rights Watch, 2009; Muller, 2017).

Neither the Alma-Ata Declaration nor the General Comment 14 deal with how participatory structures are formed. The issue is also not addressed in most South African national legislation. The White Paper (1997) is an exception, as it explicitly talks about communities electing health committees. The Western Cape Draft Policy also viewed community representatives as people elected by patients and communities.

The appointment model should also be viewed in relation to participatory theory, human rights, and PHC approaches to participation, which agree that one of the purposes of participation is to give a voice to marginalized citizens (Potts, 2008; Hilmer, 2010). To what extent structures appointed by the MEC will represent community interest, particularly marginalized voices, is a contentious issue.

Hence, there is a conceptual gap with regard to representation. There has been a lack of attention to how formation models can ensure that community participation structures represent communities.

Overall, there is a need to rethink how community participation structures are formed and the ramifications of different formation processes in research, international frameworks, national, and provincial policies. Two models are emerging: the appointment model, where health services choose community representatives, and the community-based model, where community structures choose or elect community representatives. Elections can be either by sectors or by patients and people residing in the community.

Limited roles and influence

The roles in the Act are inconsistent with a PHC and human rights approach, where participation is about decision-making influence in health governance. In relation to health committees’ duties (roles), it is evident that health committees do not have roles in health governance – in priority setting, planning, implementation, and accountability. It is equally apparent that their influence in decision-making is limited. Consider the language used to outline their duties. They can assist communities in communicating their needs but have no power in ensuring that the facility addresses those needs and no input in how they should be addressed. They can provide constructive feedback, but the facility has no obligation to respond to the feedback or address issues raised.

Concerning health committees’ powers (roles), similar issues are evident. Again, the language used is illustrative. They can request feedback on progress reports and obtain information, but they have no right to expect they get the information since health services are not obliged to provide this. Importantly, it is unclear under which conditions they may perform these powers and who makes decisions in this regard. This makes these powers weak and contingent. Health committees, hence, have no real influence or power to enforce any of these roles. Furthermore, the provision for the MEC to extend and limit the functions of committees gives the MEC absolute power to determine health committees’ roles and define the terms of participation. Finally, both a PHC and a human rights approach envision policy involvement as an essential part of community participation, but this role is absent in the Act.

The roles prescribed in the Western Cape Act are similar to the roles that health committees played in practice. The analysis of practised participation showed that 70% of health committee activities were limited forms of participation with little influence and decision-making. Instead, committees assisted clinics in day-to-day operational tasks and health promotion campaigns and provided assistance to patients with health and social needs. Roles in the Act stipulating that committees should encourage volunteers to offer their services, raise funds for the clinic and foster community support reflect a similar view – that health committees should assist clinics and be an extra pair of hands.

The current Act, then, is likely to provide for a continuation of health committees playing narrow roles incongruent with how participation is conceptualized in PHC and rights-based frameworks, namely as decision-making in health governance. Neither does the Act involve influence in policy development and implementation. In doing so, it falls short of the transformative potential of community participation in health systems.

In the linked paper, we outlined four domains for health committee participation, including a distinction between involvement and participation, with involvement being the way health committees practised their role as practical support. In contrast, participation was defined as influence in health governance. Besides these first two domains, we argued that health committees’ access to influence in policy and addressing social determinants of health should be considered. Table 2 provides an overview of these four domains mentioned in different policies and frameworks and as practised by health committees in the linked study. This overview shows how roles in the Western Cape Act are similar to how health committees practised participation but in contrast with international frameworks, the White Paper, and the National Draft Policy.

Table 2. Roles of health committees in policies and as practised by health committees

Considering how community participation should be conceptualized along these domains could be the first step in creating meaningful structures. These should build on the PHC and human rights framework but address gaps, such as whether participatory structures should also be concerned with social determinants of health. Furthermore, the issue of how to ensure that community participation structures sufficiently represent communities needs careful deliberation.

Upstream influence

An important aspect in both a rights-based and a PHC approach is that participation should occur at local, national, and global level. As the description of roles has demonstrated, health committees are considered localized participatory structures focusing on local health facilities. There are no roles that suggest influence at other levels. While focusing on the local level may be important, health committees are likely to encounter issues that need to be addressed higher up in the health system and at a policy level. This was evident in the paper on practised participation, where health committee members complained about their lack of access to the wider health system and the political system. They asserted that without access upstream, they could not address issues encountered sufficiently.

Upstream influence could occur through linkages to other structures. An essential feature in the Act is the limited articulation of collaborative, participatory structures horizontally and vertically. Although the facility manager may take measures to ensure collaborative working relationships between health facility boards, committees, and district health councils (2016: ss16(1)), there is no obligation to ensure that this occurs. Like with many other provisions in the Act, this is framed as an option. Further, there are no structural linkages for upstream influence in the health system to district, provincial, and national level. In fact, the Act does away with coordinating structures that have existed at subdistrict and district level. Tiered structures for community participation – from local to sub-district and district level – had existed in Cape Town since 1992 when the Cape Metro Healthcare Forum, an umbrella body for health committees in the Cape Town Metropole, began to organize health committees. They are also envisioned in the Western Cape Draft Policy. Along a similar line, the White Paper talks about health conferences at local, provincial, and national level. Again, the Act represents a departure from the White Paper and the Western Cape Draft Policy’s attempts to ensure coordination and upstream influence.

Enabling environment

The analysis of practised participation in the linked paper identified sustainability and functionality as two critical challenges for effective and meaningful participation. The paper also outlined several issues that impacted these challenges. Foremost among these was a lack of resources. The research demonstrated that resources such as funds for transport reimbursement, running costs, and activities were necessary for committees to functions effectively. Health committee members come from socioeconomically disadvantaged backgrounds and cannot – and should not – be expected to carry the cost of participation.

Health committee members’ lack of capacity, which was linked to their background and limited education, was another critical factor. The data on practised participation showed that there was are a correlation between health committee roles and members’ skills. The fact that they were not capacitated impacted negatively on which roles they were able to fulfil. The data indicated that health committee members would like to take up more expansive roles if they had the skills. Finally, the data suggested that the attitude of facility managers and ward councillors toward health committee participation was critical to how the committees functioned. Support from facility managers and ward councillors was raised numerous times, as was the importance of taking health committee members’ educational, social, and economic context into consideration.

The Act does address some of the challenges identified to impact negatively on health committees. The existence of health committee legislation means that health committees become statutory structures with a legal mandate. Notwithstanding the issues raised around appointed participation, having the MEC and the Health Department appoint committees may result in more committees being established and committees becoming more sustainable and functional, which may also result in facility managers being more responsive and supportive.

The Act makes provisions for support, which may result in more effective participation. There is a provision that the facility manager must take measures to ensure that the health committee performs its duties (2016: ss.16(3)(a)). Here, the minister’s role is framed as an obligation, though there is little detail on what this obligation entails. The paper on practised participation showed that facility managers did not always attend health committee meetings despite a legal requirement in the NHA. We argued that making it part of the facility managers’ key performance areas might improve their participation. Such a condition is likely to result in facility managers ensuring measures to support health committees. It is also worth noting that having a health committee is a requirement for the Ideal Clinic checklist. This vital provision may impact facility managers’ investment in health committees.

An important provision is that the facility is obliged to provide a venue. This is an essential step, addressing a problem identified in the research on health committee practice. The other forms of support, such as secretarial, administrative, and financial accounting support (2016: ss18(4)), are made conditional, depending on whether they are deemed possible. Hence, while there is a commitment to support, some provisions are expressed as optional, where framing them as an obligation would be preferable. There is a danger that framing support as optional will undermine some committees. It is also worth considering whether it would not be a better option to provide health committees with training to function without this support. Capacitating health committees would ensure both their functionality and independence.

The Act also make provision for induction and training for newly appointed members and additional training if considered necessary and appropriate (2016: ss18(8)). This is an essential provision that, like the Alma-Ata, recognizes the importance of education and training. The research on practised participation highlighted the importance of training and showed a correlation between health committee members’ skills and roles.

The final provision relates to providing reimbursement for transport expenses (2016: ss25(3)(b)). This is a necessary provision, as the research on practised participation demonstrated that the cost related to participation sometimes resulted in health committees becoming ineffective or folding altogether.

While the Western Cape Act has some provisions for support, it is imperative to note what is absent in the Act. Consider, for instance, that there is provision made only for transport costs but no other expenses such as for phones and stationery. Again, the research on practised participation made it clear that running costs for the committees were a necessity. It also showed that health committees needed funding for running health projects.

Overall, the Act makes some provision for support that may result in more effective committees, and it addresses some of the challenges experienced by health committees in practice. Still, without sufficient funding for running costs and adequate training, health committees are likely to continue struggling with sustainability and functionality.

In summary, the Act may result in more health committees being established in the Western Cape. These committees may be more effective and functional due to their status as legislated structures with a mandate and some support. On the other hand, health committees are unlikely to have much influence due to the limited roles prescribed in the Act. They are unlikely to practise a meaningful form of participation in line with a PHC and human rights approach.

Recommendations

The research points out that there are two distinct conceptualizations of community participation. In the first, community participatory structures such as health committees have narrow roles and limited influence. This conceptualization is reflected in the Western Cape Act and practised participation. In the second conceptualization, participation is viewed as influence in decision-making in health governance. This view is reflected in the PHC and human rights framework. The South African White Paper, National Draft Policy, and the Western Cape Draft Policy all are in concordance with the international framework, while the NHI is silent on participation.

We propose that the Western Cape Act be amended to address the shortcomings. At the same time, we suggest that South Africa’s National Health Insurance Bill should contain provisions for health committees. We recommend that the National Department of Health take a stewardship role in ensuring that provincial and national policies on health committees are aligned rather than the present disjuncture between national policies and those at the provincial level, such as the Western Cape.

For the Western Cape Act and the NHI Bill, we suggest the following:

1. 1. Legislation should provide an explicit conceptualization of participation, which should institutionalize more meaningful forms of participation for communities and describe a vision for community participation aligned with the international PHC and human rights framework.

2. 2. We propose that the State draws on the international framework, the White Paper and the National Draft Policy to conceptualize health committees as structures primarily involved in health governance, including accountability, at facility level. They should ensure that health services meet the needs of communities and are accountable. Additionally, these structures should be concerned with social determinants of health and have input at policy level.

3. 3. To facilitate upstream influence and influence on policy level, we suggest a tiered structure for community participation with health committees functioning at the local level.

4. 4. We also propose that the NHI Bill contains sections on how health committees are supported to become more meaningful and effective structures.

5. 5. We suggest that the Western Cape Act includes more supportive measures.

6. 6. Finally, we suggest that careful consideration be given to the formation process and the composition of health committees. This should ensure that they adequately represent communities.