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Health centre committees as a vehicle for social participation in health systems in east and southern Africa

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Health Centre Committees (HCCs) have provided one vehicle for social participation and accountability in health systems in east and southern Africa (ESA). Recognising this contribution and building on prior work on HCCs, EQUINET held a regional meeting involving those working with HCCs in ESA countries to exchange experiences and information on the laws, roles, capacities, training and monitoring systems that are being applied to HCCs in the ESA region. The meeting gathered 20 delegates representing seven countries from the region, all involved in training and strengthening HCCs. An interim desk review of existing published literature on HCCs was prepared for the meeting. The desk review covered all 16 ESA countries covered by EQUINET, that is Angola, Botswana,
Democratic Republic of Congo (DRC), Kenya, Lesotho, Madagascar, Malawi, Mauritius,
Mozambique, Namibia, South Africa, Swaziland, Tanzania, Uganda, Zambia and Zimbabwe. Delegates validated and added to the evidence presented. This discussion paper combines the evidence from the desk review and the further evidence that was presented at the regional meeting. It covers the legal frameworks, roles, composition, capacities and monitoring of HCCs in ESA countries.

The policies of ESA countries include support for participation, particularly as a part of their primary health care (PHC) approach. However, despite the almost universal policy commitment to community participation and reference to HCCs in many strategic plans, few specific policies or guidelines elaborate the role, functioning, authorities and resourcing of HCCs. Most ESA countries do not have laws that explicitly provide for these aspects of HCC functioning. Without an enabling law, HCCs may not be recognised by health managers and workers or by the communities they serve.

This report highlights that in practice HCCs are a heterogeneous set of entities, with composition, roles and functions varying across ESA countries. While their diverse composition brings different skills and interests to HCCs, they also vary in how far they represent community interests, depending in part on whether their members are elected by communities or appointed by health authorities. An inherent tension exists between how far HCCs are occupied by influential people within the community and representatives of more disadvantaged groups. While the latter bring experience and voice of those with higher health needs to planning, the former may have greater leverage in addressing the power imbalances in the interaction between communities and heath personnel.

HCC roles are often listed in guidance documents. This report proposes that rather than a disconnected list, HCC roles should be clearly located within health system processes, starting with their engagement with the community. Building an informed community strengthens HCCs in bringing community voice on needs and priorities into the decision making for and functioning of health services. HCCs bring social knowledge, experience, views on health problems and solutions within communities to jointly design and implement the plans and budgets for the health system at primary care and community levels. This joint role in governance gives the HCC the information, authority and motivation to: facilitate dialogue and consultation with communities on plans; mobilise social action; build constructive partnerships and facilitate dialogue with different actors to ensure that problems are addressed; and implement services and health actions. This raises the oversight role of the HCCs. They monitor and ensure that plans have been implemented in a manner responsive to the community, give feedback to the community and discuss with communities and health workers how to make improvements, in a cycle that again identifies new needs to feed into planning.

Effective implementation of these roles has been documented to show a positive impact on advancing the right to health, to improve the performance of PHC systems, the satisfaction Health Centre Committees (HCCs) have provided one vehicle for social participation and accountability in health systems in east and southern Africa (ESA). Recognising this contribution and building on prior work on HCCs, EQUINET held a regional meeting involving those working with HCCs in ESA countries to exchange experiences and information on the laws, roles, capacities, training and monitoring systems that are being applied to HCCs in the ESA region. The meeting gathered 20 delegates representing seven countries from the region, all involved in training and strengthening HCCs. An interim desk review of existing published literature on HCCs was prepared for the meeting. The desk review covered all 16 ESA countries covered by EQUINET, that is Angola, Botswana,
Democratic Republic of Congo (DRC), Kenya, Lesotho, Madagascar, Malawi, Mauritius,
Mozambique, Namibia, South Africa, Swaziland, Tanzania, Uganda, Zambia and Zimbabwe. Delegates validated and added to the evidence presented. This discussion paper combines the evidence from the desk review and the further evidence that was presented at the regional meeting. It covers the legal frameworks, roles, composition, capacities and monitoring of HCCs in ESA countries.

The policies of ESA countries include support for participation, particularly as a part of their primary health care (PHC) approach. However, despite the almost universal policy commitment to community participation and reference to HCCs in many strategic plans, few specific policies or guidelines elaborate the role, functioning, authorities and resourcing of HCCs. Most ESA countries do not have laws that explicitly provide for these aspects of HCC functioning. Without an enabling law, HCCs may not be recognised by health managers and workers or by the communities they serve.

This report highlights that in practice HCCs are a heterogeneous set of entities, with composition, roles and functions varying across ESA countries. While their diverse composition brings different skills and interests to HCCs, they also vary in how far they represent community interests, depending in part on whether their members are elected by communities or appointed by health authorities. An inherent tension exists between how far HCCs are occupied by influential people within the community and representatives of more disadvantaged groups. While the latter bring experience and voice of those with higher health needs to planning, the former may have greater leverage in addressing the power imbalances in the interaction between communities and heath personnel.

HCC roles are often listed in guidance documents. This report proposes that rather than a disconnected list, HCC roles should be clearly located within health system processes, starting with their engagement with the community. Building an informed community strengthens HCCs in bringing community voice on needs and priorities into the decision making for and functioning of health services. HCCs bring social knowledge, experience, views on health problems and solutions within communities to jointly design and implement the plans and budgets for the health system at primary care and community levels. This joint role in governance gives the HCC the information, authority and motivation to: facilitate dialogue and consultation with communities on plans; mobilise social action; build constructive partnerships and facilitate dialogue with different actors to ensure that problems are addressed; and implement services and health actions. This raises the oversight role of the HCCs. They monitor and ensure that plans have been implemented in a manner responsive to the community, give feedback to the community and discuss with communities and health workers how to make improvements, in a cycle that again identifies new needs to feed into planning.

Effective implementation of these roles has been documented to show a positive impact on advancing the right to health, to improve the performance of PHC systems, the satisfaction