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Health care users’ experience as a focus for unlocking opportunities to access quality health services

The objectives of this project, which ended in 2016, were twofold - to strengthen the capacity of health service users to be agents for realising their rights to health; and to build skills for providers to be responsive to user demands. These broad objectives were mutually dependent and mutually reinforcing. Taken together, they were intended to provide a basis for increasing the responsiveness of the health system to the needs and expectations of the population, and strengthen its capacity to implement the proposed re-engineering of Primary Health Care as the mainstay of the health sector. The Primary Health Care approach is dependent on active community engagement with the health services in the form of meaningful participation. The sets of results and outputs from this proposal speak directly to this aspect of PHC strengthening.  

The project had multiple elements. One strand of the work was focused on strengthening the capacity, mandate and authority of Health Committees in the Western and Eastern Cape. The results associated with this objective were (i) the achievement of clarity on the roles and functions of Health Committees, and the translation of this understanding into policy and programmatic implementation in Districts in the W and E Cape; (ii) manifesting in empowered Health Committees able to advance access to quality health care.

Although the National Health Act stipulates the existence and composition of Health Committees linked to facilities, in the context of an intention to enhance community participation, the Health Act is, itself, silent on the role of Health Committees, leaving this to provincial regulation. In the Western Cape, at the time of initiating the project, a draft policy on Health Committee existed which went some way to providing a framework for understanding what Health Committees should do. However, the tension between acting as an extra arm for understaffed and overworked primary care services (e.g. seen as Community Health Care Workers by service providers and sometime by Health Committee members as well), and, alternatively, acting to provide oversight of service delivery and a voice for the community in terms of accountability and governance, was not addressed in the policy. These concerns have emerged clearly in research conducted to date in the Western Cape Metro. Until consensus is achieved as to what Health Committees’ roles are and should be, it is difficult to institutionalise Health committees as part of the PHC re-engineering. Accordingly, a cluster of activities was planned to achieve this consensus.

In the Eastern Cape the situation is a little different.  In July 2009, a “Policy on the Establishment and Functioning of Clinic and Community Health Centre Committees” was promulgated by the Eastern Cape legislature, preceded by a long process of consultation with health committee members, staff and management of the Eastern Cape Health Department.  The policy allowed for clarification on issues such as composition of health committees, the establishment process and roles of health committees.  In 2010 the health services within the Nelson Mandela Bay (NMB) District contracted service providers to establish and train health committees at all 48 health facilities.  By the end of the year, all health committees had been established and trained in accordance with the new policy. The policy requires 3-yearly review.  This project therefore provided the opportunity to review the policy as required.  A multi-method approach of interviews and focus groups supported the process, generating findings of value to the District. Similar interventions to strengthen health committees were implemented in the NMB district. A national colloquium on health committees held in 2014 consolidated much of the work of this project with health committees.

Evaluations conducted throughout and at the end of the project showed that training of health committees and providers in community participation and on the roles of health committees could effectively strengthen community voice in health systems. The different Work Packages under the 4 Specific Objectives have all contributed to strengthening the responsiveness of the health system to the needs and expectations of the population, and to its capacity to implement the proposed re-engineering of Primary Health Care as the mainstay of the health sector.