Community ownership and participation
Health systems can be transformed to deliver better health in ways that people value: equitably, people-centred and with the knowledge that health authorities administer public health functions to secure the well-being of all communities. These reforms demand new forms of leadership for health. The public sector needs to have a strong role in leading and steering public health care reforms and this function should be exercised through collaborative models of policy dialogue with multiple stakeholders, because this is what people expect and because it is the most effective.
A more effective public sector stewardship of the health sector is justified on the grounds of greater efficiency and equity. This crucial stewardship role should not be misinterpreted as a mandate for centralized planning and complete administrative control of the health sector. While some types of health challenges, for example public health emergencies or disease eradication, may require authoritative command and control management, effective stewardship increasingly relies on “mediation” to address current and future complex health challenges.
The interests of public authorities, the health sector and the public are closely intertwined. Health systems are too complex: the domains of the modern state and civil society are interconnected, with constantly shifting boundaries. Effective mediation in health must replace overly simplistic management models of the past and embrace new mechanisms for multi-stakeholder policy dialogue to work out the strategic orientations for primary health care reforms.
At the core of policy dialogue is the participation of the key stakeholders. Health authorities and ministries of health, which have a primary role, have to bring together:
- the decision-making power of the political authorities
- the rationality of the scientific community
- the commitment of the professionals
- the values and resources of civil society.
This is a process that requires time and effort. It would be an illusion to expect primary health care policy formation to be wholly consensual, as there are too many conflicting interests.
However, experience shows that the legitimacy of policy choices depends less on total consensus than on procedural fairness and transparency. Without a structured, participatory policy dialogue, policy choices are vulnerable to appropriation by interest groups, changes in political personnel or donor fickleness. Without a social consensus, it is also much more difficult to engage effectively with stakeholders whose interests diverge from the options taken by primary health care reforms, including vested interests such as those of the tobacco or alcohol industries, where effective primary health care reform constitutes a direct threat.
This section of the health system profile is structured as follows:
The concept of community ownership and participation is key to the implementation of the primary health care renewal. Countries of the WHO African Region have advanced primary health care revitalization through the adoption of the Ouagadougou Declaration on Primary Health Care and Health Systems in Africa and its related implementation framework.
The primary health care approach empowers communities so that they can be involved in processes to help ensure that health services are people centred. This means that they should meet people’s identified health needs, encompassing physical, emotional and social concerns beyond disease categories. Services that meet people’s health needs have to be comprehensive, including health promotion, prevention, diagnosis, treatment, referral, long-term care and social health services. These services also need to be consistently available until the health problem is resolved or the risk factor has disappeared.
The Region has made significant progress in promoting and strengthening local community mobilization in health development. Many countries have set up community structures to interface with health workers, especially at the first level of the formal health system. In some countries, these community structures determine how health services are organized and operated.
Where communities are closely involved, service utilization rates are higher. However, the interface between communities and the formal health care delivery system is still weaker than desirable, because institutionalization of the primary care concept as the hub for coordination of health services at community level has not yet taken strong root. In addition, decentralization of financial and other resources for management within the primary care hubs has not yet been adequately achieved.
Community involvement in health development takes numerous forms. Some communities, working alongside the formal health system, administer medicines for the control and prevention of various diseases. An example is the community-directed treatment with ivermectin for onchocerciasis control taking place in affected African countries. In a number of countries, hospital advisory committees and village health committees play a role in promoting healthy lifestyles and managing peripheral health facilities. However, as communities discharge these duties on a mainly voluntary basis, drop-out rates tend to be very high.
- ↑ Systems thinking for health systems strengthening (pdf 1.54Mb). Geneva, World Health Organization, 2009
Participation as an individual, User and provider interactions
Given the acknowledged human and financial shortfalls in the health system, and the need for community understanding and ownership of health interventions, the concept of community participation in the health sector is extremely important. The shape and form it needs to take has been a matter widely discussed and applied throughout many decades and across a variety of health systems. It is a complex issue, as communities are expected to participate in different ways in the promotion, restoration and maintenance of health. In the WHO African Region, the concept of "ubunthu" or "umunthu" implies that an individual exists only because of the existence of others. This concept clarifies the interdependence of individuals and communities for their own survival.
It has been widely acknowledged that good relations among neighbours, and friendly communities, have the best potential to increase individual survival. In terms of communicable disease control, preventing the disease in one individual prevents its transmission to others. Therefore, communities are bound to support each other and work together for the common good, which translates into better health and increased life expectancy for all.
In countries of the WHO African Region, communities have been involved in the health system in many different ways. The most common community structures are those developed to advise health facility management teams, and those involved in the implementation of local interventions such as treatment with ivermectin against worm infestation or distribution of insecticide-treated mosquito nets to protect against malaria. In rare cases, communities may take a comprehensive approach to health care and become actively involved in promoting individual and family responsibility for the prevention and control of diseases. For example, the creation of local bye-laws has increased the percentage of deliveries attended by skilled health personnel in health facilities, increased immunization of children aged under 1 year, and driven improvements in environmental and sanitation conditions.
Community structures are formed in a variety of ways. The most frequent arise in response to a request from health partners operating within the community. The most sustainable structures are those formed around existing community institutions such as the village health committee, which is commonly led by the village headman – a traditionally acquired leadership position that does not change over generations.
In conditions where financial expenditure is required, there is a tendency for community structures to become inactive or to disappear should the necessary financial support become unavailable.
Local community mobilization
Once communities acquire a certain level of knowledge, they discuss needs and priorities among themselves and have little difficulty in mobilizing around a particular cause. Community mobilization for a specific project tends to work best where there are suitable incentives and where existing community structures can be utilized. The involvement of political parties or structures may induce the mobilization of large communities around an important health target, although success may depend on the strength of the political party or parties involved.
Services design issues at locality
Community mobilization around major health reforms has taken place in countries of the WHO African Region. Typical activities carried out through community involvement include:
- provision of information on the nature and extent of the proposed reforms via print and electronic media
- political rallies
- public addresses
- town hall meetings
- lectures in schools.
However, it is frequently found that insufficient dialogue has taken place on how to obtain maximum benefit from community participation in the anticipated public health reforms. Experience shows that communities demonstrate significant commitment as long as there is an enabling environment politically, economically and socially. The task of creating this enabling environment is the joint responsibility of community leaders and government officials.
Accountability of health services to locality and community watchdog functions
Better access to health information has created a demand for more accountability on the part of communities for their own health. They are also, increasingly, expected to perform a watchdog function, providing constructive feedback to the health system so that it can respond to recognized community needs. However, this has proved difficult to achieve for a variety of social and political reasons that do not facilitate this function.
Communities therefore tend to accept without question the health services provided by government. Feedback may be restricted to practical issues such as lack of medicines, long waiting times and poor diagnostic equipment, leaving unaddressed more strategic issues concerning a real community role in prioritizing and resolving health problems. Communities are best empowered when there is scope for them to question and propose solutions to the modus operandi in general, and on managing and organizing their health services in particular. Experience in some African countries is discouraging, especially where political strife leads to violence and loss of life at community level.
Civil society Involvement
Communities generally comprise both able-bodied and disabled individuals, and people in varying states of vulnerability. However, all have both rights and responsibilities as community members. Minimizing the suffering or deprivation of vulnerable populations or those afflicted with severe health problems can be addressed through analysing the capacities on a variety of levels of individuals, families and communities. This process can assist in targeting resources to the most vulnerable.
However, there is as yet inadequate documentation in countries of the WHO African Region in the area of community capacity analysis or the role it could play in guiding decisions on resource allocation. Hence, large disparities in health status continue within and among communities.
Accountability and "watchdog" functions
Future priorities and way forward
It is critical that communities should be facilitated in articulating the kind of knowledge and skills needed to enhance their participation in strengthening health systems. Ensuring this facilitation is a responsibility of government. More frequent and extensive dialogue on the institutionalization of community capacity analysis would help in identifying and mobilizing all endogenous potential, before seeking additional support from beyond community level. Furthermore, this capacity analysis would empower communities to carry out the "watchdog" function referred to above.
What works and why?
Communities perform well when there is an enabling environment such as good governance, unrestricted enjoyment of human rights, improved economic status, availability of essential technology and infrastructure and when their concerns are addressed holistically. Malnourished communities participate in immunization services and the promotion of healthy lifestyles with difficulty. Prevention of unnecessary tensions among tribes through effective political systems and fair economic policies ensures sustained and improved community involvement.