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:
In the Gambia, one of the guiding principles of the health policy is "changing for good" community participation and empowerment. The Bamako Initiative was implemented in some health facilities where the community were given the opportunity to manage their facilities. No legal framework exists in this regard but in Bamako Initiative facilities, communities have a major say in the running of health facilities in matters relating to financial accountability, purchasing of medication and the state of the facility.
Although there is no documented study on patient satisfaction, complaints received generally concern intermittent shortages of medications and staff attitude, especially during labour and delivery. In contrast, in non-Bamako Initiative facilities communities have little say in the running of their facilities and sometimes do not have a way of expressing their needs.
Traditional communicators are engaged in dissemination of health messages through drama, singing and demonstrations and in this way contribute health information in the local languages. Open field days have also been used as a health education strategy at the community level. However, there is a gap between knowledge and practice, which has prompted the Ministry of Health and Social Welfare to shift its health education/promotion approach towards behaviour change communication strategies to create awareness.
Health facilities are spread all over the country and most communities having a facility within 5 km distance. Each health facility has a number of outreach stations that are visited monthly to deliver antenatal care as well as infant welfare services. The outreach posts are usually temporary sites that are often poorly equipped with an inadequate number of examination beds and benches. Some labour wards do not provide adequate privacy, which is a cause for concern by the directorates of health services who are seeking to rectify such design gaps.
All health facilities are run on a 24-hour basis such that communities have access to care at all times. Long queues in some facilities, especially during the morning hours, prompt patients to delay seeking health services. Pregnant women, children aged under 5 years and those with chronic communicable diseases are exempted from service delivery fees.
Civil society organizations and structures work with communities at the grass-roots level but are usually not involved in policy-making as partners. However, given the experiences of these organizations, it will be an advantage to involve them in policy formulation.