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 on Community ownership and participation is structured as follows:
The National Health Policy Framework 2010-2020 states that “All Namibians will be encouraged and empowered to actively participate in activities which promote good health and prevent ill health at individual, family and community level, hence complementing the health and social welfare services. The public system will provide an enabling environment for this to happen through supporting community health.”
Literacy rates in Namibia overall appear to be high (MoHSS and Macro, August 2008). However, regional and district disparities exist and health literacy levels among the population appear to remain low as a whole, as evidenced by inadequate maternal and child nutrition and increasingly high non-communicable disease figures, among others. Although the causes of these problems are partly socio-economic, health education plays a key role.
General health promotion is inadequate with no national strategy, poor coordination and capacity gaps all levels. (MoHSS, 2008) Health promotion is a priority for the MoHSS, and behaviour change communication has become mainstream on the back of HIV and AIDS strategies.
HIV awareness raising and behaviour change communication has enjoyed much better success with several effective mass media campaigns, as well as a number of community-based interpersonal communication and peer education programmes (IPC). The combined result of these programmes is high awareness and knowledge about HIV in the population in general and among young people in particular, as well as improved indicators for safer sex.
In addition, knowledge of TB is almost universal, and stigma and discrimination about TB is relatively low. Opportunities for improvement in health promotion exist with people gaining increasing access to information that will enable them to manage their health through mobile telecommunications and internet usage. Efforts are being made to improve health promotion, such as the current revamping of the malaria ‘Wipe-Out’ campaign.
With regard to patient health care behaviours, Namibia’s has achieved high levels of immunisation. Coverage stands at 83% among eligible children for Penta-Valent-3 and 77% for measles. Disease surveillance and response and timeliness and completeness of immunization data need improvement to reach the recommended 80% in each district. At present 24 (70%) of the 34 districts have reached the recommended 80% for routine immunization. Approximately 2 to 3 out of 10 children are unimmunized or underimmunized, especially in rural and very remote areas.
Antenatal care (ANC) attendance in Namibia is very high at 94.6 percent, although most women tend to delay first visit to ANC, which may lead to late detection of pregnancy complications. (MoHSS, 2008; MoHSS and Macro, August 2008) Nutrition is one area of patient health care that requires concerted attention. Latest figures indicate alarmingly inadequate maternal and child nutrition with low levels of breastfeeding, despite most of the hospitals with delivery facilities declared as baby friendly (MoHSS, 2008).
Diarrhoea accounts for 29% of infant mortality, and is caused partly by inadequate sanitation and hygiene, including hand washing, poor food hygiene and unsafe water. Furthermore, the Malaria Indicator Survey 2009, revealed inconsistent use of mosquito nets and/or using the nets for fishing.
Namibia has also begun to record increasingly high non-communicable disease figures which reflect unhealthy lifestyles, including poor nutrition, lack of exercise, and high levels of alcohol abuse. Men’s involvement in the family health care has also rated poorly in rural areas. (MoHSS and Macro, August 2008)
All of this points to infrastructural problems as well as the need for health promotion and education for the uptake of healthy behaviours. Socio-economic and structural challenges that impinge on health access are contributory factors for lack of take-up of healthy behaviours. This is evident in the case of HIV. Although HIV prevalence has begun to stabilise, it remains high (13.1% in 2009).
Women and girls appear particularly vulnerable to HIV due to deep rooted gender inequality and widespread gender-based violence. (MoHSS and UNAIDS, June 2011) The CBHC Programme objectives include several that are explicitly people-centred (Directorate of Primary Health Care Services, MoHSS, February 2010).
However, further attention must be given at facility level in the public health sector. Despite favourable consumer perceptions about the quality of services, complaints of nurses being rude and not paying attention to clients have been reported. There are also language barriers (and lack of communication for the blind and the deaf) and lack of physical structures to facilitate access by people with physical disabilities. (MoHSS, 2008) Studies point to the existence of stigma and discrimination against PLHIV in Namibia’s clinics and hospitals by health workers. (Lush, Samaria, & Petrus, 2003; Lush & Ashby, 2005; Buskens, 2008)
Access to health care remains an impediment to health care seeking behaviours. This is largely due to perceived lack of health providers, costs of treatment, and transport issues, especially for rural women. (MoHSS and Macro, August 2008)
According to the 2006/07 Namibia Demographic Health Survey (NDHS), one in five households is within 15 minutes of a government health facility and three in five are within one hour of a health facility. However, significant differences in access exist between urban and rural households.
The latter are 114 minutes away from the nearest government health facility, whilst the former is 25 minutes away. Clinics and health centres are closed during weekends and holidays. (MoHSS, 2008) User fees are relatively low (from N$4 at clinic level to N$30 at national referral level for state outpatient patients) and are intended to prompt patients to enter the health services at lower level facilities as well as increase patient ownership.
Foreigners are classified as private patients, which is problematic for people visiting from neighbouring countries who often do not have the means of payment for private services. Exemption is provided for certain services such as notifiable diseases, preventive and promotive services and for vulnerable groups such as under-fives and pregnant women. It is also government policy not to turn away patients that are unable to pay, though waiver mechanisms are cumbersome and may deter patients.
The 2010 Guidelines for Implementing the National Policy on CBHC describe the roles and responsibilities of Community Health care Providers (CHCPs), Village Health Committees (VHCs), Community/Clinic Health Committees (CHCs) and traditional leaders in detail. These include the identification and coordination of the health needs in their communities, but no explicit watchdog role is articulated. Reference is made to community meetings to address community health concerns, and these are to be facilitated in a participatory manner by outreach points, clinics and health centres.
It is also the responsibility of the Regional Council to “promote the use of effective feedback mechanisms between communities and coordination committees at sub-national levels”. The implementation indicators for CBHC services include “Level of client satisfaction with service provision”. The HIVQUAL Project is implemented at some clinics in Namibia to promote dialogue on services for PLHIV.
The new PHC guideline (currently under revision) emphasises community involvement and communities play an important role in the implementation of health services. Examples of this are the contribution of volunteers during National Immunisation Days (NIDs) and community mobilisation by community leaders such as headmen, councillors and church leaders during national health events, emergencies and disease outbreaks.
Some trained Traditional Birth Attendants (TBAs) are supporting the reproductive health services at their level by ensuring clean delivery and advising women on the importance of immunisation, antenatal and post natal care, family planning and HIV testing.
As part of implementation of the PHC over the past 20 years, communities working with various organisations have been actively involved in the delivery of primary health care services at the community level. Greater commitment has been shown at all levels with the establishment of community action groups and improved collaboration between government agencies and civil society organizations.
Under the leadership of the MoHSS, UN and USG organisations, civil society organisations (CSOs) are being increasingly involved in dialogue and participation for policy and decision making at various levels. The 2010 Guidelines for Implementing the National Policy on CBHC require CSOs to observe principles that include monitoring and evaluation. CSOs working in the field of HIV and AIDS regularly participate in Technical Advisory Committees (TACs) that make recommendations to the National AIDS Executive Committee (NAEC) on programming issues. (HIV Prevention Technical Advisory Committee, July 2011)