The Status of Clinic Committees in Primary Level - Health Systems ...

with economic recession thereby placing an even greater strain on already overstretched resources particularly
in a developing country context. In their study of District Health Boards (DHBs) Macwan’gi and Ngwengwe
(2004) also point out that the capacity of such entities to perform their functions was constrained by inadequate
resources. The WHO study (1991) reports that community participation flourishes in socio-economic conditions
which are conducive to development. These include adequate staff, logistics and other resources which may be
difficult to secure in a resource poor country. The impact of poor socio-economic conditions on the functioning
of governance structures has also been noted by Boulle in her study of community health committees in the
Nelson Mandela Bay Municipality where she found that there were insufficient resources allocated to provide
the necessary support to community health centres leaving community participation a “neglected component
of the health system” (Boulle, 2007: 62).
Traditionally, the voluntary nature of serving on governance structures can affect the long term sustainability
of these structures. This can have negative effects particularly in contexts of high poverty and unemployment,
where serving on governance structures can be seen as a means of generating income. In South Africa, for
example, Health Systems Trust (HST) found that clinic committee members felt aggrieved that members of
hospital boards received stipends, while they did not. Clinic committee members expressed interest in finding
routes to being appointed on hospital boards as this was seen as a more lucrative and prestigious appointment
than serving on a clinic committee (HST, 2007). In a similar vein, but in a different economic context, the South
Australian Health Department has acknowledged that community participation through governance structures
is essential in improving and providing health services. However, they also caution that the voluntary nature
of the local health boards is not sustainable due to the added pressures with which these local health boards
have to deal. According to an Australian study “there are ever increasing pressures and demands that mean
that existing volunteer structures are stretched, in some cases, beyond their capacity” (County Health – South
Australia, 2006:1).
2.7.3 The capacity of communities to participate in health services and adequate
training for community members to enable participation
Community members may be reluctant to participate in health services due to a perceived lack of skills,
knowledge and confidence to engage with health facility staff.
Local people have few opportunities to develop their formal skills in relation to participating in health development
(Baum and Kahssay, 1999). Communities often lack the language, information, cohesion, organisational structures
and capacities for effectively engaging in these structures and can become disempowered and distrustful in the
process (Loewenson, 2000b). Communities may also lack the necessary structures, be unfamiliar with medical
terms and be apprehensive about engaging in debate and dialogue with health professionals. Programmes
therefore, must be explicit about the mechanisms and methods that will be used to overcome these obstacles
and should include community education and capacity building as a key component of budgeting and planning
for health services (Grubb et al. 2003). Ngulube et al. (2004) found that some of the weaknesses in the
performance of health centre committees (HCC) included the fact that members had an inherent fear of talking
to educated people, were unclear about their roles and lacked the resources to fulfill their responsibilities. This is
borne out by work carried out by the HST in South Africa which showed that confusion and uncertainty around
roles and responsibilities are potentially the most enduring problems facing governance structures. Research
showed that that power and authority which is perceived to rest with the health facility staff plays a strong role
in constraining the effectiveness and agency of governance structures. As a result, inappropriate power struggles
and escalating tension between the two groups have evolved (HST, 2007).
A failure on the part of the relevant health authority to train and build the capacity of community members can
also lead to less than optimal community participation. There is often a need for long term support and capacity
building of community members elected onto governance structures. In Kenya, for example, researchers
reported that it took up to two years for a basic understanding of the district health system and appropriate
support systems to be established (NPPHCN, 1996). In the Free State in South Africa, Baez and Barron (2006)
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