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EMPIRICAL STUDY
published: 30 April 2019
doi: 10.3389/fsoc.2019.00035
Frontiers in Sociology | www.frontiersin.org 1April 2019 | Volume 4 | Article 35
Edited by:
Jenny Douglas,
The Open University, United Kingdom
Reviewed by:
Guido Giarelli,
Università degli Studi Magna Græcia
di Catanzaro, Italy
Rachel Matthews,
National Institute for Health Research
(NIHR), United Kingdom
*Correspondence:
Gimenne Zwama
gimenne@gmail.com
Specialty section:
This article was submitted to
Medical Sociology,
a section of the journal
Frontiers in Sociology
Received: 15 October 2018
Accepted: 04 April 2019
Published: 30 April 2019
Citation:
Zwama G, Stuttaford MC,
Haricharan HJ and London L (2019)
Rights-Based Training Enhancing
Engagement of Health Providers With
Communities, Cape Metropole, South
Africa. Front. Sociol. 4:35.
doi: 10.3389/fsoc.2019.00035
Rights-Based Training Enhancing
Engagement of Health Providers With
Communities, Cape Metropole,
South Africa
Gimenne Zwama 1,2
*, Maria Clasina Stuttaford 1,3 , Hanne Jensen Haricharan1and
Leslie London 1
1Health and Human Rights Programme, School of Public Health and Family Medicine, University of Cape Town, Cape Town,
South Africa, 2Institute for Global Health and Development, School of Health Sciences, Queen Margaret University,
Edinburgh, United Kingdom, 3Health, Social Care and Education, Kingston and St George’s University of London, London,
United Kingdom
Community participation, the central principle of the primary health care approach,
is widely accepted in the governance of health systems. Health Committees (HCs)
are community-based structures that can enable communities to participate in the
governance of primary health care. Previous research done in the Cape Town Metropole,
South Africa, reports that HCs’ potential can, however, be limited by a lack of local
health providers’ (HPs) understanding of HC roles and functions as well as lack of
engagement with HCs. This study was the first to evaluate HPs’ responsiveness towards
HCs following participation in an interactive rights-based training. Thirty-four HPs, from
all Cape Metropole health sub-districts, participated in this qualitative training evaluation.
Two training groups were observed and participants completed pre- and post-training
questionnaires. Semi-structured interviews were held with 10 participants 3–4 months
after training. Following training, HPs understood HCs to play an important role in the
communication between the local community and HPs. HPs also perceived HCs as
able to assist with and improve the quality and accessibility of PHC, as well as the
answerability of services to local community needs. HPs expressed intentions to actively
engage with the facility’s HC and stressed the importance of setting clear roles and
responsibilities for all HC members. This training evaluation reveals HPs’ willingness to
engage with HCs and their desire for skills to achieve this. Moreover, it confirms that
HPs are crucial players for the effective functioning of HCs. This evaluation indicates
that HPs’ increased responsiveness to HCs following training can contribute to tackling
the disconnect between service delivery and community needs. Therefore, the training
of HPs on HCs potentially promotes the development of needs-responsive PHC and a
people-centred health system. The training requires ongoing evaluation as it is extended
to other contexts.
Keywords: training, health providers, community participation, health committees, governance, PHC, rights,
South Africa
Zwama et al. Rights-Based Training of Health Providers
INTRODUCTION
With global attention for people-centred health
systems gathering momentum and the World Health
Organisation’s (WHO) publication of its global strategy on
people-centred services in 2015, it is widely emphasised that
not only service users, but also communities, should play an
active and informed role in the maintenance, restoration, and
promotion of their own health (Hunt and Backman, 2007; WHO,
2015). The Alma-Ata Declaration stresses that people have the
right and duty to participate in the planning, organisation,
operation and control of primary health care (PHC), and builds
on the right to health, adopting the WHO’s definition of health
as “the state of complete, physical, mental, and social well-being,
and not merely the absence of disease or infirmity” (WHO,
1946, 1978). Community participation in the governance of
service delivery can promote people-centeredness and needs-
responsiveness of a health system (WHO, 1978, 2015). These are
characteristics of a health system in which everyone contributes
and benefits and where health care services respond to people’s
needs and expectations in a holistic manner, rather than focusing
solely on disease and the diseased (WHO, 2007, 2015).
For people’s participation to be effective and meaningful,
communities’ active and informed involvement is required
in the evaluation of strategies, decision-making, prioritisation,
and implementation of the right to health (Potts, 2008). In
a systematic review of evidence on Health Committee (HC)
effectiveness in low- and middle-income countries (LMICs),
HCs have commonly been found to provide a bottom-up
platform for community representatives to participate in health
care decision-making, monitoring and oversight (McCoy et al.,
2012). In Kenya, HCs are official structures with defined roles
to close gaps in service delivery and to hold health facilities
accountable for the quality and accessibility of the services
offered (Goodman et al., 2011). By these means, HCs can
facilitate the community’s collective ownership of PHC services
(Haricharan, 2012) as well as promote the realisation of the
right to health (Glattstein-young, 2010; Chikonde, 2017). As HCs
serve as community-based governance structures in the delivery
of primary health services, they are inherently interdependent
on the dynamics of the health system’s social, economic, and
political contexts (United Nations Committee on Economic
Social Cultural Rights UNCESCR, 2000; Gilson and WHO,
2012). This requires us to investigate such contextual factors and
cross-cutting issues that can challenge HC functioning. In their
reviews, George et al. (2015a) and McCoy et al. (2012) stress the
importance of contextual influences in understanding HCs’ role
and contribution to health systems strengthening.
A cross-case comparative study of 11 HCs in West and Central
Africa found that HCs’ individualised and non-systematic
character can leave marginalised groups excluded (Lodenstein
et al., 2017b). Even when HC powers and roles in accountability
are partially defined on a national level, full specifications of
Abbreviations: HC, Health Committee; HP, Health Care Provider; LMICs, Low-
and Middle-Income Countries; PHC, Primary Health Care; NHA, National Health
Act; WHO, World Health Organisation.
these powers and tools to execute them are needed (Lodenstein
et al., 2017b). The South African National Health Act (NHA)
states that a HC must be composed of community members, a
local government councillor and a health facility manager (The
Republic of South Africa, 2004). The Department of Health,
however, delegates the definition of HC role and mandate to
provincial policy legislation and action. All provinces currently
have legislation, draft legislation, or guidelines, which differ
substantially in the nature and extent to which HC roles and
responsibilities are described (Haricharan, 2013). Accordingly, it
was found that Provincial Departments of Health can fall short in
their guidance, direction and training of HCs, thereby negatively
impacting HCs’ effective functioning (Padarath and Friedman,
2008; Meier et al., 2012). This lack of specification on health
committees’ roles and functions, as well as HCs’ lack of power and
legal mandate, can limit their uniform functioning and effective
integration within the health system (Padarath and Friedman,
2008; Haricharan, 2012; Boulle, 2013).
In addition, there appears to be a general lack of clarity
and guidelines on HC member election procedures and the
make-up of the electorate. In South Africa, the Eastern Cape
is the only Province that fully specifies the election of HC
members through a representative democratic process in their
final draft policy on HCs (Eastern Cape Department of Health,
2009). However, this policy defines HC community members as
representatives from organised community initiatives, thereby
possibly compromising the HC member’s representativeness of
community members. A HC training manual developed for the
South African context, encourages and defines the procedure
of HC member election by the rules of the Constitution
(The Learning Network for Health and Human Rights, 2014).
In comparison to other South African Provinces, the Western
Cape had lagged behind in passing HC legislation (Haricharan,
2013). Policy developments lost momentum after the Head of
Health for the City of Cape Town, a HC champion, passed
away in 2008. The loss of this champion was a critical milestone
alongside the broader complexities of the South African health
(committee) policy context over time. The long-awaited draft
Bill on Health Facility Boards and Committees was published
in 2015 (Province of Western Cape, 2016). This Bill became
an Act in 2016 and is yet to be implemented. Even though the
Act recognises HCs as a community platform, it significantly
reduces the scope of their role in decision-making, strategizing,
prioritising, and implementing health services according to local
needs. Secondly, it allows for the provincial Minister of Health
to elect committee members, which can pose a threat to the
democratic value of HCs.
The national South African Department of Health committed
to the “re-engineering” of PHC in 2010 with the purpose
to improve service quality and integration (Barron et al.,
2010). This “re-engineering” was to be established by holding
the management of the district health system responsible for
meeting “key ministerial priorities,” implying a top-down, non-
democratic process. In June 2018, the cabinet approved the
National Health Insurance Bill with the goal to provide all South
Africans “access to quality and affordable health care services
based on their health needs irrespective of their socio-economic
Frontiers in Sociology | www.frontiersin.org 2April 2019 | Volume 4 | Article 35
Zwama et al. Rights-Based Training of Health Providers
status” (The Republic of South Africa, 2018). Strikingly,
considering its purpose, the National Health Insurance Bill
does not acknowledge the potential of HCs as a platform for
community participation, nor community participation as a
continuous mechanism to identify these health needs.
Discrepancies between policy and practice can compromise
HCs main role as an intermediary between the community
and health services (McCoy et al., 2012; George et al., 2015a).
As evaluations across East and Southern Africa and from
Brazil suggest, such discrepancies can influence nurses and
facility managers’ capacity to work with HCs and require their
education on HCs’ roles and functions (Zambon and Ogata,
2011; Loewenson et al., 2014; George et al., 2015a). George
et al. (2015b) reported that poor interpersonal skills, lack of
training, perceived lack of skill and lack of trust of providers were
challenges for community participatory platforms to improve the
quality of services.
For HCs to effectively integrate into and contribute to
a people-centred health system, HPs play an important role
in creating a responsive environment in which communities
meaningfully participate. McCoy et al. (2012) and George et al.
(2016) illustrate that there has been a predominant focus on
the capacity building of communities. While there are a few
studies highlighting both sides of the coin (Mosquera et al., 2001;
Sohani, 2005), there is an evident gap in research on the impact
of HP training on HCs’ effective and meaningful participation.
Research in South Africa has shown that while some facility
managers are aware of HC roles and functions and attend
their meetings, others are completely unaware (Padarath and
Friedman, 2008; Haricharan, 2012; Boulle, 2013). As a result, HPs
can be reluctant to involve communities and find it challenging
to be held accountable by the community, or perceive HCs solely
as an extension of service delivery (Padarath and Friedman, 2008;
Glattstein-young, 2010; Haricharan, 2012; Boulle, 2013).
The Learning Network for Health and Human Rights, a
collaboration of civil society organisations and two universities
in the Western Cape, aims to promote the right to health
through community participation. In the Cape Metropole, HC-
HP engagement was found to be challenged by untrained
community members, power imbalances, lack of mutual trust as
well as HPs’ lack of understanding of the relationship between
the right to health and participation (Haricharan, 2012). As part
of their activities to fulfil this purpose, the Learning Network
trained nearly 300 HC community members across the Cape
Metropole (Haricharan, 2017). An evaluation of this HC training
indicated that although HC training can improve levels of
participation, this is influenced by HP authority as well as power
imbalances between HC members (Chikonde, 2017). As HPs had
not been trained, a HP training manual was informed by HC
members, developed and piloted with the aim to (re-)establish
and strengthen HPs’ working relationships with HCs.
Building on everyone’s right to health and participation, this
study evaluated a rights-based, interactive training of HPs on
HCs. This paper reports the extent and nature to which HPs’
immediate and short-term responsiveness changed as a result
of the training. It sheds light on contextual factors that can be
of influence on HPs’ ability to implement their responsiveness.
Findings are discussed and their potential contribution to the
promotion of community participation in the strengthening of
people-centred health systems is described.
METHODS
Socio-Economic Profile
In 2018, the Cape Metropole population was estimated to reach
4.06 million (Western Cape Government, 2018). The Cape
Metropole is the least unequal Metropoles of South Africa with
a Gini coefficient of 0.58. For the next 5 years, the City of Cape
Town estimates that the aged population over 65 will increase at
3.4 percentage per year. This, while the child cohort (age 0–14
years) will grow by 1.2% and the working age population by
0.8% per year. With an additional unemployment rate of 11.9
percentage, this can be expected to pose a greater burden on
social systems and basic service delivery. In line with the disease
burden, PHC facilities currently offer testing and treatment of
HIV, STIs, tuberculosis, diabetes, and hypertension as well as
immunisation and child health services. To varying extents,
facilities also offer maternal and mental health services.
Training Purpose and Approach
The training manual, compiled for the purposes of the rights-
based training evaluated in this research, titled “Community
Engagement for Quality Care” consists of two main chapters
called “Relationship Building” and “Health Committees and
Governance” (Marshall and Mayers, 2015). In line with the
NHA (The Republic of South Africa, 2004), this training
aimed to promote health services that are responsive to
community participation. It facilitated reflection on the dual
obligation and responsibilities of health care providers towards
the State by referring to the national vision to achieve a
society committed to democratic values, social justice, and
fundamental human rights as well as the rights of the patient
as set out in the Batho Pele or “People First” service principles
(The Republic of South Africa, 1996, 1997).
The training adopted an experiential learning approach (Kolb,
1984), whereby the facilitators guided participants through a
reflective learning process that shed light on previous and
current practices of engaging with, and involving the community.
The importance of mutual understanding, collaboration, and
respect was illustrated through rights-based case discussions,
role plays and reflections on the values of compassion, and
professionalism. In these ways, tailored directions could be
given and environments promotive of the right to health and
participation could be illustrated.
Training Implementation and
Participant Recruitment
Thirty-four health care providers from all City of Cape Town
health sub-districts (n=8) were recruited for the training,
contributing to the diversity of the study sample (see Table 1).
These included (senior) professional nurses and clinic managers
working in City of Cape Town clinics, as well as environmental
health practitioners, health promotion officers, and programme
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Zwama et al. Rights-Based Training of Health Providers
TABLE 1 | Number of participants and sub-districts.
Training
observations,
in % (n)
Pre-
questionnaire
responses,
in % (n)
Post-
questionnaire
responses,
in % (n)
Interviews,
in % (n)
Sub-
districts
Training
group 1
58.8 (20) 85.0 (17) 85.0 (17) 25.0 (5) A, B, C, D
Training
group 2
41.2 (14) 100 (14) 85.7(12) 35.7 (5) D, E, F,
G, H
Total 100 (34) 91.2 (31) 85.3 (29) 29.4 (10) 100 (8)
TABLE 2 | Number of participants by professional position and sub-district of
origin.
Position Questionnaire
responses, in % (n)
sub-district
Interviews, in % (n)
sub-district
Clinic level Clinic manager 48.4 (15)
A, C, D, E, F, G
40.0 (4)
A, C, F, G
Senior
professional
nurse
16.1 (5)
A, C, E, F
20.0 (2)
C, E
Professional
nurse
12.9 (4)*
A, D, E
10.0 (1)
D
Sub-district
level
Environmental
health
practitioner
9.7 (3)
A, H
10.0 (1)
H
Health
Promotion
Officer
6.5 (2)
B, D
20.0 (2)
B, D
Programme
officer
6.5 (2)
B, D
–
*Two missing post-questionnaires, both professional nurses from district E.
officers working at sub-district level (see Table 2). Six sub-
districts had at least four participants attending the training, of
which two sub-districts had eight representatives each. However,
one of the remaining sub-districts was represented by two
participants both positioned at sub-district level and the other
by two environmental health practitioners. Each of the two
training groups had one male attendee, both environmental
health practitioners.
Initially, the training was intended to consist of 2 consecutive
days. However, several sub-district managers expressed their
concern about the burden it could place on the facilities when
some of their employees are away from the services for this
amount of time. As a result, it was decided to decrease the
training to 1 day followed up by another half a day at least a
month later. Training sessions were implemented in May and
July 2015 for the first (n=20) and second group (n=14) of
participants, respectively. These 1-day training sessions explored
the influences on and key elements for relationship building with
communities as well as HC composition, roles, and functions.
Preliminary analysis of questionnaires and observations was used
to feed into the agenda of the follow-up session. Accordingly,
this session intended to further develop HP skills for relationship
building with HCs, in particular on how to establish a
common vision, host a HC meeting, and manage conflict. In
addition, it would provide an opportunity to further explore
and discuss power imbalances and other practical issues raised
by participants.
Follow-up sessions were scheduled for ∼6 weeks after the
first training sessions. Only two out of 10 enrolled participants
attended the follow up training session, both holding a position
at sub-district level. The first groups’ participants cancelled or did
not attend the follow up for various reasons such as conflicting
meetings or courses, deadlines for end of financial year reports,
and staff shortages due to seasonal illness. A rescheduled,
combined follow up session was cancelled due to a low confirmed
number of attending participants. The majority of participants
expressed interest and enthusiasm for the follow-up session and
indicated to be disappointed that it did not take place.
With South Africa recognising 11 official languages,
participants’ native languages differed. Most study participants’
first language was isiXhosa (n=12), followed by Afrikaans
(n=9), English (n=7), and Sesotho (n=2). The central
sessions of the training were conducted in English, as this was the
commonly spoken language amongst the participants. The first
training group’s session was facilitated by two expert educators
from the University of Cape Town (UCT), one experienced in
training, and consulting HCs (also proficient in isiXhosa), the
other with experience as an academic teacher and professional
nurse (also proficient in Afrikaans). Due to unavailability of the
former, the latter facilitator acted as the sole facilitator for the
training of the second group.
Study Design and Data Collection
The design was based on a realist evaluation (Pawson and
Tilley, 1997). The evaluation purpose was to explore the possible
variations in nature and extent of the immediate and short-
term impact of training of HPs on their responsiveness to
HCs. In this paper, responsiveness is defined as the collection
of understandings, intentions to practices, and practices in
support of HC roles and functions. Thereby, we acknowledge
that responsiveness is inherently influenced by experiences and
contextual factors. The exploration of such factors was facilitated
by the training participants’ diversity in health care professions,
experiences, local contexts, and relationships with HCs. The
adoption of a realist approach provided a deeper insight into
the facilitating and impeding contextual factors, as well as
the dynamic interactions between societal and health systems
processes that influence HPs’ relationships with HCs and their
ability to implement an enhanced responsiveness (Pawson and
Tilley, 1997). All data was collected between May and November
2015, and the study adopted a flexible research design making
use of pre- and post-training questionnaires, direct observations,
semi-structured interviews, and field note journaling.
Field notes were diarised from the moment preparations
for training implementation started. Pre- and post-training
qualitative questionnaires and a topic guide for semi-structured
interviews were developed in consultation and concordance with
the facilitators’ vision for the training. Due to insufficient time
before training implementation, questionnaires were not piloted
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Zwama et al. Rights-Based Training of Health Providers
or cognitively tested. Before distribution, they were evaluated
by the second and third author of this paper as well as by
the training facilitators. Two attribute-inquiring questions were
improved regarding phrasing or ambiguity before distribution to
the second group. Before its use, the interview topic guide was
adjusted and probes related to questions arisen from analysis of
questionnaire responses were added.
Written notes of the training observations were taken.
These observations also provided 17.5 h of audio recordings,
of which parts were transcribed where relevant to the research
questions and where written notes lacked context or clarity. The
observations gave insight into the development of changes in
HPs’ responsiveness and contributed to the triangulation of data.
A total of thirty-one pre-training questionnaires consisting
of twenty-one, mostly open-ended, questions were completed
by fifteen clinic managers, five senior professional nurses, four
professional nurses, three environmental health practitioners,
two health promotion officers and two programme officers
(Table 2). Four multiple choice questions inquired about the
current HC status and relationship at the facility or sub-
district level. Furthermore, participants were asked about their
understandings of HC roles and benefits, their challenges in
engaging and working with HCs as well as the ways in which the
health facility can promote HC functioning.
The post-training questionnaires included sixteen questions,
of which four open-ended questions to specifically evaluate
the training format and content, one multiple-choice question
and eleven open-ended questions of which six were similar to
the pre-questionnaires. This questionnaire additionally inquired
about HPs’ views of the role of the training in changing
their understandings and practices towards HCs. Post-training
questionnaires were completed by 29 participants.
Pre-training and post-training questionnaires were perceived
as lengthy and, at times, contained short or missing responses.
The second group’s responses were overall richer in information,
as they were given more time to answer the pre-training
questionnaires, and completed the post-training questionnaires
in their own time. These participants submitted their responses
via email (n=12), resulting in missing data from two
professional nurses. This also resulted in completion up to 2
weeks after the training, which for a few participants measured
retained rather than immediate responsiveness.
Three to 4 months after the training, interviews were held
with 10 purposively selected participants (four clinic managers,
two senior professional nurses, one professional nurse, one
environmental health practitioner and two health promotion
officers). The criteria for selecting participants were based on
their differences in sub-district and HC functioning. Besides
contributing to the triangulation of earlier collected data,
interviews further explored the role of the training on short-
term HP responsiveness and their capacity to translate intentions
to practices.
Ethical Approval
The protocol was carried out in accordance with the
recommendations of the Faculty of Health Sciences Human
Research Ethics Committee of the University of Cape Town.
The Faculty of Health Sciences Human Research Ethics
Committee and the Health Department of the City of Cape
Town approved this study (FHS HREC REF 2015/062 and
ID no.: 10492, respectively). City of Cape Town sub-district
managers permitted the recruitment of training participants
for the evaluation. All subjects gave written informed consent
in accordance with the Declaration of Helsinki. All training
participants consented for the training to be observed (n=34).
Thirty-one participants agreed to complete the questionnaires
and to be contacted for an interview. All 10 interviewees verbally
consented to be contacted for follow up questions.
Data Analysis
{NVivo 10} was used as a tool to manage all data. Questionnaire
data was cleaned and anonymised in {Microsoft Excel} before
being imported in{NVivo}. This also marked the start of the
researcher’s immersion in the data. Interviews were transcribed
in {NVivo} and any text that could lead to the identification of
the interviewee was removed. The first author was responsible
for all data analysis and adopted a thematic approach as further
detailed below.
Structural coding started with the mind mapping of
questionnaire responses during preliminary analysis. These mind
maps guided the inductive coding of topics and categories into
an initial codebook. This codebook subsequently informed the
initial codebook for the observations. Having mind-mapped the
relationships between categories, and becoming familiar with the
breadth of the investigated matter, the researcher examined the
codes according to their ability to merge into categories and
sub-codes. The data type-specific codebooks were refined and
collapsed accordingly, which created small and simple codebooks
with clear distinctions between the codes. Data was re-coded
into meaningful units and the same was done for the remaining
data, which slightly expanded the codebook again, after which
the meaningful units were collapsed into themes. The first author
discussed the emerging themes the second and third author of
this paper. Similarly, as interviews were held 3–4 months after
training these were coded sometime after the complete coding
of the questionnaires and observations. This reflective pause
allowed for emotional and intellectual distance, after which the
sub-coded data were reorganised under more refined themes.
Ultimately, this resulted in a common codebook of three
categorising codes that guided the answering of research
questions, which were: understandings, practices, and intentions
to change practice. Six main defining codes provided specifics
to the categorising codes, which were; personal engagement
with HC, HC roles and responsibilities, challenges and issues,
stakeholders, role of training in changing responsiveness, and
strategies to promote HC functioning. Thirdly, thematic codes
and their descriptive sub-codes described the dimensions of the
main and categorising codes. Moreover, data were grouped for
analysis of pre- and post-training understandings, intentions and
practices as well as classified for participant attributes such as
reported HC functioning and professional position. A similar
codebook was used for every data type, with differences in
sub-codes, thematic codes and with, in some cases, additional
main codes. Generally, themes and sub-codes, as well as their
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Zwama et al. Rights-Based Training of Health Providers
descriptions, maintained close similarity to the way in which
participants phrased them.
Data triangulation and integrative analysis of themes arising
from the different types of data guided the interpretations of the
deeper meaning of codes, segments, and themes, respectively.
After the entire analysis, thematic decisions were reflected
upon as the first author’s personal views of the themes could
have changed. The diverse data revealing participants’ changing
reflections, understandings and intentions, as well as their ideas
on the role of training, were compared to the first author’s
observations and rich, reflexive field notes.
A programme theory was used to frame the interpretive
analysis of themes. This facilitated the assessment of the extent
and nature to which HPs’ post-training responsiveness outcomes,
as defined by Lodenstein et al. (2017a), can contribute to the three
interconnected principles of community participation, PHC and
people-centred health systems as described in the introduction.
FINDINGS
Current HC Presence and
Engagement Practices
Of the 24 participants at clinic level, 17 indicated that the health
facility is connected to a HC. All of these HCs consisted of
community members and a facility manager, of which eight
were said to be functioning well (by six clinic managers, one
senior professional nurse, and one professional nurse). In two of
these well-functioning HCs, environmental health practitioners
were also included as members. A local government councillor
was part of five HCs of which four were reported to be well-
functioning. A little more than half of participants indicated
that the facility regularly engages with the HC. Four clinic
managers and two environmental health practitioners reported
to never engage with the HC. All clinic managers had attended
a HC meeting at least once before. Seven clinic managers,
one senior professional nurse, two health promotion officers (a
third of total participants) attend HC meetings each month.
Ten participants (including all four professional nurses and two
senior professional nurses) had never attended a HC meeting.
HC Stakeholders
Following training, respondents’ understandings of HC
composition as defined by the NHA considerably increased (n
=29). Almost all respondents included community members
(27 vs. 15, post-training and pre-training, respectively), local
government councillors (27 vs. 10) and facility managers (25
vs. 7) in their description of composition. According to almost
half of respondents, the HC composition, as stated by the
NHA, should be complemented to include clinic workers other
than the clinic manager. Some participants added that this
would enhance communication and progress, this response
was not related to the participant being positioned at the
clinic. Environmental health practitioners were also viewed as
important members by a third of respondents for their ability
to address environmental problems that influence community
health, such as illegal dumping.
When participants were explaining personal views on HC
composition, a clinic manager expressed her concern:
“My biggest challenge in the foreseeable future is to get a ward [local
government] councillor, a proper ward councillor. Because this guy
that’s been the ward councillor for many years now for this area is
very dedicated, is very well informed, has been a lawyer himself for
many years so he’s got a lot of background. And I think that’s going
to be very big shoes to fill.”
Participants recurrently recommended that the HC engages with
community stakeholders. For instance, schools, security guards,
and social workers were seen to play a role in addressing major
social problems, drug abuse and violence in the community.
Additionally, non-profit and non-governmental organisations
as well as churches in the area were perceived to promote
awareness of the HC and avoid unnecessary duplication of
health services. For the latter reason, a clinic manager without
a HC expressed the intention to advise the sub-district’s health
promotion officer and programme coordinator, as well as non-
governmental organisations to link with the HC.
HC Roles and Responsibilities
To a greater extent than before the training, all participants made
specific reference to the importance of HCs as liaison bodies
between the wider community and the facility. It was underlined
by nurses, clinic managers and a health promotion officer that
HCs should inform the community of the challenges experienced
by the facility and about the services that are offered to avoid
unnecessary referral. In turn, the community was understood to
benefit from the HC as a platform for advocacy. According to
one of the clinic managers, the HC empowers the community
to address and clarify their fears. It was also stated that HCs
provide a true background of what needs to be done, and insight
into how a community feels and thinks: “They are able to reach
where we can’t”. Several participants explained that HCs could
identify the source of outbreaks (e.g., diarrhoea), mobilise the
community to assist with campaigns, educate the community to
prevent further spread and assist the health facility where needed.
A clinic manager mentioned that the HC can facilitate a fast
response of the services. Another clinic manager stated:
“They are the people that are your ears and your eyes, but we tend to
forget about them. [. . . ] They can make the decision or help us make
the correct decision pertaining the community in which we serve.”
Twenty-nine participants pointed out the health promotional
and educational benefit that HCs could provide for the health
facility. It was recurrently stated that HCs could assist with
outreaches, inform the content of health talks at the clinic and
help facilitate these. HC members could do home visits for the
purposes of explaining home remedies, or for recalling patients.
HC participation in promotional activities was repeatedly
perceived to benefit clinic targets. One of the health promotion
officers said: “there are programmes that are not functional in the
facility without the presence of the health committees, for instance
the Health and Safety Committee”.
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Zwama et al. Rights-Based Training of Health Providers
Most participants understood that HCs can build and promote
trust, facilitated by their interaction with both communities
and facilities, their insight into the challenges at both levels
as well as their ability to explain problems to the community
and their closer relationship to them. Other reasons for HCs’
role in trust building were transparency on what is being done
at the facility and a sense of belonging for the community. A
senior professional nurse said: “This [HCs] is a great idea. The
government has been spoon feeding the community for a very long
time. It is now the time that the society takes the responsibility,
or ownership of their health and this change [implementing HCs]
would bring a tremendous improvement in our society because they
do not feel left out.”
HCs were also identified by half of participants as being able
to assist with a smoother operation of the health care facility in
easing tensions with the community, e.g., by helping with patient
flow. Additionally, a couple of participants said the HC can set
up a helpdesk at the facility, guide and fast track patients, as
well as help management with the planning of health service
transitioning, e.g., in the case where a clinic is transformed to a
Community Health Centre. Moreover, HCs were commonly seen
as beneficial to the facility as they can receive complaints, advise
the facility on how to deal with these and lobby or help motivate
for (the expansion of) resources. A clinic manager was convinced
that services will improve and be used more as people are taking
ownership of the health facility’s decision-making.
Overall, the HCs’ participation by means of these roles and
responsibilities was commonly linked to contribute to the quality
improvement, accessibility or responsiveness of service delivery
to local needs.
Perceived Role of Training
Most participants were surprised by the interactive nature of
the training and reported a change in their perceptions as the
training clarified HC roles and responsibilities. A clinic manager
said: “I feel the training was an eye-opener and empowering.” As a
result of the training, participants indicated they learned about
the HC members and stakeholders, as well as the importance
of all members’ active involvement to be able to effectively
implement their roles and responsibilities. Many participants
specifically referred to not having known the local government
councillor should be part of the HC as stated in the NHA. It also
provided participants with insight into a HC’s importance, other
facilities’ HP-HC working relationships, the need to appreciate
HCs, their ability to address community problems through one
platform and the accompanying opportunity for partnership in
working towards a common goal. A senior professional nurse
stated that “the puzzle cannot be completed” without HCs, as they
play a key role in communicating between different community
stakeholders. The majority of participants perceived HCs as
an essential component in every community and facility, and
confirmed a renewed insight into their importance, or perceived
them as more valuable, post-training. The training was also
said to facilitate a better understanding of what HCs should
do and how to support HC functioning. According to a senior
professional nurse, the training gave her a different perspective
of the responsibilities of HCs, now making it easier to set
boundaries. An environmental health practitioner no longer
viewed the HC as a threat to HPs, as the training clarified that the
facility managers’ roles are not taken away from them. A clinic
manager noted that the training teaches staff that HCs are not
there to fight with HPs. Almost half of clinic managers found that
their perceptions about HCs’ roles and functions had not changed
as a result of the training. Reasons being that HC already clearly
outlined their roles or that they have always seen HCs as vital or
valuable to the health facility’s functioning. One of them added,
“. . . it is just that some of the health committee members did not
have a clue of what their roles and responsibilities were when they
were still functioning.”
Translating Understandings and Intentions
to Practice
Clinic managers indicated that current barriers to their
engagement with HCs are related to their own availability as well
as their HC members’ level of commitment. HPs’ unavailability
was, particularly among clinic managers and nurses, commonly
explained by workload, having too many meetings already
and HC meetings being held after hours. HC members’ lack
of commitment was repeatedly attributed to HC members
having hidden agendas, being unavailable due to employment
and not keeping to meeting times. A lack of funding was
commonly identified as a challenge to retain HC volunteers,
and for both HPs as well as community members to attend HC
meetings. A clinic manager’s view was that health committees
should be funded regardless of whether they focus solely on
HIV and tuberculosis care. Based on her observations, this
explained different levels of HC functioning across sub-districts.
Alternatives to monetary compensation were also considered, as
a clinic manager illustrated:
“. . . what came out for me also is how to motivate your community
to take part. Not to just think of the money, but to think of
something that is a stepping stone for them to maybe get a job. It
is information that can go on their CVs at the end of the day. They
gain experience, they gain knowledge, they meet new people. [. . . ]
However, the negative of that is that people then sometimes expect
to be placed in a position. . . Because of the high unemployment
rate at the moment, people don’t want to work for free. So there,
we also need to then get people to become creative with how they
can raise funds.”
Other key challenges in working together with HCs were
indicated to be a misunderstanding of and lack of mutual
respect for one another’s roles and responsibilities, leading
to crossing boundaries and, consequently, mistrust. A clinic
manager illustrated:
“One of the negative things could be that HC members feel that they
can work with clients and they have the authority to go through, to
handle clients’ folders, because they are the health committee.” She
advised: “People [everyone at the clinic] should know their role and
function, they [HCs] should be aware of their role and function,
then we won’t step on the other’s toes.”
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Zwama et al. Rights-Based Training of Health Providers
Trust building was more generally perceived to be promoted by
training and clear guidelines on roles and functions, providing
the HC with an opportunity to present on their roles and
responsibilities, maintaining honesty as well as establishing a
common vision at the start. Furthermore, HPs identified HCs’
attitudes and judgment as challenging to their relationships.
As expressed by a clinic manager: “I think if both of us [HPs
and community members] have a positive attitude towards one
another, we can move mountains.” Moreover, power differences
were recurrently understood to be resolved by understanding and
setting clear cut roles and responsibilities, ensuring transparency
and sharing power equally. As formulated by a clinic manager:
“Do not run, do not make me your subordinate, but make me
somebody that you work with, then I think we could function.”
Five participants stated that they would not engage differently
as they were already dealing with community related issues,
the HC was already functioning well, or they had established
a relationship in which there was an awareness of boundaries.
Other reasons for not being completely convinced of different
personal engagement were the HCs’ lack of visibility in the
participants’ current position and the need for time off work to
engage with them. In contrast, a programme officer indicated that
she would assist the facility managers in the HC role, even though
she was not working with HCs herself. Nurses said they would
consult the HC about ways to improve health talks, to provide
more guidelines regarding HC functions, and to involve them in
decision-making pertaining to the community. Clinic managers
intended to actively participate in meetings more regularly,
request help in various work areas, and to invite the local
government councillor to assist in establishing a new committee.
Another clinic manager said that the training, because it
provided self-development and stimulated an awareness of what
is happening at other facilities, made her willing to improve
her relationship with other HC stakeholders. Other participants
intend to encourage the HC to run a helpdesk and facilitate active
co-operation between all HC members and HPs.
Two clinic managers contacted the local government
councillor regarding the HC as a result of the training. In one
instance, it had not yet been possible to reach the councillor, and
in the other, the councillor would connect the clinic manager
to an active community member who could become involved.
Aside from these two cases, most intentions to change practices
remained intentions for the duration of this evaluation, with
some participants feeling constrained by their superiors. A clinic
manager pointed out that her manager questioned her training
attendance because of her workload. Some participants therefore
perceived it relevant to train other health care providers, such
as the sub-district managers and the second in charge. An
environmental health practitioner said: “At the beginning I
was t old not to make myself clever. [. . . ]I don’t think I can take
initiative on this, because it’s not part of my work.”
DISCUSSION
This section discusses the above reported post-training
responsiveness of HPs to HCs as community-based governance
structures. Further, we shed light on the potential contribution
of HPs’ enhanced responsiveness to the people-centeredness of
health systems. Moreover, study and training limitations as well
as recommendations are described.
The evaluated HP training cross-cuts the six key mechanisms
to HP responsiveness identified in Lodenstein et al. (2017a)
realist review of social accountability initiatives in LMICs. In
their proposed programme theory, the authors suggest that HP
responsiveness outcomes are influenced by (i) HPs’ perceptions
on the legitimacy of the social accountability initiative, (ii)
their feelings of support, safety, appreciation, and (iii) of
moral responsibilities and obligations, (iv) their fear for public
or professional reprisal, (v) their self-identification with the
initiative’s claims or ideals and perceived self-capacity to act, and
(vi) their perceptions on health care users. The authors categorise
HP responsiveness outcomes as “receptivity,” “relations,” and
“responsiveness.” In Table 3, the earlier described themes
and findings on HP reported post-training understandings,
intentions and practices towards HC functioning are organised
by these HP responsiveness outcomes (Lodenstein et al., 2017a).
The contextual factors of potential influence as identified by
HPs and, to a lesser extent, in the discussion below are also
summarised in this table.
Receptivity
“Receptivity” is the collection of attitudes, awareness and
acceptance around the social accountability initiative. Following
training, HCs were increasingly perceived as beneficial to
the facility, besides their benefit to the community. HPs
increased responsiveness towards HCs’ roles and responsibilities
consisted of improved understandings of what these roles and
responsibilities are and how to support them. Furthermore,
HPs increasingly welcomed the active involvement of the
local government councillor and the environmental health
practitioner as HC members, as well as engagement with other
community stakeholders. This receptivity can form a foundation
for enhancing relations and health services responsiveness
outcomes, thereby facilitating the availability of health services,
mobilisation or reallocation of resources and targeting the
environmental and socio-economic determinants of health. This
would contribute toward the holistic approach of people-centred
health care and systems and the right of everyone to a complete
state of social, mental and physical well-being (Backman et al.,
2008; WHO, 2015). However, HP receptivity to HCs is subject to
HP identified contextual influences such as mutual respect, trust
and (feeling subjected to) HC community members’ judgment.
Health Service Responsiveness
To avoid confusion with our own definition of HP
responsiveness, we refer to responsiveness as the outcome
of HP responsiveness as “health service responsiveness.” It
is defined by the concrete actions towards improving service
provision in line with citizen concerns (Lodenstein et al.,
2017a). HPs contribute to people-centred, needs-responsive
healthcare when they provide an enabling environment in
which the community is truly represented and participating,
can take control of their own health and provided a platform
to engage with the health system as a whole (WHO, 2015).
HPs showed enhanced understandings and intentions towards
the participation and representation of the community in the
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Zwama et al. Rights-Based Training of Health Providers
TABLE 3 | Summary of themes and findings on HP post-training responsiveness to HCs and contextual influences.
HP reported
post-training
responsiveness
Understandings of HC roles and
functions
Intentions to engage
with HCs
Practices
towards HC
functioning
Identified contextual influences
Receptivity - Local government councillor as part of the
HC
- Importance of engagement with other
community stakeholders
- Mutual importance and benefit of HC as a
liaison body for HPs and community
- HC roles and responsibilities
- How to support the HC
- Invite local government
councillor to assist with
new HC establishment
- Assist clinic manager
with HC roles
- Contacted
local
government
councillor
- Mutual respect
- Understandings of roles and responsibilities
- Crossing of boundaries
- Trust
- HC attitude and judgment
Health service
responsiveness
- Avoid duplication of health services and
inform patients on services offered
- Identify outbreak sources —prevent spread
- Fast response of services
- Community mobilisation for campaigns
- Assist with health promotion and patient
recall
- Management of patient flow
- Help with: decision-making regarding
community, planning health service
transitions, complaint management,
resource motivation
- Consult HC to improve
health talks
- Involve HC in
decision-making
regarding community
- Encourage HC to
run helpdesk
Not evaluated - Broader community awareness of HC
presence and roles
- Representativeness of members*
Relations - Importance of all members’ active
involvement
- Have a common vision from the beginning
and partnership working towards it
- Clear cut roles and responsibilities
- Need for appreciation of HCs
- Trust-building, transparency, honesty
- Community ownership
- Easing tensions
- Community and facility awareness of HC
presence and roles
- Role of training
- Sharing power equally
- Regular, active meeting
participation
- Facilitate active
cooperation between
HC members and HPs
- Provide more guidelines
regarding HC roles
Not evaluated - HC member commitment and availability
- HC member retention
- Repeated training of HCs*
- Individual agendas
- Governmental priorities*
- Hierarchy
- Current position held
- Guidelines
- Policy and legal framework*
- Workload
- Transport money
- Fund raising initiatives
- System funding priorities
- Clinic manager availability (workload, after
hour-HC meetings, other meetings)
*Identified in the discussion.
setting of goals, decision making and problem solving regarding
their identified needs, concerns, and expectations. The extent
to which the needs-responsiveness of local health services can
be improved will be influenced by the level of awareness of
HC presence and roles amongst the broader community as
well as the extent to which HC members are representative
of the community that the facility serves. The exact extent to
which HCs would be promoted to actively participate in the
monitoring, strategizing, and planning of service delivery, and
the weight of their participation in the decision-making remains
unclear and is dependent of HP-HC relations.
Relations
The “relations” outcome is described by the changes in
interactions and accountability between communities and HPs.
This outcome appears to be the most dynamic in nature.
Similarly to the other HP responsiveness outcomes, the relations
outcome influences and is influenced by the other two outcomes.
Following training, HPs expressed understandings and intentions
towards the active involvement of all HC members, their own
regular active participation in meetings, and strategies for the
building and strengthening of relationships. Such understandings
of strategies promotive of HCs’ role in building trust included the
setting of clear roles and responsibilities, appreciating HCs and
working towards a common vision in equal partnership. These
HP understandings and intentions can facilitate an enabling
environment and opportunities for community members to
meaningfully participate in the strengthening of governance and
accountability within the health system. Hence, HP enhanced
responsiveness following training can play a role in decreasing
the “participatory deficit” in the way health services are planned
and delivered, contributing to the people-centeredness of service
delivery (WHO, 2015). The HP-community relations shape the
environment in which HP receptivity to HCs can be influenced
and determine the extent to which the community participates,
subsequently influencing health care responsiveness outcomes.
Moreover, HP-community relations are in itself influenced by
e.g., the feasibility of HC meeting times for HPs and priorities
of a variety of actors across the system, including HC community
members and supervisors.
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Zwama et al. Rights-Based Training of Health Providers
Potential Role of Contextual Influences
When provincial priorities in the Eastern Cape changed, health
promotion managers’ and health advisors’ role to develop,
establish and support HCs were only maintained in a few cases
after reviving these roles (Boulle et al., 2008). As identified in
this evaluation, unresponsive superiors can impede HPs’ ability
to engage with the HC. In Kenya, sustainability and replication
of HC success required more than once-off training of both
community members and health staff, continuous follow-up, as
well as commitment from district level authorities (Sohani, 2005).
A legal framework recognising and specifying HCs’ full capacity
as well as some funding to facilitate transport costs for meetings
may also be required to build sustainable working relationships
between HPs and HCs. However, the opposite can be true.
In Guinea, a HC’s functioning was attributed to the intrinsic
motivation of its members and a HC in the DRC developed their
own operational guidelines and received voluntary community
contributions (Lodenstein et al., 2017b). This evaluation has
shed light on the current presence of HPs who are already
responsive to HCs, have promoted HC functioning or have
good relationships with HCs irrespective of political agendas.
Furthermore, evidence from Sub-Sahara Africa and Bangladesh
(Knox, 2009; Tembo, 2013) shows that although policy and
legal frameworks are important in formalising HC power and
mandate, their utility can be limited in the absence of a basic
level of trust. This suggests that HPs increased responsiveness to
community engagement can positively influence opportunities
for the community to participate and facilitate HC functioning
despite crosscutting issues and contextual factors affecting
their functioning.
Even though there are presumed plans for a national roll
out of HC training through the training of trainers, provincial
and national policies appear to only move further away from
meaningful community participation in the delivery of PHC
(Province of Western Cape, 2016; The Republic of South Africa,
2018). The current nature of implementation of health reforms,
the lack of defined allocated power to HCs and the limitations
to HC member selection points at the technocratic nature
of participation in the South African health system. If South
Africa is to achieve “universal health coverage” with its National
Health Insurance Bill approaching finalisation, it is important to
underline and advocate for the role HP-HC relationships and HP
capacity building can play in the decision-making, planning, and
implementation as well as strengthening of needs-responsive and
people-centred PHC. However, we acknowledge that despite HP
training, HCs will be subject to other contextual influences while
navigating the system. Hence, HP training should be part of a
concerted effort to improve HC functioning.
Role of Training
In short, HP training that adopts a rights-based, interactive
approach, and cuts across the six mechanisms for change
of HP responsiveness to social accountability initiatives, can
promote HP responsiveness outcomes. This study contributes
to the conceptualisation of the programme theory proposed by
Lodenstein et al. (2017a). The training facilitated HPs’, receptivity
to HCs and it also provided HPs with the understandings and
skills to develop appropriate intentions and, in some cases,
implement practices towards building HC relations and health
care responsiveness.
This evaluation confirmed HPs’ key role in the functioning
of HCs and provides momentum for the wider investigation of
the role of such rights-based, interactive training in promoting
social accountability initiatives. In light of our findings, we
recommend that HP long-term responsiveness to HCs following
training is also evaluated and the training is tested in other
contexts. Considering the ever-changing relationship dynamics
and contextual influences, both HPs and community members
could benefit from iterated interactive training over time. For
this purpose, the value and feasibility of jointly organised follow
up-sessions is worth exploring further.
Limitations
This study may have been subjected to an inclusion bias. HPs’
ability to attend the training could have been influenced by
the priorities and workload of their respective clinic or sub-
district at the date of training. Besides, only HPs linked to
“City of Cape Town clinics” were included in this study. City
of Cape Town clinics differ from other clinics in the Cape
Metropole as they are managed by the municipality instead
of the provincial government. Historically, these clinics were
more health promotional, preventative and community-oriented.
The provincially managed health facilities originally delivered
curative services only. Some HPs could therefore have already
been more responsive to the concept of community participation.
Another current difference is that City of Cape Town clinics are
managed and run by nurses only.
The changes to training implementation had consequences on
the comprehensiveness of the evaluation and may have impacted
rigour. Despite willingness from the participants, the lack of
opportunity to follow-up on the first training session could
illustrate that competing priorities are a challenge in committing
to the full, intended training programme. It would therefore
be worth exploring the socio-political and economic influences
on cross-health system level stakeholders’ responsiveness to
community participation, HCs and HP training on community
participation through HCs.
The study was constrained by time. Ideally, a longer evaluation
period could have allowed for time to translate, pilot and
validate the questionnaires. The absence of the translation
of our methods into most participants’ first language limited
the cultural acceptability of our methods, potentially losing
out on local meaning and cultural connotations. Nonetheless,
the questionnaire responses were consistent with the training
observations and there was room for the exchange of cross-
cultural and -lingual understandings during training sessions and
semi-structured interviews. A longer study period could have
facilitated a push for the rescheduling of follow-up sessions.
Participants raised issues for discussion in these sessions which
could have further developed HPs’ practical skills to establish a
common vision, host a HC meeting and manage conflict. This can
be a limitation to the implementation of participants intended
strategies. It would also be recommended to further investigate
the role of training on the long term responsiveness of HPs in
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Zwama et al. Rights-Based Training of Health Providers
building working relationships with HCs and on HC functioning.
For instance, a documentary review of the HC meeting minutes
was initially proposed in order to assess HPs’ pre and post-
training interactions with HCs.
CONCLUSION
Interactive, rights-based training of HPs on community
engagement can enhance HP responsiveness to HCs. As a result
of this training, HPs were receptive of HCs as community-based
accountability structures. Furthermore, they demonstrated
understandings of and intentions towards the strengthening
of HP-HC relationships and the promotion of HC roles and
responsibilities in the delivery of PHC. HPs’ responsiveness
following training can facilitate HC potential to improve the
needs-responsiveness of PHC and the people-centeredness of
health systems. Considering the contextual influences that HP
responsiveness can be subjected to, this training should be tested
and evaluated further.
AUTHOR CONTRIBUTIONS
GZ designed the study, collected, and analysed the data.
MS and HH provided feedback and input throughout these
stages. GZ wrote the manuscript on which MS, HH, and LL
provided feedback.
FUNDING
This research was financially supported by the European Union
(EU Grant Number: DCI-AFS/2012/302-996), the Canadian
International Development Research Centre (IDRC Project
Number: 106972-002), and the South African National Research
Foundation (Grant Number: 116270).
ACKNOWLEDGMENTS
This study would not have been possible without the City
of Cape Town Health Department and their respective sub-
district managers granting permission for health care providers
to be recruited for the training and evaluation thereof. Finally,
we would like to express our gratitude to the health care
providers for their voluntary participation in this study as
well as Prof. Pat Mayers and Ms. Fundiswa Kibido for
facilitating and kindly accommodating the evaluation of the
training. The dissertation by GZ, submitted in partial fulfilment
of the Master of Public Health at the University of Cape
Town, formed the foundation of the work presented in this
paper (Zwama, 2016).
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Conflict of Interest Statement: The authors declare that the research was
conducted in the absence of any commercial or financial relationships that could
be construed as a potential conflict of interest.
Copyright © 2019 Zwama, Stuttaford, Haricharan and London. This is an open-
access article distributed under the terms of the Creative Commons Attribution
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