PHM-Exch> EFFECTIVE HEALTH CENTRE COMMITTEES CAN BRING LIFE INTO OUR HEALTH SYSTEMS

[Claudio Schuftan]

EFFECTIVE HEALTH CENTRE COMMITTEES CAN BRING LIFE INTO OUR HEALTH SYSTEMS
(The EQUINET Regional Meeting On Health Centre Committees
February 2014)       EXCERPTS
Social participation is central to the success ofprimary health care (PHC)
oriented health systems. There are, however, wide differences in how far
they are implementing this policy view. There are many shortfalls in
meaningful levels of
social participation in health systems. Health Centre Committees (HCCs) are
known by a range of names in different countries but are joint community-
health worker structures at primary care level. They offer one way for
systems to facilitate social participation and shared decision making
between communities and health personnel. There is evidence that they can
contribute to quality of and equity in access to health care and improved
health outcomes. HCCs provide a key mechanism for communities to
participate in revitalising PHC and for strengthening and monitoring
service delivery.

Despite this, while HCCs exist in some form in most countries, they often
have no formal legal status or are not trained, resourced or active.
Generally while guidelines often set HCC composition and duties, they are
less clear on how they are funded or on their role in towards social
accountability. Despite their role in bringing community voice to service
planning and the requirement that they represent communities, HCC members
are not always elected by communities, have
variable levels of community involvement and influence and may be liable to
political control.

To some extent this reflects ambivalence towards whether HCCs are more a
voice for the community to influence health services, or an outreach for
services to reach and influence communities. Both roles are important, but
where do HCCs focus their time and energies? There is concern that in some
countries HCC roles have become 'commodified,' with the resources available
to them based less on community interests or needs than on what is paid
for, often
by international organisations.

Hence rather than the common practice of a long list of apparently delinked
and equally weighted roles, the meeting identified roles of an HCC in a more
systemic way, linking these to processes in health systems. The process
starts with building an informed health literate community, obtaining
community views and drawing on this to bring community voice and experience
into the interaction with health service personnel, to jointly design and
implement plans and budgets for the health system at primary care and
community level. This joint role in governance gives the HCC the
information, authority and motivation to go back to communities to
facilitate dialogue and social action on health plans; to make sure that the
agreed plans have been implemented, and that the duty bearers are
capacitated, supported and resourced to deliver on plans and that they do so
in a manner that is responsive to the community. HCC members should thus
bring the direct experience and views of communities into the system,
supporting understanding and reflection within communities on how to improve
health, and advocating for improvements, with other sectors or at higher
levels of the health system. This means that HCCs are more likely to thrive
where health systems are themselves PHC oriented, facilitate action on the
social determinants of health and support participatory planning and
practice, than where they are organised largely around individual medical
care with top down power.

HCC members need to have resources and skills across all these areas of
functioning to complement their inherent social capacities and to enable
them to overcome power imbalances in the relationships between themselves
and health authorities. While there is a lot of training activity taking
place, this may be limited to specific disease problems or interventions,
may not address the general community health literacy or spectrum of HCC
abilities needed and may lack follow up to evaluate its effectiveness or to
sustain it. Training may not include some key areas such as budget tracking
or assessment of community benefit. Further those providing training for
HCCs may themselves lack competencies to build skills in areas such as
budget planning or tracking.
For HCCs to be effective in PHC oriented roles, communities themselves need
to be health literate and empowered.
Social rights to health care, to information and meaningful participation
can provide a foundation for this and should be included in all
constitutions of the region and in updated national or public health law.
Regulations should more clearly define the duties, powers, roles and
constitution of HCCs, and guidelines set these in a more systematic manner.
However all this is likely to remain on paper unless it is accompanied by
processes for capacitating systems and for supporting social activism and
information.

A number of areas for follow up need attention and action by national
authorities and organisations working in health, in relation to legal
provisions, guidance, election, composition, functioning and capacity
building of HCCs. While the specific cultural contexts differ, minimum
guidance for these areas can be set,
such as on the core content of and processes for comprehensive HCC training,
and that countries budget for the capacity building and functioning of HCCs.
As for all other areas of health system performance, it is proposed that
the health information system and communities monitor and collect
information on the functioning, performance and impact of HCCs.

The commitment to network by practitioners working with HCCs must continue
to link regionally, including to document, to share and make their work
more visible. At a time of increasing attention to domestic resources for
health, the most critical resources are people. The challenge is for policy
actors to turn commitments into action and to give systematic attention to
the effective functioning of HCCs, as key social assets for health.

Please send feedback or queries on these issues to the
EQUINET secretariat: admin at equinetafrica.org. For more information on the
issues raised please visit www.equinetafrica.org
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