In Feb 2014, Black Sash conducted two 'RMCH District Learning Workshops' to share the results of our RMCH baseline study, following a rapid situational analysis of community health committees and alternative accountability mechanisms focussing on health and/or RMCH issues. These workshops were conducted in Mthatha in the Eastern Cape (EC) & Pietermaritzburg (PMB) in KwaZulu-Natal (KZN). In both provinces we were afforded great turnout and participation, particularly from community health committees.
Our team presented the key findings and recommendations of the baseline study which include some of the following insights:
• Challenges with Election Process, Composition and Recruitment: Representatives of committees are often not democratically elected by the catchment population of the clinic or Community Health Centre. Instead they are chosen by the facility manager, the induna/ traditional leader or another DoH official. It was often found that inadequate mobilisation and awareness raising was undertaken prior to the election date.
• Low Levels of Literacy and Inadequate and Inappropriate Training: Literacy was found to be a key barrier to the functionality of committees. In spite of the great need for training and capacity building for committees to play the role envisioned for them, in neither district have formal training manuals and programmes been developed. Existing training is often limited to providing representatives with the complex national and provincial policies for community health committees which are difficult to comprehend without thorough training to engage with its content.
• Conundrum of Stipends and Incentives to Participate: Across the board there is a huge demand for stipends from members of committees. They are currently operating as an unfunded entity and representatives (often from poor households) have to pay for transport and other running costs. Poor attendance at committee meetings is often due to members being unable to pay for transport to attend, especially where they live far away from the facility. A lack of youth participation was reported as they are not willing to serve in structures where there is no remuneration.
• Lack of engagement between committees and the community: Most committee engagement with the community in both districts was limited to the suggestion box placed at the clinic.
• Poor Understanding of the Reporting Structure & Health Governance System: Key informants identified certain officials as acting as gatekeepers however since committees do not understand the reporting system, they are unable to navigate themselves past gatekeepers to ensure challenges are resolved at higher levels of the district health system if need be.
• Findings on alternative accountability mechanisms (Civil society/multi-stakeholder organisations and forums):We found that there are a number of civil society organisations and forums which are functioning well, focusing on RMCH issues and which are already engaging in accountability tools such as community monitoring, public hearings or budget tracking. Currently there is limited to no engagement between the community health committees and alternative accountability mechanisms. Communities recommended that we engage with Imbizos, and War Rooms (specifically in KZN) as important community forums. Black Sash will aim to create institutional linkages between them and the committees.
Some of the key recommendation Black Sash made to address these challenges included:
* Training around appreciation of the democratic process and increased vigilance around elections of committees
* Focus on mobilising youth to participate in committees
* We must develop appropriate training programmes for committees which takes the literacy challenge into account
* Appropriate methods for community mobilisation and consultation should form part of the training *Ensure clear designation of responsibility within DoH to oversee & provide the training and adequate resourcing to realise this
* Reimbursement for out of pocket costs needs to be provided by the DoH & commitment secured in district health plan & budget as well as in legislation
Read more about general feedback following the presentation of the baseline findings from stakeholders; presentation on proposed intervention strategy to strengthen community health committees; general feedback following the proposed Black Sash RMCH intervention.
General feedback following the presentation of the baseline findings from stakeholders
Feedback on the baseline study was generally very positive. Following the presentation of the findings of the situational analysis, participants offered the following additional suggestions to improve the functioning of the community health committees
* Training should be held on a regular basis, including refresher training
* Training for the CC/CHCCs must be practical, visual & participatory in order to allow all members including the illiterate to participate
* In order to attract youth membership onto the committee stipends should be provided or other incentives such as skills development or bursaries
* More thorough mobilisation and awareness raising needs to occur before elections are held for committee representatives to ensure they are democratically elected by the catchment population of the health facility. Strategies that could be employed include setting up posters in public places such as schools, the clinic, taxi ranks and using the local radio stations
Presentation on proposed intervention strategy to strengthen community health committees
The Black Sash intervention will involve 1) Providing training to the 'RMCH Action Groups' comprised of community health committees and civil society/multi-stakeholder partners 2) Supporting the RMCH Action Groups to implement a community scorecard process to address RMCH challenges in their community.
Some of the key themes of the training will include: an understanding of the district health system; the role of community participation in health; roles and responsibilities of community health committees; health rights and
responsibilities, with a focus on RMCH; and tools on community monitoring.
The training will ensure that the RMCH Action Groups are equipped with necessary basic capacities to fulfil the multiple and integrated roles communities are meant to play in health promotion. The focus of this training would respond to the key challenges identified in the situational analysis. The training will also enable them to undertake community monitoring (using the community scorecard tool) in their respective communities.
General feedback following the proposed Black Sash RMCH intervention
Participants were generally receptive and supportive of the proposed RMCH intervention, and were positive that it could work in their district. In both districts there were concerns around ensuring youth participation for implementing the intervention as they are unwilling to work without stipends or other incentives. It was mentioned that these incentives don't necessarily have to be monetary but that out of pocket costs involved in committee activities need to be covered.
Another threat to the intervention is that the implementation period falls over the elections. The result is that it will be hard to mobilise health officials and ward councillors (who are members of committees) to participate. Other community forums such as the War Rooms in KZN will also be very politically heated during this time. It was raised that Ward Councillors (who champion War Rooms) are needed to be able to mobilise the community, however with the upcoming elections they are very busy and have their own agendas so the timing of the intervention is not very good. Concerns were also raised that this intervention might be used as an election tool in the community instead of what it was proposed to be used and seen as. Receptive to the advice offered by stakeholders at both these meetings, Black Sash decided to postpone implementation of the intervention until after elections.
It was also suggested that the intervention be introduced to the community correctly; including all community leaders and relevant stakeholders, and that they need to be made aware of the intervention to avoid creating any conflicts. It was proposed that War Rooms could be used in KZN and Imbizos in the EC to introduce the CSC as an intervention tool; Black Sash will be heeding this advice.
Lastly, participants indicated that effort need to be put into ensuring the health facility staff and district Department of Health officials are on board, to ensure the success and sustainability of the intervention.
Following a very positive response from the two district workshops on Black Sash's proposed intervention, our RMCH project team will used the following onths to refine our training programme and intervention tools in preparation for implementation of a pilot project in each of the focus districts.