Submission on the Draft Western Cape Health Facilities Boards and Committees Bill, 2015

Submission on the Draft Western Cape Health Facilities Boards and Committees Bill, 2015:

31st July 2015

This submission is made jointly by the organisations listed at the end of this document. We urge the Health Department to respond to and take on the comments and recommendations made in this submission.

What is in this submission?

The submission firstly comments about the process of developing the Bill. Secondly, itthen summarises the evidence from research on community participation around the world. Thirdly, the submission then outlines briefly how community participation is provided for in terms of national and other provincial policies and legislation as a comparison to what has been proposed in the Western Cape. Fourthly, the main part of the submission then focuses on comments and recommendations related to contents of the Bill – both strengths and weaknesses/concerns. Lastly, we propose a process for revising the legislation for community participation in the Western Cape.

The background to developing the Bill and a flawed process

Health committees have been functioning in the Western Cape since 1989 and have been coordinated under the Cape Metro Health Care Forum since 1992. In 2008, the Western Cape Health Department and the Cape Metro Healthcare Forum (CMHF) developed a draft policy on Health Committees which provided functional direction to the operation of health committees in the Metro. However, this policy was never adopted despite continual discussion about its adoption.

In 2012, the Provincial Health Department indicated that it could no longer recognise health committees until legislation was in place to regularise the institutional environment for community participation. Provisions that covered the costs of activities of Health Committees that had been in place until then were stopped on the basis that there was no financial directive, supported by policy, to legitimise such funding.

With the establishment of the District Health Council for the Cape Metro in 2012, the matter of recognising health committees was taken up as part of the outreach mandate of the DHC. Two community consultations were held (in May 2014 and Feb 2015) at which there was extensive discussion of the role and place of Health Committees and of the process of legislating for health committees. Two important points came out of those discussions: Firstly, there was agreement on the criteria for interim recognition of health committees until legislation was in place and on steps to take that forward.Secondly, the discussions also focused on the processes that would be required to ensure community input to the draft legislation. In particular, there was agreement that communities must be consulted and their voices heard. The CMHF undertook to assist in dissemination of the legislation to communities.

However, despite this commitment to involve communities in the process of consultation, we point out that:

a)There has no interim recognition of health committees since it was first discussed in May 2014 nor any efforts to set in motion the directives needed to resource committees that are recognised and functioning effectively.

b)The Bill was released without informing the Cape Metro Healthcare Forum or the District Health Council which has the mandate to pursue community participation.

c)One month was given in the Gazette for feedback on the bill. Only after the inappropriateness of this timeline was pointed out to officials in the Health Department and to the DHC was the timeline extended by an additional month.

d)There was no implementation of any consultative processes in the Sub-districts preparatory to a DHC on the 25th July even though we were led to understand that the Health Department would support such processes.

Given the long incubation of this bill, the many promises made around involving communities in the process and the importance of getting this right from the start, we believe this bill is being rushed through with undue haste and this is an unsatisfactory process.

What is the International evidence?

There are three reviews of the experience in mainly Lower-Middle Income Countries that confirm that Health Committees can play important roles in health system governance and in enhancing the responsiveness of health services[1]. The research has shown that health committees can have a positive impact on access to, and quality of services if the committee system is appropriately designed, committee members are empowered, health committees are supported by other synergistic health system interventions and attention is paid to ensuring health committees are representative structures. The roles of health committees found in international studies include enhancing accountability, achieving greater community voice, supporting advocacy for better services, input to planning and spreading the reach of health promotion and disease prevention services. Studies have also shown that poor support for health committees, both in South Africa and other African countries have jeapordised the potential of health committees to play a role in strengthening the health system and articulating community voice[2]. The importance of a clear and appropriate legal framework for health committees is thus critical. We refer to regional and national consultations held in 2014 where the roles of health committees have been confirmed and consensus reached on the importance of health committees as vehicles for democratic governance in health[3].

What is the situation across the country?

A recent rapid appraisal of health committee policies across South Africa showed that all provinces have guidelines, policies or legislation on Health Committees. Although these vary greatly in length and detail, all policies - at least to some degree – conceptualise health committees as governance structures[4]. This entails health committees playing a role in planning, strategy, oversight and accountability. Some examples of HCs involvement in planning and strategy include the Eastern Cape Policy, where committees must ‘oversee adherence and provision of the primary health care packages’; the Free State where committees ‘advice management of the health facility’; the Gauteng policy stipulates that committees should ‘participate in strategic planning and operational processes with a view to advising management’. The Northern Cape policy states that health committees should ‘ensure that the strategic direction, vision and values of the establishment aligns with the needs of the community’, while neighbouring province, the North West, describes health committees as governance structures that are required to participate in Governance and Management meeting where planned and remedial action is taken.

With respect to health committees’ accountability role, two areas emergedas important in most provincial documents: Their role in monitoring and in complaints management. Thus, Eastern Cape’s policy ensures that health committees ‘receive regular report on the performance of facility management in meeting the objectives of the facility as determined by achievement of indicators and targets’. The same policy states that committees should ‘monitor the extent to which the management of the health facility addresses and resolve complaints’. In KwaZulu-Natal, health committees are expected to provide the MEC with bi-annual reports on the performance of the clinic, while committees in the Free States are asked to investigate administrative complaints about the health facility and recommend solutions to the District Health Council. In addition, Free State committees are responsible for investigating health service delivery problems and make recommendations to the District Health Council. Mpumalanga’s health committees are tasked with monitoring the investigation and resolution of complaints, while the committees in the Northern Cape must monitor management performance. The North West policy entails provisions for committees both to oversee the resolution of complaints and monitor availability of essential drugs and customer care.

In the National Guideline issued by the Department of Health (in 2012), there are many governance roles identified for Health Committees, many of which are similar to those listed above. The Table below indicate where the Western Cape Draft Bill differs from the National Guideline with respect to roles and powers.

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Table 1. Comparison Roles and Powers in WC Draft Bill to National Guidelines
Roles and Duties / Roles and Powers in WC Draft Bill (2015) / Roles and Powers in National Guideline (2014
Advisory / N/A / Provide expert advice
Participatory / Assist manager to identify community priorities and strategies to address priorities / Assist formulating strategy, draw up plans; assist in setting inst. policy; Act as advocates of the institutions’ interests
Monitor / Request feedback on measures to improve service quality / Assist in monitoring performance agreements
Conduct scheduled visits without impeding service delivery so as to provide constructive written feedback / Monitor the effectiveness of communication between institution and community
Monitor the investigation and resolution of complaints;
ensuring equitable access
Redress / Assist the community to communicate needs, concerns and complaints so that they can be appropriately addressed / Assist institutional managers in conducting disciplinary proceedings and resolving disputes; Provide forum for patient and public’s grievances
Engagement / Foster community support for the facility / Provide a visible presence so as to build relations with staff
Service / Encourage volunteers to assist / N/A
Fundraising / N/A / Raise funds for recreational facilities for staff; amenities for patients; Raise additional funds for the institution
Governance / N/A / Assist and support institutional management with policy and strategy
Powers
Advisory / Can make recommendations on any matter relating to Committee’s functions / Make recommendations to MEC on financial matters; to the province on infrastructure and maintenance.
Can direct recommendations to the MEC, HoD, facility manager or municipality / Advising institutional management on community engagement
Access to information / Can obtain any information from management (provided does not violate confidentiality) / Exercise the right of access to any information which may be required
Request progress reports / receive regular management reports
Investigate / Conduct surveys, meetings and workshops in community / Involvement in complaints management
Communication / Disseminate information to communities on mission, services, standards, policies, financial status, etc. / regular report back meetings and the dissemination of information to the community; fostering partnerships of institution within the wider community
Hold open board/ committee meetings, open days institution
Human resources / n/a / Assist management to appoint staff; Review institutional staffing practices for fairness; Assist managers to create career development pathways for staff; Recommend outstanding staff for commendation by the MEC
Financial / Can raise funds, provided committee is linked to a board and pays donated funds to a board / Support approval of purchases of equipment for submission to district; Recommend the budget prepared by the institution; Assist management in the appropriate deployment of funds

It is thus clear that the Western Cape Bill omits many important governance issues that are included elsewhere in the country and are contained in the national guideline.

What are the strengths of the Bill?

1. This is the first time the W Cape Health Department has recognised health committees officially in terms of legislation, thereby enacting what is set out in the National Health Act.
2. The Bill tries to address both health committees and hospital boards as community participation structures in one bill.
3. The Bill recognises that facility managers must play their part in allowing health committees to be effective by stating that “the facility manager must assist the Committee to perform its duties and must cooperate with the Committee.” We welcome this provision and would like to add that (a) the Bill should ensure that facility managers know the roles and functions of the HCs to avoid conflict; and (b)the department should ensure that facility manger’s performance is evaluating in terms of community participation as a KRA.
4. It responds to the Department’s vision 2030 in which it states that “Greater effort will be made to make the statutory structures more functionally effective as conduits of community perspectives. This will include more effective communication and information sharing, capacity development within these structures and deepening of the trust and respect between them and the Department. Notwithstanding the complexity of community involvement, the Department will strive to increase community involvement in the design of health services.”

What are the problems with the Bill?

Despite the purpose stated in the bill to ensure “community support for, and involvement in, health facilities and theirprogrammes", we believe the Bill falls far short of what It could achieve.

1. Health Committees should be structures for democratic governance.
   The Bill states that one of its purposes is to ensure “the establishment of representative and accountable health facility Boards and Committees as statutory bodies."
2. It is not possible for Health Committees to function as bodies representing the community if they are appointed by MEC, as the Bill currently states. The MEC cannot be familiar with every community and will not be In a position to satisfy herself that the community members nominated are “nominated by a body that … is sufficiently representative of the interests of the community concerned.”
3. Health committees should therefore be elected from the community if they are to be democratic governance structures. Health committees must be accountable to the communities who elect them; otherwise, community participation becomes meaningless.
4. The MEC should develop regulations which set out the process and criteria for elections.
5. These criteria should include measures to address diversity in the membership of the committees such that women, youth, disabled persons and other vulnerable groups have opportunity to be represented. The Bill should explicitly indicate that Health Committees should have diversity in their composition and in the organisations from which members are elected.
6. Facility manager and ward councillor are ex-officio on the committee. The Bill should state clearly that leadership offices on the Health Committee should be held by community members.
7. The Bill imagines that health committee mandates can be achieved by infrequent meetings four times a year. It also makes no provision for health committee members holding meetings in communities to report back or solicit input. The Bill therefore conceives of health committees having very limited participation roles. This is not a basis for community participation in health. The Bill should recognise that health committees need to meet frequently and engage in community outreach and meetings as part of their key responsibilities.
8. The Bill does not expect the Committee to have a constitution, nor does it prescribe a code of conduct. We believe that for health committees to function as vehicles of democratic governance, it is essential that every health committee have a constitution and a code of conduct, which is applicable to all members, including ward councillors.

1. The powers and functions given to health committees in the Bill aregenerally trivial and inconsistent with national, provincial and local policies.
2. There is inconsistency between powers and functions accorded to Hospital Boards and to Health Committees. In general, health committees have weaker powers and fewer functions. If health committees are truly intended to be truly “conduits of community perspectives,”the bill needs to revisit the powers and functions allocated to health committees, more consistent with the national guideline. For example, health committees are not described as advising on policy or strategy, do not shape the mission, values and policies of the services, and may only request reports. Health committees are not allowed to do inspections unannounced. These are all inadequate when considering the Province’s vision which cites a commitment to “increase community involvement in the design of health services.”
3. We therefore propose that health committees should have roles in (i) planning health service delivery, including the identification of community priorities for the attention of the services; (ii) contributing to departmental strategy; (iii) monitoring and accountability of services (such that visits to monitor should not be known beforehand to the facilities); (iv) involvement in complaints resolution; (v) advocacy for improving the quality of services; (vi) right of access to information (not just to request but to receive reports and information).
4. Health committee roles should include the role of providing input to shaping mission, vision, value, policies and programmes of the services.

1. Sustainability of Health Committees
2. The Province’s Vision 2030 makes a commitment to ensuring health committees are “more functionally effective” through “information sharing, capacity development.” More recently, the draft provincial discussion paper on PHC mentions that “capacity development will be needed to ensure the effective functioning of these structures” [boards and health committees].However, the Bill is entirely silent on the question of training and mentoring other than talking about induction of members appointed for their first term of office. Our experience has been that training to empower health committee members is essential for committee to function effectively and requires long-term support and mentorship. The Bill needs to provide for this rather than leaving it optional for the department.
3. The Bill recognises the need to reimburse health committee members for transport. However, the work of health committee members incurs many other bona fide costs that should be covered by the department if it wants genuine participation. These include cell phone costs (to arrange meetings, liaise with other stakeholders) and costs of travel to and from community meetings. The Bill should recognise that there are many other costs to community participation that it should not expect health committee members to bear. The bill mentions “other allowances” payable without defining what these mean.
4. The Bill should emphasise and clarify the role of the ward councillor to mobilise resources and help to solve problems identified by the HC.
5. The Bill precludes health committees from fundraising independent of a Hospital Board, but does not address the question of what should be done if the Hospital Board is non-cooperative, or unwilling to support the health committee’s fundraising. The Bill needs to address this.

1. The way community participation is structured is problematic
2. There is no structured linkage between health committees. The Bill does not talk about how committees should communicate with each other or feed information upward into District Structures. The District Health Council is mentioned but there is no structural relationship with health committees. This is not functional nor does it encourage participation. The Bill should set up a set of structures in which committees and boards are able to come together at sub-district and district level, and where there is tiered representation upwards, through committees electing representatives to higher structures, ultimately represented on the District Health Council. It is not sufficient to include a provision whereby the MEC “may take measures to ensure collaborative working relationships between Boards, Committees and District Health Councils.” Rather, the Bill should set out the intent of the department to set up a democratic structures based on tiered elections upward, and indicate that the MEC will (not ‘may’) take measures to put effect to this intention.
3. The Bill is not clear on why clustering of health committees would be desirable nor does it give any guidance on criteria that would inform such clustering. Since it is left almost entirely to the discretion of the MEC, there is a problem in that bona fide functioning health committees might be shut down using this provision. If the Bill is to retain reference to clustering health committees, the rationale and criteria should be explicitly stated in the bill.
4. Where a facility serves patients from more than one ward, then there should be more than one ward councillor on the HC and this should be reflected in the Bill.

1. Lastly, the bill treats HCs as if there is no history to health committees in the Western Cape, despite the fact they have existed for decades and been active and recognised by the Health Department in the past. In terms of the Bill, health committees only come into existence when the Head of Health calls their first meeting, unlike Hospital Boards, where the Bill recognises the need for a transition period for existing hospital boards. This is a travesty of the history of community leaders, such as Uncle Polly, who campaigned tirelessly for promoting the voice of communities in the province. The Bill needs to start from a different point in thinking about a transitional period for recognition of health committees, many of which continue to function well despite being starved of resources for more than two years.

A proposed process for revising the Bill