September 2010
Issue 1
Critical Health Perspectives
Publication of the People’s Health Movement, South Africa
Community Health Committees as a vehicle for
participation in advancing the right to health.
Gabriela Glattstein-Young, Leslie London,
School of Public Health & Family Medicine, UCT.
From the earliest rhetoric
of global Primary Health
Care, the role of commu-
nity participation has
been considered one of
several key ingredients
required to improve
community health. The
extent to which this is
paid more than lip ser-
vice by Ministries of
Health who profess PHC,
and the extent to which
different efforts to estab-
lish meaningful commu-
nity participation actually
contribute to community
health gain and the right
to health, remains uncer-
tain.
Health committees
In South Africa, a commit-
ment to community par-
ticipation has been reit-
erated through national
and provincial policy
documentation. The Na-
tional Health act of 2003
established community
health committees as
formal structures for par-
ticipation in health (Box
1), yet, studies from
Southern Africa under-
score serious shortcom-
ings in the implementa-
tion of meaningful com-
munity participation.,
Recent international de-
velopments have empha-
sized the importance of
participation for the reali-
sation of the right to
health. Paul Hunt, former
UN Special Rapporteur
on the Right to The High-
est Attainable Standard of
Health, has formally rec-
ognized participation as
a human right and an
integral component of
the right to health. In-
deed, the interdepen-
dency of human rights
means that the realization
of the right to health is
contingent upon the at-
tainment of other human
rights, such as participa-
tion. Importantly, Hunt
also acknowledged the
dearth of research ex-
ploring the interface be-
tween participation and
the right to health as
clear linkages between
the two are not well de-
veloped.
This paper explores
whether community par-
ticipation through health
committees can advance
the right to health, and
what constitutes best
practice for community
participation through
South African health com-
mittees. The paper re-
ports on a series of 32 in-
depth interviews with
members of three Com-
munity Health Commit-
tees and health service
providers in the Cape
Metropolitan area and
provides some valuable
insight into these areas.
Community participa-
tion and right to health
The interviews revealed
that, even in resource-
constrained settings,
community participation
through Health Commit-
tees can advance the
right to health. This
mainly occurs through
reported improvements
in the acceptability and
accessibility of local
health services. Still, pro-
gress is restricted by the
amount of power held at
Volume 2.
different levels of deci-
sion-making. Where a
Community Health Com-
mittee is supported by a
facility manager through
his/her regular involve-
ment in Committee meet-
ings and where a Com-
mittee is allowed to have
a greater impact on deci-
sions in the facility, more
concrete progress to-
wards the right to health
can be made. Neverthe-
less, most Health Com-
mittees are limited in
their ability to influence
decisions at the health
systems level. The human
rights literature supports
the use of a rights-based
approach as a “powerful
tool” for communities to
advance their right to
participation.
Barriers and facilitators
Interview participants
often described the rela-
tionship between the
Health Committee and
service providers as
strained, characterised
by limited communica-
tion and contestations
over power.
The most prominent bar-
riers to participation
mentioned by partici-
pants, included under-
representation of vulner-
able and marginalised
groups, and the absence
of a formal mandate giv-
ing Health Committees
clear objectives and the
authority to achieve
them. This in turn limited
the progress made by
some Health Committees
since an absence of visi-
ble change reinforced
perceptions that they are
Health for All
Now!
Critical Health Per-
spectives does not nec-
essarily represent the
views of PHM-SA. For
more information see:
http://asnahome.org/
peopleshealth/
Contact the editors:
nmyburgh@uwc.ac.za
Box 1: South African National
Health Act 61 of 2003
CHAPTER 6: HEALTH
ESTABLISHMENTS
Clinics and community
health centre committees
(1) Provincial legislation
must at least provide for the
establishment in the province
in question of a committee for
(a) a clinic or a group of clin-
ics; (b) a community health
centre; or (c) a clinic and a
community health centre or a
group of clinics and commu-
nity health centres.
(2) Any committee contem-
plated in subsection (1) must
at least include (a) one or
more local government coun-
cillors; (b) one or more mem-
bers of the community served
by the health facility; and (c)
the head of the clinic or
health centre in question.
(3) The functions of a com-
mittee must be prescribed in
the provincial legislation in
question.

Page 2
Health committees and Community Participation contd.
powerless. Other factors
that limited their impact
were a lack of consensus
on Health Committee
roles and functions and
the position of facility
managers as gatekeep-
ers to the Committees
involvement in facility
operations.
On the other hand, par-
ticipation was enhanced
by committee member’s
experience in health and
community development.
In addition, when facility
managers were willing to
share decision-making
power with the commit-
tees, they enjoyed more
meaningful levels of par-
ticipation.
Best practice lessons
Several characteristics of
Health Committees were
identified that promoted
more meaningful partici-
pation:
(1) A facility manager
who helps tip the balance
of power from health
professionals towards the
community by sharing
decision-making with the
Health Committee and by
involving the Committee
in facility operations.
(2) A form of appren-
ticeship in which newer
Health Committee mem-
bers learn skills and pro-
cedures from more ex-
perienced members.
(3) Intersectoral activity
through the regular in-
volvement of ward coun-
cillors and environmental
health officers in Health
Committee meetings and
activities.
(4) A mechanism for the
Health Committee to be
involved in the reviewing
and resolution of patient-
based complaints at
health facilities.
(5) Use of the media and
written sources of infor-
mation by Committees
increases their visibility
in the clinic and in the
Critical Health Perspectives
community, disseminates
important health-related
information, informs the
community of Health
Committee activities and
broadens participation.
(6) Achieving small
gains acts as positive
reinforcement and
strengthens the Health
Committees to achieve
bigger gains.
Recommendations
(1) Policy framework
A comprehensive provin-
cial policy framework for
Western Cape Health
Committees has been
drafted but is yet to be
formally adopted by the
MEC for Health. Based
on the findings of this
study, the proposed
framework should in-
clude:
(a) Extension of Health
Committee authority to
include involvement in
community needs assess-
ments, programme plan-
ning and resource-
allocation decisions at
the community level. It
must establish mecha-
nisms to reinforce the
involvement of local
councillors and environ-
mental health officers
and consider ways to
increase representation
of vulnerable and mar-
ginalised groups on the
Health Committees. The
framework also required
a detailed plan for com-
munities to be involved
in decision-making and
problem-solving at the
health-systems level
through the Cape Metro
Health Forum (CMHF)
executive.
(b) Monitor and evalu-
ate community partici-
pation using indicators
that have been jointly
developed by the CMHFs
and health service stake-
holders.
Other recommendations :
(2) Establish ongoing
training and capacity-
building to strengthen
Health Committees and
enable them to partici-
pate in decision-making
(e.g. training around the
Province’s APP planning
processes).
(3) Establish a learning
network of Health Com-
mittees, including ap-
prenticeships between
more and less experi-
enced Health Committee
members. While it is not
always possible to retain
Committee members for
long periods of time, the
formation of a learning
network for Health Com-
mittees should be consid-
ered as an important part
of capacity-building
strategies. In this net-
work, weaker Commit-
tees would be able to
learn and grow using
stronger Committees as a
resource.
(4) Promote involve-
ment of vulnerable and
marginalized groups.
Evidence from the litera-
ture indicates how fair
and equal representation
is heavily influenced by
the physical and eco-
nomic costs of participa-
tion. Efforts to widen par-
ticipation should there-
fore include an honest
consideration of its costs
(i.e. lost wages while at-
tending workshops or
meetings, costs of child
care, transportation) and
steps to minimize the bur-
den of such costs, such
as, the provision of a
monthly stipend.
It is hoped that the find-
ings from this study can
inform policy develop-
ment around health com-
mittees in the Western
Cape, and enhance com-
munity participation more
broadly in the future.
Volume 2. Issue 1
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