Implementing community participation through legislative reform: a study of the policy framework for community participation in the Western Cape province of South Africa

ABSTRACT: BACKGROUND: Amidst an evolving post-apartheid policy framework for health, policymakers have sought to institutionalize community participation in Primary Health Care, recognizing participation as integral to realizing South Africa's constitutional commitment to the right to health. With evolving South African legislation supporting community involvement in the health system, early policy developments focused on Community Health Committees (HCs) as the principal institutions of community participation. Formally recognized in the National Health Act of 2003, the National Health Act deferred to provincial governments in establishing the specific roles and functions of HCs. As a result, stakeholders developed a Draft Policy Framework for Community Participation in Health (Draft Policy) to formalize participatory institutions in the Western Cape province. METHODS: With the Draft Policy as a frame of analysis, the researchers conducted documentary policy analysis and semi-structured interviews on the evolution of South African community participation policy. Moving beyond the specific and unique circumstances of the Western Cape, this study analyzes generalizable themes for rights-based community participation in the health system. RESULTS: Framing institutions for the establishment, appointment, and functioning of community participation, the Draft Policy proposed a formal network of communication -- from local HCs to the health system. However, this participation structure has struggled to establish itself and function effectively as a result of limitations in community representation, administrative support, capacity building, and policy commitment. Without legislative support for community participation, the enactment of superseding legislation is likely to bring an end to HC structures in the Western Cape. CONCLUSIONS: Attempts to realize community participation have not adequately addressed the underlying factors crucial to promoting effective participation, with policy reforms necessary: to codify clearly defined roles and functions of community representation; to outline how communities engage with government through effective and accountable channels for participation; and to ensure extensive training and capacity building of community representatives. Given the public health importance of structured and effective policies for community participation, and the normative importance of participation in realizing a rights-based approach to health, this analysis informs researchers on the challenges to institutionalizing participation in health systems policy and provides practitioners with a research base to frame future policy reforms.     

成都市老年人健康管理现状分析

<正>老年人是我国基层医疗卫生机构重点服务对象,老年人健康管理是基本公共卫生服务重要内容之一。2009年成都市制定《成都市城乡基层医疗卫生机构基本公共卫生服务绩效考核标准》,对城乡基层医疗卫生机构开展老年人管理的数量、方式以及效果进行了明确要求。     

Service providers' views of community participation at six Australian primary healthcare services: scope for empowerment and challenges to implementation

Community participation is a key principle of comprehensive primary health care (PHC). There is little literature on how community participation is implemented at Australian PHC services. As part of a wider study conducted in partnership with five South Australian PHC services, and one Aboriginal community controlled health service in the Northern Territory, 68 staff, manager, regional health executives, and departmental funders were interviewed about community participation, perceived benefits, and factors that influenced implementation. Additional data were collected through analysis of policy documents, service reports on activity, and a web‐based survey completed by 130 staff. A variety of community participation strategies was reported, ranging from consultation and participation as a means to improve service quality and acceptability, to substantive and structural participation strategies with an emphasis on empowerment. The Aboriginal community controlled health service in our study reported the most comprehensive community participation. Respondents from all services were positive about the benefits of participation but reported that efforts to involve service users had to compete with a centrally directed model of care emphasising individual treatment services, particularly at state‐managed services. More empowering substantive and structural participation strategies were less common than consultation or participation used to achieve prescribed goals. The most commonly reported barriers to community participation were budget and lack of flexibility in service delivery. The current central control of the state‐managed services needs to be replaced with more local management decision making if empowering community participation is to be strengthened and embedded more effectively in the culture of services. Copyright © 2014 John Wiley & Sons, Ltd.     

政府办与社会办社区健康服务中心的绩效管理分析

目的通过对政府办与社会办社康中心的比较,探索社区健康服务绩效管理的方向。方法对龙岗区政府办的129家社康中心和社会办的13家社康中心的年报表内容进行分析,运用描述性流行病学研究方法中的横断面调查进行研究。结果政府办与社会办社康中心在政策支持、功能完善、业务开展、人力资源、经济运营和整体管理评估等指标上各有其特点。结论社会办社康中心在解决"看病难、看病贵"问题上发挥了积极的作用,今后应合理引导其落实国家基本公共卫生服务。为实现政府办社康中心的可持续健康发展,完善其管理体制是当务之急。     

非政府组织在全球健康治理中的作用研究

全球健康体系正在经历变革和更新,从而带来全球健康参与者的重大转变。非政府组织(Nongovernmental organization,NGO)作为全球健康体系中的一个关键参与者和决策者,具有全球健康治理的丰富经验,可以为中国参与全球健康决策与治理提供系统性的经验。本文旨在研究NGO在全球健康领域中的作用。结果发现,NGO在全球健康领域中的作用可以总结为四个方面:倡导、实施、支持和社区动员,但同时NGO也会给全球健康治理带来一些潜在的风险,如某些NGO所代表的国外组织或政府的利益和本国利益产生冲突;NGO组织可能会吸引当地卫生官员和技术人员加入,从而削弱了本国卫生人力和卫生体系;捐助者驱动的资助模式可能不能完全用于国家健康需要的优先领域。中国和中国NGO在借鉴经验的同时,也要合理规避这些风险。     

大型三甲医院与政府联合举办社区卫生服务中心运作模式分析

大型三级甲等医院与区政府联合举办社区卫生服务中心,缓解医院门诊压力,解决居民看病难问题,同时为出院患者提供延续治疗服务。此模式社区卫生服务中心业务用房和医疗设施设备的配置均由地方政府免费提供,交由医院独立经营管理,服从地方卫生主管部门的行业管理。该中心成立三年以来,随着知晓率不断提升,业务工作量逐年呈现大幅度上升,相当于成都相似规模其它社区卫生服务中心的3倍以上,病人满意度大于99%。三甲医院与区政府联合举办社区卫生服务中心,高水平的基本医疗技术赢得了社区居民的高度信任,极大的提高了中心的知名度,促进了公共卫生服务的开展;公共卫生服务的有序开展进一步提升了中心基本医疗业务的知晓率,促进居民选择就近就医,真正实现了分级诊疗。     

The growing influence of non governmental organisations (NGOs) in international health: challenges and opportunities

The growing influence of non governmental organizations (NGOs) in international health is occurring in the face of major challenges and opportunities. These challenges include the continued increases in global poverty status, the growing influence of private-funded health systems, the need for sustainability of external-funded programs, and the clamour for community participation in the planning and management of external-funded programs. Opportunities include the near universal recognition of the indispensable roles of NGOs by bilateral institutions and governments, the current emphasis on global trade by developed countries, and the need to develop political and economic systems that are equitable and promote social development. This article is an overview of these challenges and how these challenges can become excellent opportunities for NGOs to improve the health and social development of target communities in developing countries.     

浙江省乡村医生参加临床进修的可行性调查

目的：了解浙江省乡村医生参加临床进修,接受临床指导的可行性。方法：采用自行设计的《乡村医生临床进修可行性调查表》,对全省84个县（市、区）卫生局发放问卷调查,对收集的数据进行分析。结果：26个县的乡村医生实行乡村一体化管理;22个县的乡镇卫生院（社区卫生服务中心）实行收支两条线;22个县的乡村医生临床进修费用和工资补助由本级财政和单位共同承担,4个县由所在单位承担;26个县的乡镇卫生院（社区卫生服务中心）在乡村医生临床进修期间,可以派医生到村卫生室顶岗;41个县认为乡村医生参加临床进修1~3个月,可以替代2年一次的注册培训。结论：乡镇卫生院（社区卫生服务中心）对乡村医生实行乡村一体化管理,并实行收支两条线的情况下,乡村医生参加临床进修和临床进修费用及工资补助是可以落实的;临床进修替代注册培训的时机尚不成熟。     

武汉市社区卫生服务中心中医药服务现状调查

目的 调查武汉市社区卫生服务中心中医药服务现状。方法 于2021年3月对武汉市10个城区28家社区卫生服务中心的28名管理者、211名中医药从业人员以及481名社区就诊居民进行问卷调查。采用Excel 2013软件统计分析数据。结果 28家社区卫生服务中心2021年度中医就诊人次仅占总就诊人次的11.18%,均开设了中医药相关科室,中医治疗设备基本配备,但中医药服务项目较单一,仅围绕老年人群的保健项目开展率较高;均不同程度开展了中医慢病管理项目,但仅糖尿病(消渴病)、高血压(眩晕病)开展率为100%,其他慢病管理项目开展率均≤50%。28家社区卫生服务中心中医药从业人员以大专学历、初级职称为主,且有8.1%无职称人员。社区居民对中医药服务需求较高,但了解程度较低。结论 应以加强中医药慢病管理为切入点拓宽中医药服务范围,加强社区中医药人才培养和队伍建设,加大中医药宣传力度,创新中医药服务模式,加强监督与考核。     

Partnership in rural water supply and sanitation: a case study from Bangladesh

A non-governmental organization (NGO) for drinking water supplyand sanitation conducted a two-year rural Water Supply and Sanitation(WSS) project in wide areas of rural Bangladesh. The projectprovided handpumps, latrines, and hygiene education to ruralpeople through NGO partners. Its performance was evaluated throughinterviews with women users, women pump caretakers and trainersfrom partner NGOs. Of 295 health NGOs (partners), 233 NGOs participated in thewater supply programme and 153 of them participated in the sanitationprogramme. This multi-agency collaboration demonstrated thepotential for reaching widespread underserved and unsurved peoplein a logistically efficient way. About 100 000 people were providedwith access to handpumps. The potential for revolving the financialassistance in sanitary latrine production/promotion was observed.The project, however, lacked the 'soft-ware' achievements, thatis, community participation, personal hygiene practices andeffective use and maintenance of the WSS provisions. This reconfirmsthe difficulties experienced in this field, even at multi-agencycollaboration levels. Sustainable measures for 'hardware' aswell as 'software' activities should be addressed appropriatelyat multi-agency levels also.     

Guthrie house: a rural community organizing for wellness

This paper is interested in the issue of community participation and empowerment in health care provision and decision-making. In Canada, the present scope for public involvement in planning or managing the state's health and social services system is limited. This poses a particular problem for rural communities--places where the provision of health care services has historically been limited when compared to urban locations. These rural communities are now facing a double burden as public policy moves increasingly towards a retrenchment of the welfare state. This paper examines one rural community's response to this double burden. The village of Elgin in rural Ontario recently established Guthrie House, a community-based resource center for health and wellness services. Community participation in this case involved a level of control whereby local citizens together defined the health and social care services that they saw as best meeting the needs of their community. This form of community participation is considerably different from the forms of public involvement in the established medical system and represents a critical link to 'empowering' the local community as partners in health care. Through an examination of Guthrie House, the paper presents a review of some critical 'characteristics' which mark successful community self-help organizations and concludes with a discussion of the policy implications for greater community participation. It is argued that such community participation in health care is a policy option which government should be paying particular attention to in these times of fiscal constraint, increasing health care needs and increasing consumer dissatisfaction with government service provision mechanisms.     

The work of community health workers in major cities in Brazil: mediation, community action, and health care

This paper examines the role of community health workers (CHWs) and discusses the challenges in performing their multiple functions as: mediators linking the community and health services, community organizers, and care providers. A survey of CHWs was conducted in four towns in Brazil. The results indicate that during their home visits and community actions, the CHW perform educational and care activities for priority groups. Some CHWs work in health centers, where their functions include care management for chronic patients. The results indicate gaps in the work actually done, mainly as regards the expectation that CHWs would play a more political role, mediating between the communities and public policies, especially health policy. The CHWs in Brazil are general-purpose health personnel with a hybrid role that oscillates from technical to political profile.     

Maximizing participation of Hispanic community-based/non-governmental organizations (NGOs) in emergency preparedness

To better understand social and structural changes needed to maximize community-based participation in emergency preparedness, 27 organizations, representing 12 states, participated in a study of the National Alliance for Hispanic Health. The study assessed social change needs (social will, community readiness, assets, and barriers) and structural needs (organizational capacity to integrate services into emergency management efforts locally). Results show high social will but little community readiness. Most non-governmental organizations (NGOs; 96%) were willing, but ill-prepared (65%) to face large-scale emergencies. Assets include bilingual/bicultural personnel, cultural competency, local knowledge, and public trust. Barriers include lack of culturally appropriate training and resources. Structurally, most NGOs want to link with voluntary organizations (79%) and public health departments (74%), but lack integration and coordination. Maximizing timely participation of these underutilized stakeholders in emergency planning can ensure culturally-proficient, community-tailored emergency plans, increased public confidence, and timely compliance with evacuation orders, thus helping to save lives.     

浙江省家庭医生服务供需匹配现状及其对接策略研究* ——以平湖市为个案

目的通过对平湖市钟埭街道社区居民、家庭医生团队成员和队长进行调查,了解家庭医生服务供需匹配状况,发现存在的问题,提出促进家庭医生服务供需对接的策略和建议。方法 2018年4—5月对钟埭街道社区居民进行实证调查,采取多阶段随机抽样的方法抽取305名居民为调查对象,了解需方现况;对45名家庭医生和5名家庭医生团队队长进行调查,了解供方现况。结果结合问卷调查和访谈结果发现,目前社区卫生卫生服务中心提供的家庭医生服务存在供需不匹配的问题。究其原因,主要有家庭医生数量不足和质量不高、社区卫生服务机构硬件基础不够完备以及供需双方积极性均有待提高等。结论家庭医生制度的纵深发展离不开对供需对接策略的思考,可以从家庭医生队伍培养、社区优质卫生资源整合、公众参与表达机制建构、精准化签约服务供给以及供需双方签约积极性双提升等方面着手构思。     

2011—2012年浦东新区社区卫生服务机构五项能力评价研究

目的量化评价并对比分析2011和2012年浦东新区社区卫生服务机构的五项能力。方法运用自行设计的调查表,对2011和2012年浦东新区所有社区卫生服务中心的五项能力进行横断面调查,并采用描述性统计、单因素分析及线图进行资料分析。结果 2012年浦东新区社区卫生服务中心的机构实力、经济运行、改革创新和主任管理表现优于2011年（P〈0.05）,而两年的社区服务能力没有差异（P〉0.05）;2012年不同区域的机构实力和改革创新能力存在差异（P〈0.01）;2012年各机构在经济运行能力的差异比2011年有所缩小。排名较靠后的主任管理能力两年间有较大改善,而排名靠前的机构在改革创新方面提升比较大。结论 2012年浦东新区社区卫生服务中心的绩效普遍优于2011年。各区域的五项总能在城郊间尚存在一定差距,建议加强社区卫生资源配置的政策倾斜、进一步强化信息化和人才队伍建设,并通过开展各类经验分享交流会,缩小差距。     

无锡地区基层医务人员脑卒中社区管理知信行调查

目的 分析无锡地区基层医务人员脑卒中社区管理知信行(KAP)的调查结果,分析KAP的影响因素。方法 以无锡市基层医疗服务中心负担慢性病管理的医务人员为研究对象。采用多阶段分层整群抽样的方法于2021年5月按10%比例抽取8家社区卫生服务中心从事慢性病管理相关工作的医务人员(包括全科医师、公共卫生医师、护理人员、中医师等)进行脑卒中KAP问卷调查,采用描述性分析方法对医务人员脑卒中知信行情况进行分析,并使用单因素、多因素分析方法对医务人员脑卒中社区管理KAP影响因素进行分析。结果 共纳入512名基层医务人员的问卷进行分析,其中全科医师154名,公共卫生医师54名,护理人员227名,中医师77名。基层医务人员对于脑卒中社区管理的知识得分为(29.68±9.23)分,态度得分为(31.02±4.32)分,行为得分为(33.63±2.67)分。多重线性回归分析结果显示,经济发达地区(β′=0.137)、全科医师(β′=0.523)的医务人员脑卒中管理知识得分较高,经济发达地区(β′=0.324)、全科医师(β′=0.203)、知识得分高(β′=0.553)的医务人员脑卒中管理态度得分高,经济发达地区(β′=0.506)、全科医师(β′=0.434)、知识得分高(β′=0.619)、态度得分高(β′=0.719)的医务人员脑卒中参与得分较高。结论 该地区基层医务人员具有一定水平的脑卒中健康管理工作的知识,但是对于该项管理工作的认可程度以及参与程度有待提升,在社区中实际开展的相关管理工作的深度与广度也不足。有关部门需要在政策层面做出调整,改变现有的工作模式,对基层医务人员加以正确的指引。     

信息技术对社区卫生门诊服务流程重组的效果评价

目的:评价信息化技术在社区卫生服务中心门诊流程优化和提高医疗服务满意度方面的作用和效果。方法:通过观察法记录两社区卫生服务中心同一时期时段各37名和49名的门诊病人的就诊流程和时间,并以问卷的形式调查111名和100名就诊病人对医疗服务流程的满意度。结果:实现信息化能明显缩短就诊流程中所耗费的时间,门诊病人对医疗服务的满意度较高。结论:信息化技术的应用促进了门诊流程优化和医疗服务满意度提高。     

Context matters in NGO-government contracting for health service delivery: a case study from Pakistan

Contracting non-governmental organizations (NGOs) for health service provision is gaining increasing importance in low- and middle-income countries. However, the role of the wider context in influencing the effectiveness of contracting is not well studied and is of relevance given that contracting has produced mixed results so far. This paper applies a policy analysis approach to examine the influence of policy and political factors on contracting origin, design and implementation. Evidence is drawn from a country case study of Pakistan involving extensive NGO contracting for human immunodeficiency virus (HIV) prevention services supported by international donor agencies. A multilevel study was conducted using 84 in-depth interviews, 22 semi-structured interviews, document review and direct observation to examine the national policy design, provincial management of contracting and local contract implementation. There were three main findings. First, contracting origin and implementation was an inherently political process affected by the wider policy context. Although in Pakistan a combination of situational events successfully managed to introduce extensive and sophisticated contracting, it ran into difficulties during implementation due to ownership and capacity issues within government. Second, wide-scale contracting was mis-matched with the capacity of local NGOs, which resulted in sub-optimal contract implementation challenging the reliance on market simulation through contracting. Third, we found that contracting can have unintended knock-on effects on both providers and purchasers. As a result of public sector contracts, NGOs became more distanced from their grounded attributes. Effects on government purchasers were more unpredictable, with greater identification with contracting in supportive governance contexts and further distancing in unsupportive contexts. A careful approach is needed in government contracting of NGOs, taking into account acceptance of contracting NGOs, local NGO capacities and potential distancing of NGOs from their traditional attributes under contracts. Political factors and knock-on effects are likely to be heightened in the sudden and aggressive use of contracting in unprepared settings.     

A manual for community mental health activities for a public health center in Japan]

A system for treatment of persons with chronic mental disease such as schizophrenics in the present structure of the Japanese public Health Center is proposed. Presently, while cases are handled by responsible staff members, incorporation into the health center system with full utilization of its personnel and resources is seldom accomplished. There is a necessity for a systems approach in order to organize essential programs that would provide care for the mentally diseased. Health centers would have three main roles in this system: as a coordinator of mental health resources in the community, as a specialized agency for case management, and responsibility for public relations in its service area. For proper administration of its system, health centers should follow a team concept. The team would consist of a director of health centers, physicians, part-time psychiatrists, public health nurses, psychiatric social workers and clerical staff. At case conferences discussion of whether a prospective case should be registered, assessment of the needs, and development of management plans for all of the registered cases would be conducted. The files and documents of each case would be deleted or re-registered 5 years after initial registration. Cases would have a case-manager to coordinate public health care, including home visits, family care, psycho-educational consultation and crisis intervention. Health centers would be responsible for bringing together available social resources such as sheltered workshops and transient residential programs. The goal of health centers' mental health activities would be to facilitate the normalization of the mentally diseased within the community.