Consultation and dissemination with community stakeholders and Department of Health
To take forward recommendations from evaluation of the first action learning cycle in May 2019, we convened a consultation and dissemination workshop on 13 November 2019 with officials from Mpumalanga province, Ehlanzeni district, Bushbuckridge sub-district and local health facilities of the Mpumalanga Department of Health, as well as community representatives from three villages within the MRC/Wits-Agincourt Health and Demographic Surveillance System.
The objectives were to:
(1) disseminate research processes and evidence;
(2) explore skills exchange with a focus on community participation and engagement, and;
(3) identify resources required and future activities for engagement in the programme.
Following short presentations, discussions centred around 3 themes: community engagement in health systems and planning, opportunities for change within a decentralized health system (decision spaces), and multisectoral collaboration.
Community engagement in health systems and planning
“We can avert service delivery protests with collaborative learning platforms. Thank you DoH for giving us an ear to speak to you” [Community Stakeholder]
VAPAR community stakeholders had shared experience, ensuing discussion focused community engagement as key to improving service delivery and acceptance of interventions and programmes. Challenges were raised. There is need to understand community needs and priorities to plan and run programmes from their perspective, rather than imposing government priorities. Collaborating with communities reduces inequalities and promotes sustainable solutions. There are already strategies in place such as the Integrated Development Plan (IDP) and clinic committees, but there are challenges in implementation, exacerbated by traditional leaders and communities not being united, lack of attendance at events like open days was interesting, also different age groups (e.g. some fora seen as only attended by elderly – e.g. CDFs). It was agreed that there is a need to look at existing structures and identify what is working and not and why, and that the VAPAR programme creates a platform for community to engage with DoH. While community engagement is important, it usually happens when departments have programmes or campaigns to deliver to the community. Instead of listening to community priorities and needs, they address their own agenda. However, these spaces or platforms should also be used to engage with community and deliver appropriate information relevant to the community.
Opportunities for change within a decentralised health system: ‘decision space’
“We must not be afraid to make mistakes, that’s when we learn”
After an overview of the international and national mandates for community engagement, including mandates within health system initiatives such as PHC re-engineering, including Ward Based Primary Health Care Outreach Teams (WBPHCOTs), school health nurses, and the Ideal clinic, the discussion focussed on role of the Community Health Workers (CHWs) in these programmes. Community stakeholders felt that CHWs are
not visible in communities, while DoH participants felt that community members have the responsibility to use the structures in their communities to engage with CHWs. There are challenges in monitoring CHWs: Clinic Operational Managers (OPMs) are overwhelmed, and there is some confusion since some CHWs are funded through DoH, while others are not, creating problems in administration and delegation of responsibilities. Challenges are aggravated by lack of communication and dialogue with the right stakeholders. In an ideal world, stakeholders from different government departments would work together but it’s not happening because priorities and mandates are different. Stakeholders confirmed that fluidity of roles between middle and senior manager is a further challenge. There are good policies and strategies to improve the systems and outcomes. However, facilities sometimes do not manage to reach set targets, and to avoid punitive measures, they bypass the system in order to be certified as performing facilities. It seems that the DoH targets may not encourage person-centred services. The VAPAR process works to develop safe spaces for service providers from different levels to share challenges, build communicative power, and collectively find solutions.
“You can’t have an ideal clinic when you have no water” [Researcher]
Following a presentation on decision spaces, discussion centred around opportunities for strengthening abilities of planners and managers to receive and respond to evidence and make decisions based on evidence as part of routine functions in the health system. Two main points emerged:
(1) The organisational culture in DoH i.e. management vs leadership, disjuncture / disconnection, quick solutions for complex problems which are not sustained, plus details on the ‘inherited’ challenges of the current CHW structure is the daily reality for health workers and directly impacts on the service rendered to communities, as well as the abilities to connect with a wider set of stakeholders;
(2) There is a need for a collaboration platform / safe space which will facilitate cohesion between DoH and the community (and cohesion between CHWs and the community), as well as ‘safe space for health workers to share what they experience, and to ‘reach out’ to other levels and sections, engaging a wider group of actors, with whom collective agendas can be cooperatively progressed. This will reduce the effect of silos between departments and even within them; the piecemeal responses (e.g. HIV hiring separate community workers); the planning cycles being out of sync across the sectors making joint planning more challenging.
VAPAR provides collaborative learning platforms, bringing together concerned actors for collective progression towards shared priorities, in independent processes and potentially within existing structures such as War Rooms and the IDP collaborative planning processes. This process will continue in Feb 2020 progressing the second cycle and taking the results of this consultation into our design