Public views on community involvement in local health services in South Africa

Public Health (1997) 111, 399±404 ß The Society of Public Health, 1997

Public views on community involvement in local health services in South Africa GC Chimere-Dan Population Research Programme, University of the Witwatestrand Johannesburg, Box 339, WITS 2050, South Africa An analysis of the information collected in a nation-wide health survey shows that the South African public favours the involvement of communities in local public health services. There are variations in the support for community involvement in four aspects of health services examined, namely decision on opening times of clinics, determination of patient-provider relationship, recruitment of staff and determination of service charges. Multivariate analysis indicates that the level of support for community involvement is signi®cantly low for Whites relative to other races, lower for rural residents than for city dwellers and high for people with a very good health status. Further focused research is required for improved understanding of the problems and policy options in community involvement in public health programmes. Since 1994 the new government has consistently expressed a strong commitment to involve communities in the design and implementation of health policies and programmes. However, considerable amount of uncertainty remains on how to translate such commitment into practical action at the local level. Keywords: local health services; community involvement; patient-provider; service charges; staff recruitment; South Africa

Introduction There is a growing body of literature on the broad subject of community involvement in health programmes.1±20 However, little empirical information exists on speci®c aspects such as the communities' understanding of the concept of involvement, public support for involvement at the local level, strategies for implementing community involvement and the implications of different models of involvement for the structure of national and local health services. Until recently, public health services in South Africa did not provide adequate health care for the entire population. Nor did it involve communities to a signi®cant extent in the development and running of local health services. From the onset of the political transformation that preceded the democratic elections in 1994, policy makers expressed a commitment to restructure the highly fragmented public health services with strong emphasis on community involvement in the development and implementation of health policies and programmes.21 However, although community development in general has received substantial research attention in South Africa, community involvement is a relatively new concept in the delivery of health services. Since 1994, the national and provincial departments of health have taken steps to involve the public in identifying areas or priorities. Policy statements on how to involve communities range from support for the use of democratically elected representatives21 to the formation of community health committees.22 In the most recent policy document which outlined the national health goals, objectives and indicators for South Africa until the year 2000, the establishment of structures to promote community involvement at the national, provincial and local levels is recognized as the indicator of action with respect to initiating community involvement.22 Correspondence: GC Chimere-Dan Accepted 23 April 1997

Amidst these developments, the views of the public or speci®c communities on community involvement have not been examined in any detail for South Africa. A recent community-level study to examine community perspectives on selected indicators of community involvement in health programmes showed that community members are willing to make any sacri®ces implied in their involvement.19 Given the governments's emphasis on community involvement in public health programmes,22 knowledge of public perception on community involvement is important for successful implementation of public health services. The objective of this paper is to examine the level and correlates of public support for community involvement in local public health services. Aspects of health services examined are opening times for health clinics, decisions on the relationship between patients and service providers, recruitment of staff, determination of the cost of local health services and an overall measure of community involvement. Method This paper is based on information collected in October 1994 in a national survey of health inequalities in South Africa which was funded by the US-based Henry J Kaiser Family Foundation. A probability sampling design, strati®ed by race, province and rural±urban residence was used to collect health and related data from 4003 households. Details of the methodology are contained in the survey report.23 The sub-set of the data used for the present analysis consists of information from 3796 men and women aged between 16 and 64 y inclusive. The survey collected information on public views on the involvement of communities in the following components of local public health services. (The question was asked as follows: `Some people feel that people in the community should have a say in running local public health services. Do you or do you not think that people should have a say in: (I) Deciding when local clinics should open? (ii) How staff deal with

Public viewsÐlocal health services GC Chimere-Dan

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patients? (iii) The appointment of staff members? (iv) What people should pay for services?' The questions were read out to the respondents and they were required to answer yes or no). (I) decision on when in the day local clinics should open, (ii) the relationship between staff and patients, (iii) the appointment of staff members and, (iv) the cost of local health services. In the ®rst part of the analysis, the responses to these four variables were examined separately. The association of each of these variables with a set of demographic, socioeconomic and self-rates health factors were analysed. Formal tests of the statistical signi®cance of the bivariate associations was conducted using the chi-square (w2) statistic. In a further analysis, a composite measure of support for community involvement in health was developed using the responses to each of the four aspects of local public health services identi®ed above. Initially the new variable was set to zero and incremented by one if a respondent supported community involvement in each of the four aspects of local health services. The resulting variable has values that range from zero to four, representing people who support community involvement in none and those who support community involvement in all four aspects of local health services. Lastly the scores of this measure of community involvement were recorded using values lower than three to indicate low and values of three and four to indicate high levels of support for community involvement. Multivariate analysis of support for community involvement was carried out using the logistic regression technique. The independent variables used in the bivariate and multivariate analyses comprise three demographic measures, namely age, sex and marital status, three sociocultural measures, namely area of residence, race and education, two economic measures, namely current work status of respondent and monthly household income and two indicators of potential health care needs, namely present status of the respondent and the presence of a child under the age of six in the household. Attention is drawn to the fact that problems in the analysis of public views on community involvement collected in this study arise primarily because the survey on which the present paper is based was not designed with primary emphasis on community involvement. As a result, the data do not contain as much detailed information on community involvement in health as would be expected in a study that is exclusively focused on the subject. This limitation notwithstanding, the study collected the most recent and nationally representative data on public views on community involvement in the running of public health programmes in South Africa. Results High level of support for community involvement The results shows a high level of public support for the four aspects of community involvement examined in this study (Table 1). Quite a high percent of the respondents support community involvement in determining when health clinics open (83.4%). Over 74% of the respondents support community involvement in determining the nature of patient-provider relationship (74.7%) and in decisions about cost of services (70.7%). The lowest level of support is recorded for community involvement in the selection of staff for local public health programmes (51.8%).

Variations in the level of support for community involvement Only three variables, namely type of area of residence, race and health status, showed consistent and high statistically signi®cant associations with the four measures of community involvement (Table 1). The highest level of support for community involvement is observed for residents in White farms (White farms are commercial farms owned by White South Africans and constitute a signi®cant proportion of the rural areas employing predominantly Black workers.) while the least level of support is expressed by residents in rural homelands. Support for the four aspects of community involvement is highest for Indians and lowest for Whites. People who perceived themselves to be in a very good state of health support community involvement in the four aspects of community involvement more than others. The lowest level of support for these aspects of community involvement was reported by those in a fair state of health. Age of the respondence, sex, occupation and the presence of a child in the household do not show statistically signi®cant associations with support for community involvement in any of the four aspects of local public health programmes. Marital status is signi®cantly associated with support for community involvement in staff selection (P < 0.05) and in decisions about the cost of services (P < 0.05), but shows no signi®cant association with support for decision about when local public health clinics open and patient-provider relationship. Education is signi®cantly associated with only support for community involvement in patient-provider relationship (P < 0.01) and in recruitment of staff (P < 0.001). Household income is signi®cantly associated with only support for community involvement in the selection of local-based health staff (P < 0.001).

Determinants of levels of support for community involvement Bivariate and multivariate analyses of the determinants of the overall level of support for community involvement in local public health services (Table 2 and Table 3) con®rm the major results identi®ed in Table 1. A majority of the respondents (65%) support community involvement in local health services (Table 2). Three factors that show highly signi®cant statistical associations with the level of support for community involvement are race (P < 0.001), type of area of residence (P < 0.001), and health status (P < 0.001). With simultaneous controls of other background factors, it is observed that Blacks, Coloureds and Indians have signi®cantly higher levels of support for the involvement of communities in public health services than Whites (Table 3). In particular, the level of support for community involvement among Indians is over eight times higher than the level of support among Whites. The level of support among town dwellers and residents in white farms are signi®cantly higher than the level of support among metropolitan residents. Rural homeland residents have a signi®cantly lower level of support for community involvement that people in the metropolitan areas, and those with fair health condition have a signi®cantly lower level of support than those in a very good state of health.

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Table 1 Percentage of respondents who support community involvement in aspects of local public health services by background characteristics (N ˆ 3796) Aspect of community involvement Characteristic

Deciding when clinics open

Patient/provider relationship

Appointment of staff members

Deciding on the cost of services

ns 83.9 83.7 84.7 83.2 80.7 ns 84.6 82.9 ns 83.3 80.7 81.8 89.4 ** 85.3 82.6 81.5 87.7 80.0 *** 84.0 83.2 95.4 74.9 ns 79.5 83.6 83.2 84.2 84.5 82.7 ns 84.0 83.3 84.7 81.7 83.3 ns 82.8 83.8 82.3 85.5 80.8 ** 87.2 84.4 81.3 81.6 ns 83.4 83.4 83.4

ns 75.3 75.2 76.2 72.9 72.7 ns 75.4 74.4 ns 76.2 73.0 75.1 77.1 *** 77.7 77.5 66.9 81.1 63.8 *** 72.3 79.0 93.7 68.8 ** 68.6 69.4 74.1 77.5 77.4 73.6 ns 74.4 74.1 77.6 73.3 75.6 ns 75.4 73.0 72.5 77.7 74.3 ** 78.2 75.3 70.3 75.7 ns 75.3 74.1 74.7

ns 52.9 52.5 50.7 53.8 49.8 ns 52.0 51.8 * 52.1 50.2 52.8 63.1 *** 49.6 55.5 49.2 65.9 43.1 *** 52.4 55.4 72.3 34.8 *** 51.9 52.5 55.8 53.2 49.4 39.8 ns 49.5 53.3 54.4 51.4 54.0 *** 57.4 53.6 52.5 53.1 43.6 *** 57.9 52.4 45.7 52.5 ns 50.3 53.4 51.8

ns 71.0 69.0 72.6 73.1 68.1 ns 72.8 69.8 * 71.6 68.6 73.8 76.0 *** 71.3 72.5 68.2 80.1 62.1 *** 68.1 72.9 90.8 66.7 ns 67.9 71.1 71.7 71.7 68.7 69.5 ns 71.5 68.4 71.6 70.9 71.4 ns 71.5 69.9 71.2 70.5 71.7 *** 74.1 70.6 66.0 72.6 ns 71.5 69.8 70.7

Age group < 20 20±24 30±39 40±49 50 ‡ Sex Male Female Marital status Single Married Wid/Sep/Div Cohabiting Type of area Metropolitan Town Transit urban White farms Rural homeland Racial group African Coloured Indian White Education No schooling SubA-Std 3 Std 4±6 Std 7±9 Matric completed Post matric Occupation Working Unemployed Student Housewife Retired-Disabled Household income No income < R 600 R 600±R 999 R1000±R3499 R3500 ‡ Health status Very good Good Fair Poor Child in the household No Yes Total

Note: Wid ˆ Widowed; Sep ˆ Separated; Div ˆ Divorced. *** ˆ P < 0.001; ** ˆ P < 0.01; * ˆ P < 0.05; ns ˆ not signi®cant.

Discussion This survey draws attention to the high level of support for community involvement in local public health programmes in South Africa. Whatever the public perception of the concept is, they do desire to be involved in different aspects of local health services. Such a high level of support for

community involvement in health services would most certainly be related to the widespread demand for popular participation in local self-governance that reached a climax in the 1994 general elections following the demise of the apartheid system. Racial differences in the level of support for community involvement are noteworthy. The results show a signi®cant

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Table 2 Bivariate association between public support for community involvement and background characteristics in South Africa 1994 (N ˆ 3796) Level of support for community involvement Characteristic Age group (ns) < 20 20±24 30±39 40±49 50 ‡ Sex ns Male Female Marital status (ns) Single Married Wid/Sep/Div Cohabiting Type of area*** Metropolitan Town Transit urban White farms Rural homeland Racial group*** African Coloured Indian White Education (ns) No schooling SubA-Std 3 Std 4±6 Std 7±9 Matric completed Post matric Work status (ns) Working Unemployed Student Housewife Retired-Disabled Monthly income (ns) No income < R 600 R600±R 999 R1000±R3499 R3500 ‡ State of health*** Very good Good Fair Poor Child in the household (ns) No Yes Total

Low

High

35.3 35.2 33.8 33.4 37.5

64.7 64.8 66.2 66.2 62.5

33.7 35.5

66.3 64.5

34.3 36.7 32.6 29.1

65.7 63.3 67.4 70.9

33.0 31.8 41.2 24.2 47.9

67.0 68.2 58.8 75.8 52.1

37.1 31.2 9.8 44.8

62.9 68.8 90.2 55.2

38.2 38.2 33.5 32.9 35.2 38.7

61.8 61.8 66.5 67.1 64.8 61.3

35.0 35.2 33.7 35.6 34.8

65.0 64.8 66.3 64.4 65.2

32.8 36.7 34.6 32.8 37.7

67.2 63.3 65.4 67.2 62.3

31.2 34.3 39.9 33.8

68.8 65.7 60.1 66.2

34.5 35.4 35.0

65.5 64.6 65.0

Note: *** ˆ P < 0.001; ** ˆ P < 0.01; * ˆ P < 0.05; ns ˆ not signi®cant.

racial divide in the level of support for community involvement in local public health services. Further studies are needed to determine whether the low level of support among Whites relative to other racial groups is a result of differential access to available health services, differences

in cultural understanding of the concept of community involvement or other reasons. Similarly, there are no obvious explanations for the low level of support for community involvement among rural homeland dwellers relative to residents of metropolitan areas, and for the signi®cantly low level of support among people who reported their health to be fair relative to those reporting their help to be very good. The results here invite a wider discussion of the current state and prospects of community involvement in health in South Africa. Firstly, the concept does not appear to have the same meaning to communities and policy makers. For the former, studies have suggested that the concept would mean, among other things, involving communities in identifying and setting priorities, decision making on appropriate delivery patterns and budgeting and evaluating actions.22±26 But there is presently no clarity on what the concept means to policy makers in practical terms, especially in the key areas of decision making and programme management at the community level. In general instances however, the Department has employed the concept (CIH) merely as a means of informing communities about and gauging their reactions to government proposed actions in public health. Vague as the of®cial usage of the concept might be, the Department of Health maintains a commitment to involve communities in the making and implementation of health policies. The pre-election health plan of the African National Congress provided for community involvement at the national, provincial, local and community levels through a system of advisory committees,21 and the national government is currently developing this commitment by a proposal to establish a national health consultative forum which will represent both statutory and non-statutory organizations involved in health. The National Health Bill which is expected to be passed by Parliament in 1997 provides for the establishment of health management structures at the local level which will be expected to promote public participation in health.27±30 At the provincial level, some governments, namely, Free State,31 Mpumalanga 32 and the North West 33 have drafted bills that emphasize community involvement. While the establishment of structures would indicate action on the part of national and provincial governments, it is uncertain that community involvement in public health programmes will necessarily follow the new structures. It remains to be seen how important community involvement will be when set against other pressures on decision makers in the national and provincial health departments. Conclusion Successful involvement of communities in meaningful and sustainable ways in health services requires a good understanding, borne out of innovative public health research, of the determinants of levels and variations in support for community involvement in local public health programmes. With reference to policy, a major challenge for the national health system is to determine the optimum level of priority to be accorded to community involvement in the face of political, economic, and ®scal pressures. It is probably too early to evaluate ongoing attempts on the part of the South African government to put into practice its expressed commitment to involve communities in all its health and other policies and programmes.

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Table 3 Logistic regression of level of support for community involvement in local public health programmes (N ˆ 3796) 95% CI for odds ratios Variable Age group < 20 20±29 30±39 40±49 50 ‡ a Sex Female Malea Marital status Singlea Married Sep/Div/Wid Cohabiting Area of residence Metropolitana Town Transit urban White farms Rural homeland Racial group Black Coloured Indian Whitea Education No schoolinga Sub A±Std 3 Std 4±6 Std 7±9 Matric completed Post matric Work status Workinga Unemployed Student Housewife Retired-Disabled Household income No income < R 600 R600±R999 R1000±R3499 R3500 ‡ a Health status Very gooda Good Fair Poor Child in household Yes Noa

b

P values

Odds ratio

Lower

Upper

70.200 0.004 0.158 0.230

0.092 0.303 0.974 0.227

0.81 1.00 1.17 1.25

0.55 0.75 0.90 0.96

1.19 1.33 1.51 1.64

70.049

0.557

0.95

0.80

1.12

70.268 70.393 70.172

0.154 0.032 0.419

0.76 0.67 0.84

0.52 0.47 0.55

1.10 0.96 1.28

0.340 70.205 0.721 70.422

0.000 0.140 0.000 0.000

1.40 0.81 2.05 0.65

1.17 0.61 1.47 0.51

1.68 1.07 2.87 0.83

0.323 0.416 2.148

0.022 0.004 0.000

1.38 1.51 8.57

1.04 1.13 5.70

1.82 2.02 12.87

0.010 0.293 0.370 0.265 0.234

0.947 0.053 0.021 0.150 0.252

0.79 0.80 1.06 1.14 1.03

0.73 0.99 1.05 0.90 0.84

1.39 1.80 1.98 1.87 1.88

70.104 0.013 0.108 70.152

0.527 0.941 0.608 0.373

0.90 1.01 1.11 0.85

0.65 0.71 0.73 0.61

1.24 1.43 1.68 1.20

0.358 0.127 0.195 0.107

0.086 0.443 0.220 0.419

1.432 1.13 1.21 1.11

0.95 0.81 0.88 0.85

2.15 1.57 1.66 1.44

70.204 70.403 70.112

0.062 0.000 0.329

0.81 0.66 0.89

0.65 0.53 0.71

1.01 0.83 1.12

0.036

0.690

1.03

0.89

1.20

a

Reference category.

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