Dr. Mahesh Shukla, Senior Technical Advisor, LMG
Health committees are one of the most widely implemented community-level participation and accountability mechanisms in Africa and Asia. They represent multiple constituencies at community, facility, district, and provincial levels, and bring together diverse stakeholders including community members, health workers, and health managers with a view to better understand and respond to health needs.
At the Third Global Symposium on Health Systems Research on September 30 – October 3, over 170 sessions and 572 posters were presented on health policy and systems research. Many of these focused on health committees and their contributions to strengthening the responsiveness of health systems. Contributing to this exchange of knowledge, the Kenya Medical Research Institute (KEMRI)/Wellcome Trust, the Health Finance and Governance Project, the Public Health Foundation of India, and the Leadership, Management & Governance Project (LMG) presented a panel on Building collaborative and equitable governance mechanisms: Experiences strengthening health committees in diverse health systems contexts.
The panel presented their research on health committees from different country contexts, and discussed how these governance committees broker different interests from multiple constituencies and contexts. The panel also talked about factors that underpin effective functioning of these multi-stakeholder health committees and how they can become more effective in meeting the health needs of the community. Participants remarked on the importance of inclusion among health committees. There are tendencies to include the groups who are easiest to access, which may marginalize some constituencies. It is important to have diverse committee membership to build trust, coalesce, and to create opportunities for everyone to voice concerns. Many comments also pertained to committee responsiveness, to which the panel recommends: appointing competent people; orienting and supporting members; moving control from the health workers to community members; creating a conducive policy environment; and collaborating across sectors.
In Kenya, health committees that include community representatives were established at all government health facilities in the 1980s. Recently, their role has been expanded to include management of the Health Sector Services Fund. Panelist Evelyn Waweru of KEMRI/Wellcome Trust observed that there are opportunities for improved functioning of the health facility management committees by having clear definitions of their roles and responsibilities and by providing supportive supervision.
Similarly, in Ethiopia, health centers and hospitals are now governed by boards with community representation (98% of hospitals and 92% of health centers have governing boards, and 69% of hospital and 61% of health center boards review financial and technical performance). Tiliku Yeshanew of the Health Finance and Governance Project in Ethiopia presented evidence on the responsiveness of the health facility governing boards and concluded that the committees have helped clarify community expectations for the health facility and identify health service delivery gaps that were not previously recognized.
“We didn’t give services after 5:30 PM local time, but now workers are delivering services in their time off. Previously, night duty was for emergency cases only, but now others can also get services during night. We pay to those who work in their time off.”
— Staff representative of health center governing board, Oromia region
“We have used the discussions with the community as input to our health center action plan. As a result, we have worked on the gaps and we have identified the sources of the problems. Then we have reported back to the community that we have solved the problems that had been raised by the community.”
— Chairperson of health center governing board, Oromia region
In India, over 500,000 village health, sanitation, and nutrition committees include frontline health workers, local political leaders, and community members, and are expected to carry out various tasks spanning village health planning, health facility monitoring, health promotion, and facilitating access to health, nutrition, and social services. The Public Health Foundation of India’s Kerry Scott shared the initial findings of their VOICES study in India that showed that ongoing facilitation of the work of these committees by providing them orientation, training and capacity building support is vital to their success in meeting community health needs.
Finally, health shuras, or health committees, exist at provincial, district, health facility, and community levels in Afghanistan as forums for information sharing, coordination, and monitoring of health services. More than 100,000 individuals serve as members of these committees and perform a governing role. The LMG Project shared implementation research in three provinces and eleven districts of Afghanistan where consistent application of effective governing practices by the provincial and district health coordination committees showed encouraging results in terms of performance of provincial and district health systems. When Provincial Public Health Coordination Committees and District Health Coordination Committees consistently applied the effective governing practices over a period of six months, we saw 13 to 21% improvement in their governance and 20% increase in antenatal care visit rate in the pilot provinces.
Findings across these varied settings suggest that health committees are expected to perform a governing role and they have a clear opportunity to influence the performance of the health facility or health system they govern; however, research also shows that committees often lack the capacity to fulfill their governance responsibilities. To realize their full potential, we must make investments in building their capacity to not only govern, but also govern well.