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A Literature Review of District Health Systems in East and Southern Africa: Facilitators and Barriers to Participation in Health

Author: L L Levers, F I Magweva and E Mpofu
Date: 2007
Size: 26 pages (127 KB)

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Summary

What are the facilitators and barriers to community participation in district health systems (DHSs) in sub-Saharan Africa? This literature review by the Regional Network for Equity in Health in East and Southern Africa (EQUINET) explores evidence on community voice, roles and participation at district level. The analysis is based on case studies in six countries: Botswana, Lesotho, Namibia, Rwanda, Swaziland and Tanzania.

Research and training on participatory healthcare in sub-Saharan Africa need to work with local citizens as ‘knowers' rather than as ‘objects of study’ in order to close the gap between knowledge and action. Health services need to systemically include the perspectives of citizens, through appropriate multi-disciplinary approaches, an informed knowledge of sectoral priorities, and practical measures for empowering all people. Further research needs to be done on health literacy, intentionality and the paradox of decentralisation.

The findings are discussed under the following headings: community-based health structures; community voice and roles in DHCs; the effects of DHC organisation on community participation; district representation of community interests at the national level; and gaps in the literature:

  • Government documents offer varying levels of detail about structures, but little operational information. Consultation on community needs and plans is absent or not readily accessible.
  • Government health care strategies do not include structural mechanisms for ensuring participatory procedures. Providers of health services are presumed capable of translating policy into practice without specific training or preparation.
  • Barriers to participation include: the attitudes of professionals; the failure to see health-care practices as a part of a larger service-delivery system; the inability to operate systemically; and the inability to recognise opportunities for authentic engagement.
  • There is little evidence of participatory health mechanisms for voicing local concerns at the national level. The degree and nature of consultation appear to be shaped by the degree of political will and power relations.
  • A gap exists between policy ideals and practice with regard to participation.

Culturally informed understandings of differing perspectives on health are needed. Any future research should be done in the context of the connections between poverty, health, equity and participation.

  • Community-oriented healthcare systems that are responsive to the needs of citizens are likely to be more successful than externally imposed systems which serve the needs of a distant provider.
  • Investments and measures are needed to fund, exchange knowledge on, assess performance in, provide social leadership for and strengthen community capacities for participatory processes and mechanisms.
  • Governments need to consider viable forms of collaboration with traditional health systems and incorporation of indigenous knowledge.
  • Talk of participation should not obscure an authentic process for establishing community voice and for delineating roles, backed by health literacy and other capabilities.
  • Features of centralised systems continue to affect participation, even under policies of decentralisation. There is little discussion regarding bottom-up representation of community concerns at the national level.
  • There is a need for a clearer conceptualisation of what is commonly meant by Primary Health Care (PHC) and DHS, so mechanisms and policies can be located within these conceptualisations.

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Source: Lopez Levers, L., et al., 2007, 'A literature review of district health systems in east and southern Africa: Facilitators and barriers to participation in health', Duquesne University, Counselling for Health International (CHI) Trust and Pennsylvania State University for the Regional Network for Equity in Health in east and southern Africa (EQUINET), EQUINET Discussion Paper No. 40, Harare
Author: Lisa Lopez Levers , levers@duq.edu ; Elias Mpofu , exm31@psu.edu
Duquesne University, http://www.duq.edu/


 

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