By: Elsbet Lodenstein (Royal Tropical Institute/VU University, Netherlands)
Conflicts of interest are Health Committees’ raison d’être
A recent article on Health Committees (HCs) by George et al. (2015) discusses the intermediary role that HCs play between communities and health facilities. The effectiveness of this role depends on the trust and support that communities and health providers put in HCs, which in turn depends on how well HCs balance community and health facility interests. We would like to further this discussion, inspired by a Roman legend and our own study findings.
In ancient Roman religion, Janus is the god that presides, over war and peace. Janus is associated with gates, doors, and passages that were open in time of war, and closed in time of peace. He has two faces, one looking to the future and one to the past (Wikipedia). Janus-faced symbols exist in all cultures, such as in this Nigerian mask to represent different forms of duality.
Janus and Health Committees
What does this have to do with Health Commitees? HC members in our study in Benin, Guinea and DRC often described their own role as “bridges” (“jouer le pont”) between the community and the health centre. Other respondents referred to HCs as “gatekeepers” to ensure a smooth running of the health facility, to “filter out” potential problematic patients and to soothe misunderstandings between users and providers. Besides their role in the daily co-management of the health centre, this brokering role seemed part of daily practice and crucial for users as well as providers. Similarly, when asked what HC members’ ideal profile would look like, participants often responded that besides “knowing about health, and being able to apply the management tools”, HC members would need the ability to understand both medical and community interests on health care and be able to mediate between them. Hence the comparison of HCs with Janus and the question this blog addresses: how do HCs cope with their dual role as representatives of the interests of both users and providers? And is this dual role desirable or should we focus on one role?
In our study, we saw HCs using both faces, sometimes deliberately emphasizing one face over the other. When HCs used their “community face” they engaged in monitoring health workers’ behavior at the health centre and in advocating for quick or better treatment of patients, better public display of consultation fees or protecting users from misbehaving health workers by using formal reporting mechanisms. HCs using their “provider face” engaged in supporting material distribution, sensitization campaigns, conduct household visits, co-manage drug funds, ensure cleanliness of the health centre or provide health services.
What does the literature say about the dual role of Health Committees?
In the literature, Falisse et al. (2012) suggested that the dual role of controlling and criticizing on the one hand and collaborating on the other could be conflicting but in our study most HCs seemed to be able to cope with combining the roles; McCoy (2011) who conducted a literature review concludes the same. So is the ambivalence in roles of HCs a problem or not? During our reflections, we came across the work of Eric Wolf, an anthropologist who wrote on the complexity of group relations in 1956, way back before the Bamako Initiative. From his point of view, Health Committees’ role is actually to maintain the tensions between users and providers; they should not settle conflicting interests since by doing so, they would abolish their usefulness for both groups. In this sense, HCs would not have a raison d’être but for the tensions between users and providers or communities and the state at large. This would require HCs to carefully use their Janus face and navigate between the two roles. This suggests that the dual role of HCs should be strengthened and that it is possible for HCs to act simultaneously as representatives of the health system and as advocates for communities from which they come.
What is your point?
How does this work in your settings and experience? To what extent are HCs capable to navigate interests? Does the composition and mode of election matter? Should both roles be strengthened or are you in favor of HCs focusing on one role?
Please, send us your opinion at the section ‘Comment’ !!!
Commentaire de Audace Makamba
A mon avis il y a une confusion qu’on entretient depuis plusieurs années: Au moment où le secteur de la santé n’avait pas assez d’agents pour prester les services et soins de santé, il devait trouver une solution et une des solutions était de recourir aux ASC ou ASV auxquels quelques notions étaient données pour suppléer cette carence. Ceci tout en disant, dans l’égoïsme des professionnels de santé, que ces agents devaient être des bénévoles au moment où eux étaient rémunérés en sachant bien que ces agents sont pauvres et qu’ils n’avaient pas le choix (fiers d’être choisis et revêtus d’un statut particulier. On a embelli ce poste en donnant des critères pour y accéder.
Des années durant, jusqu’aujourd’hui, nous les professionnels de la santé, on oublie les notions de base: Le système de la santé appartient à la population qui doit le gérer directement ou en utilisant les techniciens que nous sommes, sans oublier les autres catégories plus outillées que nous pour ce faire, notamment les anthropologues, les sociologues, les économistes et autres. Une autre notion de base qu’on oublie aussi, c’est la pyramide de Maslow. Dans beaucoup des pays, ces ASV sont la même dénomination que le “DOCTEUR”, tout comme les infirmiers, les pharmaciens et autres. Quoi de plus normal que ces ASV cherchent eux aussi à faire la même chose et avoir les mêmes avantages ou s’y rapprocher (un ASV nous disait à Buake que tout allait bien sauf qu’il avait une rupture de stock en fils de suture! Il n’est pas le seul: regardons autour de nous tous ces dispensaires et tous ces étalages des médicaments.
Nous memes, nous écartons ces ayants-droits (ASC) de la gestion de leur système de santé, sauf pour des choses secondaires, et nous leur demandons de faire ce que nous nous devrions faire et on invente toute une panoplie des raisons qui, toutes, dénotent de notre insuffisance.
Je suis dur, je sais, mais nous devons nous remettre en question, d’autant plus que tout le monde dit que ce sont les recommandations de l’OMS, c’est l’UNICEF, etc.
Que doit-on demander à ces vaillantes personnes sinon d’agir comme ce que j’ai vu à Pikine (Dakar) en 1986, où ce comité de gestion ne permettait pas à ce Médecin chef de l’entité de s’occuper de LEUR dépôt pharmaceutique car lui n’était qu’un agent de l’Etat appelé à travailler n’importe où. Il nous appartient aussi d’être plus inventif pour amener chaque citoyen à adopter un comportement favorable à la santé, santé vue comme élément essentiel dans sa vie comme les autres aspects de base.
Voilà ce qui peut nous écarter de cette dualité de Janus, dualité qui n’est pas nécessairement mauvaise car chacun d’entre nous la vit au quotidien sans en faire “un métier” comme on le fait aujourd’hui.
Audace Makamba
It is my strong belief that the dual role of HCCs is what defines the committee and also its roles. The work that the Community Working group on Health(http://cwgh.co.zw/) has done over the past decade with HCCs has brought this notion out strongly.
A 2009 Training and Research Support Centre (TARSC) and Community Working Group on Health (CWGH) assessment on Primary Health Care (http://tinyurl.com/5rdnh7v) found out that functioning HCCs were associated with higher levels of satisfaction with services, attributed to the communication, improved understanding and support for morale that they build between communities and health workers.
This goes to show that HCCs offer an opportunity to take forward the shared local priorities across health workers and communities and to discuss how to accommodate differing priorities between them.
In Zimbabwe, Health Centre Committees (HCCs) identify priority health problems with communities, plan how to raise their own resources, organize and manage community contributions, and advocate for available resources for community health activities. They discuss their issues with health workers at the HCC, report on community grievances about quality of health services, discuss community health issues with health workers and also discuss health worker issues with the community through various community feedback mechanisms