IN-DEPTH: Are clinic committees a missing link in SA’s COVID-19 response?

IN-DEPTH: Are clinic committees a missing link in SA’s COVID-19 response?Patients waiting at a screening station at Site B Community Health Centre in Khayelitsha. PHOTO: Nasief Manie/Spotlight
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Community Health Committees (CHCs), also called Clinic Committees, can be a powerful link between the community and primary healthcare facilities. Many clinic committee members however say they feel side-lined in government’s COVID-19 response.

Some told Spotlight they get little to no support from government and are not provided with personal protective equipment (PPE). During lockdown, this meant many clinic committee members had to stay home, leaving little to no oversight of health services at clinics during a time when many clinics are temporarily closed whenever a staff member tests positive, leaving patients to seek care at alternative facilities.

Why clinic committees matter?

According to Professor Leslie London, Head of the Division of Public Health Medicine at UCT, CHCs play an important role in primary healthcare but this role and the powers of these committees have been a grey area long before COVID-19.

Mzwanya Ndibongo, chair of the Khayelitsha Health Forum, training volunteers to help with COVID-19 cases. PHOTO: Nasief Manie/Spotlight

London says in 2003, the National Health Act was adopted and gave powers to clinic committees, but the Act was not specific on what exactly these committees should do and who should be in these committees.

It was left for provinces to decide.

CHCs include a (primary healthcare) facility manager, ward councillor and representatives from the community. With some CHC members nominated by the community and others appointed by the provincial health MECs, their role is to provide oversight and accountability on how primary healthcare facilities are managed.

“For a long time, there was no legislation, so it was difficult for them to fully execute their roles,” says London, adding that each province deals with clinic committees differently.

Community members waiting at the Site B CHC in Khayelitsha. PHOTO: Nasief Manie/Spotlight

Not fully utilised

Fast-forward to the COVID-19 pandemic and, London says CHCs could have been better utilised to fight the pandemic.

“Many of the health committees are active citizens. They can help with COVID-19, but they couldn’t easily do their work because they’re not fully supported. There was no protective equipment given to them. Those who got protective equipment from the clinic were due to the relationship they have with the facility managers,” he says.

Tamara Sam, secretary of the Khayelitsha Health Forum, says when COVID-19 hit the province, clinic committees were “kicked aside and not roped in to help”.

“When the country was shut down, and we were on level five, we couldn’t work. People were calling us and complaining about issues in their communities and we couldn’t do anything. We sat and watched as things got out of hand and we decided to write to the MEC so that we get permits. We only got permits for the chairperson and the secretary,” says Sam.

Tamara Sam, secretary of the Khayelitsha Health Forum, says when COVID-19 hit the province, clinic committees were “kicked aside”. PHOTO: Nasief Manie/Spotlight

By Thursday 23 July, the Khayelitsha subdistrict had recorded 7 504 positive cases.

“When cases were increasing by the day, we knew we had to play our role and ensure that regulations are followed. We had to go out to the communities and explain and emphasise the washing of hands and why it is important. We had to tell people why they need to wear masks and how it was going to help our area. We started WhatsApp groups to disseminate information. We called and worked with various stakeholders to ensure lockdown rules are adhered to.”

The Forum also lends a hand at the quarantine site set up at the Thusong Centre in Khayelitsha. “Things are not easy,” Sam says. “People are still not adhering to the rules for quarantine. We now have to be health committees and counsellors at the same time because those in the quarantine are complaining to families outside about issues in the quarantine centre. We get phone calls of people crying saying they want to come out, people are dying at the centre so we have to talk to both parties and make them understand what is going on,” she says explaining that this is all done mostly from their own pocket as there is no stipend or any form of compensation for the work they do.

Empowering communities through CHCs

Coordinator for the People’s Health Movement (PHMSA), Tinashe Njanji, says CHCs across the Cape metro have been hard at work, educating communities, assisting with isolation and quarantine, de-escalating potential community conflict when cases of infection have been noted and encouraging hand-washing and sanitising in communities.

“Now that we see that the epidemic has far outstripped the ability of the health service to screen and test in communities, we are more reliant on community action to control the spread of COVID-19. So, we need community voices that are trusted to mobilise safety in our community spaces,” says Njanji.

Lunga Makamba, a facility manager at Gugulethu Community Health Centre (CHC), says “building positive relationships between a healthcare facility management team and health committee members is imperative for the benefit of the community”.
Makamba says in her area, health committees are being called upon to motivate community members to practise social distancing and to wear their masks. “At Gugulethu CHC, during this pandemic, it has been a challenge to successfully collaborate on a regular basis but assistance is provided where necessary.” Mkamba says Gugulethu CHC has scheduled meetings for the year with health committee members as a communication platform to harness suggestions, improvements and collaboration.

View from the Eastern Cape

 Noxolo Mafumana, a committee member of the District Health Forum in Nelson Mandela Bay in the Eastern Cape, says they do what they do out of love for their community since their work is voluntary and they only get R500 quarterly which mostly covers airtime or transport.

“It’s not even easy to get the money. Payments are not being paid out. There are no approval letters for clinic committees. We have to fight. How do we work like this?” she asks.

“Our suggestions (to facilities’ management) always fall on deaf ears, but when things start to go wrong and our suggestions were not taken into consideration, that is when they remember that there is a structure called CHCs. Some facility managers listen, others ignore health committees. When they want our help to protect them against the community, they know us. So, we can’t really say we work well together. We only work well when there is trouble brewing,” Mafumana says.

Thembisile Nogambula, chairperson of the District Health Forum in Nelson Mandela Bay, says as CHCs they provide oversight, social mobilisation and health advocacy. “CHCs should know their roles but you find out some of them are not sure of their roles in these facilities and they end up being sent to get fruits by facility managers or nurses,” he says.

Nogambula says the CHCs role is instrumental in monitoring if clinics are meeting immunisation and other targets. During lockdown, this monitoring is especially important as surveys show there has been a significant drop in childhood immunisations. “We go out to the community and encourage them (community members) to take their children for immunisation and also encourage them to go for their chronic medications,” Nogamula says. “We take part in quality assurance and resolving complaints and ensuring that the complaints box is opened at least once a week,” he says.

Christine Jansen is a member of the Manenberg Health Forum. She says ward councillors rarely share information with the clinic committee. PHOTO: Nasief Manie/Spotlight

 View from the Western Cape

Back in the Western Cape,  Christine Jansen, Manenberg Health Committee chairperson, says COVID-19 has impacted the way they work as they are not going to the clinics as much as they want to.

“Ward councillors are not sharing much information with us,” she says.

Another member in Jansen’s committee, Gadija Da Costa, says some challenges they face are that information is usually “flowing from [the] top down”.

“Most of the times we talk to ourselves, no one listens to us. There is a top down approach which really doesn’t work because we are the people on the ground and we know what the community wants. We want services for our community, so we put suggestions. There is no feedback from facility managers. They don’t sit in our meetings. If we are lucky and they sit in, it’s always a rush. How do we work like this and how do we move things forward because there is no assistance at all,” she says.

Gadija Da Costa, member of the Manenberg Health Forum, bemoans the lack of support to clinic communities. Sometimes it feels like we talk to ourselves, she says. PHOTO: Nasief Manie/Spotlight

View from Gauteng

CHC members in Gauteng echo many of the sentiments raised in the Eastern and Western Cape.

Thandiwe Khatshanyane, a CHC member at Moroka clinic in Soweto, says how effective they are, largely depends on facility managers.

“At times you get a facility manager who is engaging and is open with everything. At times the facility manager doesn’t even want anything to do with us, like they don’t need our assistance. It’s not easy, we try. Clinics face a lot of challenges like long queues, staff shortages and shortages of medication,” says Khatshanyane. “Before COVID we would go into a facility and check the queues and also check medications if they are still within the expiry date and engage with clients to hear their concerns. The facility managers will inform us of nurses that absconded or that are sick and how that will affect service delivery, so we explain that to the patients. Now we can’t do that.”

 The struggle to build partnerships

Njanji says that health committees are not formally recognised in many provinces. “Even if they are recognised, they do not receive any training or support. They are expected to do this work voluntarily and often do not get compensated for their costs,” he explains.

“Where facility managers recognise the value of health committees, they give them the authority to monitor and bring issues to their attention to resolve problems. They may ask the health committees to provide information to communities and explain some of the challenges with services. They should also allow the health committees to bring the needs expressed by the community to the facility manager so that these needs are addressed in the facility’s plans. This gives the health committee opportunity to give input on planning for health services,” says Njanji.

But CHC members such as Leslie Sylvester, a member of the Manenberg Health Forum, says they “have zero power”.

“We don’t have a say and it’s difficult to do what we do. Information is filtered from top to bottom. On paper, we have powers, but in reality, we don’t have a say. It’s never a two-way conversation. Nobody comes to the party when we have planning sessions or outreach events. It is a tremendous battle to get the big guys like councillors, facility managers to sit down and listen to our suggestions. They are always in a rush and we can’t sit in a meeting like civilised people and express what needs to happen in our facilities,” he says.

Leslie Sylvester from the Manenberg Health Forum says, clinic committees only have “power on paper”. PHOTO: Nasief Manie/Spotlight

Russell Rensburg, Director at the Rural Health Advocacy Project, believes there is scope for improvement. “There is a lot that needs to be fixed. There are a lot of overlapping and competing structures that should be reformed and roles clearly defined,” he says.

Department responds

Nomawethu Sbukwana, spokesperson for Western Cape Health MEC, Nomafrench Mbombo, says “each facility was given the discretion” whether they wished for the committee members to offer assistance at the facilities or not.

“This is in light of the fact that their traveling to and being in the facility does come with safety risks for the members and others,” she says.

Sbukwana confirms there is no stipend as CHC community members serve on a volunteer basis. “There is however room to claim for transport costs to and from meetings which must be claimed from the facility they serve,” she says.

Sbukwana acknowledges CHCs’ oversight powers to encourage and ensure accountability and stewardship of resources at the clinic. “They assist the community to effectively communicate its needs, concerns and complaints,” she says.

Health activists like Rensburg, however, argues that such acknowledgement must mean “properly getting them on board, giving them clear guidance, putting the power in their hands, [so] they can be a powerful asset in the community and can do things”.

“Their role is to link the community to the clinic and they should be involved in every aspect of the facility and above all there should be a budget for them to be able to do the things they need to do,” he says.