Lessons from community participation in primary health care and water resource governance in South Africa: a narrative review

Figures & data

Table 1. Analytical framework: combined frameworks of community participation.

Framework	Description and limitations	Framework Constructs	Constructs
Arnstein, 1969: Ladder of citizen participation	The framework, one of the best known, comprises eight rungs on a ladder, which relate to the forms and extents to which citizens are involved and have obtained decision making power. The bottom of the ladder, referred to as non-participation, include two rungs: manipulation and therapy. The third, fourth and fifth rungs which are informing, consultation and placation are described as tokenism. Under this category, participation may fail to affect outcomes and the status quo may remain. At the top of the ladder are three rungs, partnerships, delegated power, and citizen control, collectively referred to as degree of citizen power. At this level, participation is meaningful, and citizens have power in decision making and can affect change.	Manipulation, Therapy, Informing, Consultation, Placation, Partnership, Delegated power, Citizen control	Forms and extents
Cornwall, 2008: Participation meaning and practices	Cornwall argues that all forms and meanings of participation could be found in a single project or process at different stages depending on the context and dynamics of participation. Cornwall proposed that the following influence both participation and the outcomes: the intentions of those who initiated participation, claimed spaces, or invited spaces, who participates, who is excluded or who excluded themselves, influence, what activities people participate in, and at which stage in the process.	Context, Dynamics, created spaces, Invited spaces	Contexts and dynamics
Rifkin,1986: Lessons of community participation	Rifkin reviewed more than 200 participatory health programmes and developed a planning framework to improve community participation with four lessons. Firstly, it is practically impossible to have a universally acceptable definition of community participation given the complexity and dynamics of the process. Secondly, sustainable community participation processes cannot be established through health programmes alone, but require an integrated approach open to community priorities that may not be related to health. Thirdly, the political environment influences community participation. The fourth lesson is that it is not realistic to have a universal model for community participation programmes considering its context dependency. These lessons assisted in the development of three questions which are: Why participation? Who participates? And how do they participate? When answered, the questions would help address the dynamic process of community participation and assist clarifying and implementing programme objectives	Context, Dynamics	Contexts, Dynamics
Limitations of the frameworks	First, there are always power relations and inequalities at play. Those with authority in many cases find it hard to let go of power and recognize the voice of the marginalised. However, increasing participation is a crucial way in which capacity and authority can be acquired. The other limitation is that not everyone is willing to participate, and participation requires dedicated citizens. One cannot assume that participation might have a single outcome, unexpected delays might arise trying to reconcile conflicts and consensus processes might not adequately respect differences. Meaningful participation relies on adequate resources and quality information.

Figure 1. Literature search flow chart.

Table 2. Community participation through the establishment of health committees in Primary Health Care facilities across South Africa.

Discussed by	Province	Study Design	Sample	Description
Padarath and Friedman, 2008	KwaZulu-Natal, Eastern Cape, Free State, Gauteng, Limpopo, Mpumalanga, North West, Northern Cape, Western Cape	Mixed methods: Cross-sectional survey Focus group discussions(FGDs)	Interviews conducted with facility managers in all nine provinces. 3 Focus group discussions with clinic committee members	The study investigates the existence and functions of health committees. Data was collected on the number of health (clinic) committees associated with public primary health facilities, composition, membership, and scope of activities. Data for 2003 and 2008 was compared to determine progress in health committees.
Meier et al, 2012	Western Cape	Qualitative: Policy analysis	Semi-structured interviews with key informants and stakeholder discussions	The study investigates the challenges in developing health policy for health committees in Western Cape. Documentary policy analysis and semi-structured interviews on the evolution of South African community participation policy.
Boulle et al, 2013	Western Cape	Mixed Methods Survey Qualitative	A survey held with 94 health committee members. Focus group discussions with clinic committee members were conducted with 14 clinics.	The study was conducted in Nelson Mandela district across 49 PHC facilities to understand the role of health committees and the challenges they face.
Haricharan, et al 2021	Western Cape	Qualitative	Interviews with key stakeholders, FGD with health committees	The study investigates the distribution and allocation of health committees, understand their functioning, and factors that influence functioning, training needs and recommendations to strengthen them. Health committees were identified through information from Cape Metro health forum eight subdistricts’ fora and speaking with PHC facility managers at individual clinics. Interviews were also done with key stakeholders and focus group discussions with three health committees.
McKenzie et al, 2017	South Africa	Case study	N/A	A case study in South Africa of Primary Health Care System Profiles and Performance (PRIMASYS) that aims to advance the science of PHC to support efforts to strengthen PHC systems and improve implementation, effectiveness, and efficiency of PHC interventions.
Haricharan et al 2014	Western Cape	Mixed Method: Survey Qualitative	Participant observation. In-depth interviews with key-stakeholders, FGDs and survey conducted with clinic committee members	The work was done to better understand the roles and functions of health committees in a re-engineered PHC system and the best institutional and the legal framework to maximise the contribution of health committees to a responsive health care.
Cleary et al, 2015	Western Cape	Qualitative	A series of reflective multi- stakeholders’ workshops including clinic committee members	The work was done at Mitchells Plain sub-district health system. A set of engagements were conducted to bring multiple stakeholders into conversation with each other. Community profiling and local action groups (LAGs) were developed for continuous engagement to strengthen the district health system through community participation. LAGs comprised mainly health committee members.
Mulumba et al, 2018	Eastern Cape and Western Cape	Intervention study	405 and 202 committee members in Western Cape and Eastern Cape respectively	Training intervention to enhance the potential of health committees. A training guide and an instructor manual was developed, and training was conducted with health committee members. Specific training activities included capacity building for health committee members, engaging with health officials and policy makers, building civil society networks, producing, and distributing educational materials.
Zwama et al, 2019	Western Cape	Qualitative	34 Health care providers from City of Cape Town health sub-districts	Evaluated a right-based, interactive training of health providers with health committee on relationship building, and governance, health provider authority and influence as well as how power imbalances affect health committee functioning. Health provider training aimed to establish and strengthen health provider’s relationships with health committees.
Esau et al, 2020	Western Cape	Qualitative	11 Managers and health facility supervisors; 7 participated in 2 FGDs and 4 in key informant interviews.	Explored the experiences of the training of the facilitator (ToF) learning programme in one district whether training was done according to the intention of ToF learning programme and whether selected trainers understood and were able to apply the training to the health committee.
Haricharan, 2015	South Africa	Qualitative	Telephonic interviews conducted with representatives of all nine provincial health departments	Reported the status of provincial health committees’ policies, draft policies or guidelines and support available to health committees.

Table 3. Participatory water governance bodies: Catchment Management Agency (CMA); Water User Association (WUA); Irrigation Board (IB) and Catchment Management Forum (CMF) included in this review.

Discussed by	IB/WUA/ICMA	Province	Description
Boakye et al, 2012	Msunduzi CMF	KwaZulu-Natal	Exploring the involvement of previously disadvantaged and marginalised communities in Catchment Management Forums (CMF).
Boakye et al, 2012			Investigating the extent of participation of previously disadvantaged in water management.
Chibwe et al, 2012	Inkomati -Usuthu CMA	Mpumalanga	Understanding water reform process and factors behind outcome of decentralization process of Inkomati Usuthu CMA.
Brown, 2012			Exploring the potential of participation to change geography of water.
Brown, 2011			Exploring the institutionalization of participatory water resource management in post post-apartheid South Africa.
Denby et al, 2016			Examining how the efforts at implementing Integrated Water Resource Management translate into practice and the interpretations, challenges and outcomes surrounding the implementation are understood and affect people.
Brown, 2014			Assessing what can and cannot be expected from participation through comparisons and differences between processes and outcomes.
Seshoka et al, 2004	Lower Olifants WUA	Western Cape	Lower Olifants WUA and historically disadvantaged individual needs, degree of decentralization, transformation process and Integrated Water Resource Management practices.
Seshoka et al, 2004	Great Letaba WUA	Limpopo	Establishment of Letaba WUA, water management issues, water users, waterworks, and management practices of the Letaba WUA.
Seshoka et al, 2004	Vaalhart WUA	Northern Cape and North west	Transformation and degree of involvement of historically disadvantaged individuals.
Fayse et al, 2004	Umlaas WUA	KwaZulu-Natal	The extent to which the need for historically disadvantaged individuals could be satisfied by the WUA. Establishment of the Irrigation Board into a WUA and current and future involvement of historically disadvantaged individuals.
Fayse et al, 2004	Hereford IB	Mpumalanga	Management of Hereford IB and involvement of the historically disadvantaged individuals in the Hereford IB.
Meissner et al, 2016	Breede Gourizt CMA	Western Cape	The establishment of Breede-Overberg now known as the Breede-Gourizt CMA, the politics and strategies involved in its establishment.

Figure 2. Map showing the location of water governance bodies included in this study.

Source: Merged impression of water governance bodies as presented by Faysse, 2004 and Meissner, 2016.

Table 4. Number of health committees per province, and their responsibilities.

	Province
	Eastern Cape	Free state	Gauteng	KwaZulu Natal	Limpopo	Mpumalanga	Northern Cape	North West	Western Cape
Number of Health Committees	696	139	1488	592	492	263	169	301	200
% of clinics with health committees	95	46.3	100	100	100	83	100	100	46.7
Average members per committee	15	7	8	15	9	12	5	7	12
General roles and function of health committees	Oversee adherence and provision of PHC packages, identify health problems in community, monitor and report extent to which the PHC facility meets health indicators and targets, performance management, monitor how the PHC facility manage complaints submitted by patients and communities, hold management accountable for implementing decisions made during committee meetings, foster partnerships with other community stakeholders, fundraising for PHC activities, raise and manage Health committees funds, advocate for use of PHC facilities as the first point of entry of health care, provide a platform for the patients and community grievances, social mobilisation, be visible, build relationships with PHC staff.
Composition	Community members, community representatives (for example representatives of certain sectors such as traditional health council, NGOs, women’s group etc.), facility manager or clinic staff and local ward councillor. The national average for health committees is 10 members.
Appointment	Election of community representatives vary across provinces, some are elected during community meetings, or volunteering, others are elected by the local councillors, or health committee chairperson or clinic staff.
Finances	Health committees not much involved in planning and budgeting and expenditure processes, though they are required to raise funds to support their activities. They are expected to execute certain activities with no budget provided.