In 1978, the Alma Ata declaration affirmed that care is a fundamental right as well as a social justice target. Furthermore, it set primary health care (PHC) as the key to meet this target and emphasised full participation (and self-reliance and self-determination) of the community. More than four decades later, community participation remains essential to attain UHC by 2030 as promoted by the WHO.
Like most of the Sub-Saharan African (SSA) countries, the Democratic Republic of Congo (DRC) has been committed to this worldwide health agenda. The DRC is one of the biggest yet poorest SSA countries (with 64,5% living below the multidimensional poverty line and a Human Development Index (HDI) of 0.480). The national health policy (PNDS) for 2019-2022 affirms community participation as essential to reach UHC. In this policy document, weakness of the community dynamic in support of the demand for care has been cited as a major issue. Hence, considering that the community dynamic is central to the functioning of PHC and the achievement of UHC, it is important to understand the reasons behind the gap between national policies and reality, and to reflect on ways of filling this gap.
Community participation mechanisms will be discussed here in terms of their effectiveness in enhancing quality PHC. More in particular, in this article I focus on the local health system in Nyangezi, South-Kivu province, DRC. Nyangezi is a health district where Artsen Zonder Vakantie, the INGO I am working for, has been involved in quality care improvement for more than a decade. Although community participation has been well integrated in national policies and strategies of the last 20 years, it does not appear to be functioning (well) in this district.
I will first provide some insight on the (national) policy context, then I’ll discuss the causes of the gap between policies and reality in Nyangezi district (and probably a number of other health districts in the DRC), and will end by proposing some concrete steps forward.
The four lenses of community participation
Community participation has been looked at from various perspectives by scientists, health policy makers and programme managers. For instance, back in 1988, Rifkin et al defined community participation as “a social process whereby specific groups with shared needs living in a defined geographic area actively pursue identification of their needs, take (informed) decisions and establish mechanisms to meet their needs”. More recently, Schneider et al proposed four ‘lenses’ to look at community participation: a programmatic lens (with a utilitarian purpose), a relational lens (with more focus on empowerment), a collective action lens (with focus on mobilization and collective action) and a critical lens (with a social justice purpose).
In the current DRC national health policy, improvement of health service provision and continuity of care at the different levels of the health system is defined as one of three strategic axes. On this axis, a specific programme is dedicated to strengthening community participation. This programme promotes effective participation by building committee members’ capacities to enter into dialogue around the planning, implementation and evaluation of health interventions. Moreover, recent (2019) guidelines setting norms and standards by the Ministry of Health emphasise the advantage of community participation in operationalizing health strategies at a district level.
However, these guidelines and norms propose either using the population for outreach purposes (via community relays) and/or actively involving them so that they can set their own priorities through their representation in community participation bodies, the Health Area Development Committees (CODESAs). The CODESA is a formal channel at health centre level, made up of community leaders and civil society leaders. Its chair is elected for two years and is involved in health centre management. The CODESA is meant to represent the voice of the population in planning, co-managing and mobilising local resources for the revitalization of health services, and also in strengthening the capacity of communities in the mobilisation of local resources. Accordingly, keeping in mind Schneider et al’s abovementioned lenses, I would argue that community participation in the DRC has been considered through a (mainly) “programmatic” and to some extent also a “relational” lens, using the community to implement health interventions that have been developed without their genuine participation.
How are things in Nyangezi health district?
In line with national norms, Nyangezi health district has 12 CODESAs corresponding to its 12 health areas. These committees are mainly used to set up preventive and promotional health activities in the communities and to report to the health centres. Members work on a voluntary basis, so there’s a high opportunity cost given the level of poverty prevailing in this district. In addition, there is an implicit hierarchical relation between the community relays and health professionals which creates confusion about the roles of CODESAs. This undermines the ability of CODESAs to voice their concerns, control and monitor health care activities. In this way, the capacity to set their own priorities is neither reinforced nor considered as part of their formal duties. As a consequence, in Nyangezi health district,communities have little influence on decisions regarding geographical and financial accessibility, acceptability and appropriateness of care, which are considered to be essential dimensions of a functioning PHC system with a view on accelerating progress towards UHC. Participation is thus more about outreach and consultation in Nyangezi health district. Current power relations do not enable co-decision making.
The way forward
Nevertheless, more power sharing between the communities and the health providers/managers is necessary for co-decision making. Many not-for-profit actors, among which non-governmental organizations (NGOs), intervene at community level, either with vertical or horizontal programmesin which a number of their interventions are inter-sectorial. There is thus an important window of opportunity to contribute to strengthening self-reliance and self-determination of the communities they target. Programmes aiming at strengthening health systems should primarily include discussions at community level to promote community initiatives and avoid instrumentalising.
More importantly, clarification (and distinction) of community relays’ roles in outreach activities from the CODESA’s central role in steering health care provision would help in balancing the power sharing with health professionals at a health area level. Enforcing CODESA mandates will be essential in this respect.