Governance, equity and health: Impact Of ,Participatory Mechanisms And Structures In Equity And Quality Of Health Service Delivery TJ Ngulube, R Loewenson, I Rusike, M Macwangi, C Njobu, A Ngwengwe EQUINET GoVERN theme In 2002/3 EQUINET implemented a multi-country research study to examine the impact of Health Centre Committees (HCCs) and District Health Boards (DHBs) in bringing about equity in the primary health care services in Zambia and Zimbabwe. The research work sought to examine equity from an EQUINET perspective, with emphasis that equity related work needs to define and build a more active role for important stakeholders in health, and to incorporate the power and ability people (and social groups) have to make choices over health inputs and their capacity to use these choices towards health. The studies found that social groups at either end of the extreme of the spectrum of wealth and poverty do not participate in the Health Centre Committees (HCCs), which is otherwise judged to be relatively representative of community groups. The studies indicated that areas with HCCs generally performed better on Primary Health Care (PHC) statistics (EHT visits, ORS use), on contacts with their communities and had better community health indicators (health knowledge, health practices, knowledge and use of health services) than in those without. HCCs had taken up environmental health and service quality issues as an additional service outreach and link. They find out community needs and organize service inputs such as drug purchases, building waiting/ mother shelters, water tanks and toilets. They also provide health information. These roles appear to enhance their credibility with the community and the health staff. They also mobilize additional resources for health from community and other sources. In Zambia, HCCs were increasingly taking part in health activities at facilities, and being increasingly relied on by health workers. Members of HCCs were credited with bringing about improvements in the effectiveness of public health interventions, as well as bringing about the spirit of self-reliance and solidarity in their communities. There were some failings and shortcomings too that hindered their efforts: HCCs had limited impact on management issues at the health centres, in meeting the needs of vulnerable groups as well as in clinical care issues. Lack of information and asymmetry in knowledge were key factors that prevented the attainment of greater equity. On the other hand, deepening poverty levels in the country made community mobilization, the urge to volunteer and participation difficult. There was consensus that available resources were not enough to meet all the health challenges faced and such meager resources could not provide for appropriate incentives to encourage the spirit of volunteerism. These studies suggest an association between HCCs and improved health outcomes, even in the highly under-resourced situation of poor communities and poorly resourced clinics. Despite the existence of any written guidelines, HCCs have weak formal recognition, are poorly resourced and poorly trained or informed for their role HCCs seem to be vulnerable to a number of factors limiting their effectiveness, including weak formal recognition by health authorities, lack of own area of authority, unclear reporting structures and role definition. Given this their performance is influenced by the attitude and responsiveness of the health authorities and the participation of strong community leaders, both highly variable across districts. The HCCs have noted their lack of knowledge or training on the health system and lack of resource investment in their functioning. Health authorities show some ambivalence and lack of consensus on HCC roles. The CHESSORE study on HCCs has shown that even with a somewhat ambivalent attitude from health authorities, a strong will to sustain and maintain their participation in health service delivery exists. This strong community will to be part of their health services needs to be built on and enabled. . Their resource limitations arise within their communities and in the primary care level of the health system they operate in, particularly where there are falling resources allocated to district outreach, to primary health care and to quality of care at clinic level. The ambivalence around their recognition and functioning and the lack of resources directed at their activities reflects the general under-resourcing of the primary care level of the system. Increasing poverty levels make effective demand or organized voice at community level difficult to achieve and sustain, and may be defensively responded to in such a situation. It may thus be argued that the strengthening of DHBs and HCCs as vehicles of community participation is thus deeply bound with the strengthening of the PHC and primary care level of the health system.