Equity Beyond Access Community Participation and Power in Health Committees in Cape Town
1
Public Health Medicine, University of Cape Town, Capetown, South Africa
Popul. Med. 2026;8(Supplement Supplement 1):A1330
ABSTRACT
INTRODUCTION:
Equitable health systems require not only access to services but also equitable participation in decision-making1,2. In South Africa, health committees were established within the public primary healthcare system to facilitate community participation, accountability, and responsiveness at facility level3. However, their roles, authority, and influence remain unevenly defined and implemented2,4. Understanding how existing participatory structures function is critical for advancing equity in health governance5. This study examined current practices of community participation in two sub-districts of the Cape Metro: Klipfontein and Khayelitsha.
METHODS:
A convergent parallel mixed-methods design was employed between March and September 20246. Data were collected from 132 questionnaires and 13 focus group discussions across 19 committees representing 19 clinics. Quantitative data were analysed using descriptive statistics, while qualitative data were analysed thematically using NVivo 14. The study explored motivations for participation, operational roles, enablers and barriers, capacity limitations, power dynamics, and understanding of the National Health Insurance.
RESULTS:
Committee members were primarily motivated by civic commitment, social recognition, and access to health information. Committees functioned mainly in supportive operational roles, with limited involvement in governance or strategic decision-making. Enablers included training, collaborative relationships with facility staff, incentives, and recognition. Barriers included inter-committee conflicts, lack of institutional recognition, limited logistical support, unequal power relations, and low awareness of the National Health Insurance. Participation was largely procedural rather than strategic, revealing persistent inequities in voice, power, and legitimacy within public health governance.
CONCLUSIONS:
Despite the existence of formal participatory structures, health committees operate with limited decision-making authority, constraining their contribution to equity and accountability. Strengthening participation requires clearer role definition, sustained capacity building, institutional recognition, supportive policy frameworks, and adequate operational resources. These reforms are essential to position health committees as legitimate governance actors capable of engaging meaningfully with forthcoming health system reforms.
Equitable health systems require not only access to services but also equitable participation in decision-making1,2. In South Africa, health committees were established within the public primary healthcare system to facilitate community participation, accountability, and responsiveness at facility level3. However, their roles, authority, and influence remain unevenly defined and implemented2,4. Understanding how existing participatory structures function is critical for advancing equity in health governance5. This study examined current practices of community participation in two sub-districts of the Cape Metro: Klipfontein and Khayelitsha.
METHODS:
A convergent parallel mixed-methods design was employed between March and September 20246. Data were collected from 132 questionnaires and 13 focus group discussions across 19 committees representing 19 clinics. Quantitative data were analysed using descriptive statistics, while qualitative data were analysed thematically using NVivo 14. The study explored motivations for participation, operational roles, enablers and barriers, capacity limitations, power dynamics, and understanding of the National Health Insurance.
RESULTS:
Committee members were primarily motivated by civic commitment, social recognition, and access to health information. Committees functioned mainly in supportive operational roles, with limited involvement in governance or strategic decision-making. Enablers included training, collaborative relationships with facility staff, incentives, and recognition. Barriers included inter-committee conflicts, lack of institutional recognition, limited logistical support, unequal power relations, and low awareness of the National Health Insurance. Participation was largely procedural rather than strategic, revealing persistent inequities in voice, power, and legitimacy within public health governance.
CONCLUSIONS:
Despite the existence of formal participatory structures, health committees operate with limited decision-making authority, constraining their contribution to equity and accountability. Strengthening participation requires clearer role definition, sustained capacity building, institutional recognition, supportive policy frameworks, and adequate operational resources. These reforms are essential to position health committees as legitimate governance actors capable of engaging meaningfully with forthcoming health system reforms.
| eISSN: | 2654-1459 |
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