Community Infrastructure

There were two local formalised grassroots committees which were central to determining how PHO planning was initiated: the Joint Transport and Health Services Subcommittee31 and the Health Services Review Steering Committee. Both committees were established to meet specific local needs and were seen to complement the work of other community organisations such as Senior Citizens, Citizens’ Advice Bureau and Horowhenua Grey Power32. Shared membership and aligned goals created an opportunity for both a formal and an informal coordinated effort between these two committees and the Steering Committee. It was the Health Services Review Steering Committee’s identification of the need to commence PHO establishment planning which provided the impetus for the PHO Steering Committee formation to occur. This subcommittee determined the PHO planning process (that there be a PHO Steering Committee), the membership and provided one option for commencing work (seeking a proposal from Grafton Consulting Group). The Joint Transport and Health Services Subcommittee provided an avenue for disseminating information about PHO establishment progress to the wider community. The Chair of the

31 _{The Joint Transport and Health Services Subcommittee reports through the Horowhenua District Council’s}

Development Committee to the Horowhenua District Council. It comprises both Council representatives and selected public members and deals with predominantly local health and transport issues. It has no formally ratified Terms of Reference.

Joint Transport and Health Services Subcommittee was the deputy mayor and also a member of the PHO Steering Committee.

There were community links at the DHB and local government governance levels which were central to the PHO establishment success. At the DHB governance level there were two elected members33; one lived in the Horowhenua and the other in the Otaki. The Horowhenua DHB Board member was also a Horowhenua District Councillor. While not directly involved in initiating plans for PHO establishment, he did attend the public meetings called to discuss PHO establishment (March to May 2003) and observations made of proceedings at the CPHAC meetings confirmed that he had been briefed about Steering Committee issues and acted as an advocate for this Committee at the CPHAC meetings. The DHB Board member who resided in Otaki was Chairperson of the CPHAC and also a member of the Reference Group for part of the data collection period.

To summarise, community representatives on the Steering Committee were also members of the:

¾ Horowhenua District Council,

¾ Joint Transport and Health Services Sub-Committee, ¾ Health Services Review Committee, and,

¾ Reference Group.

All committees had a shared commitment to improving health services in the Horowhenua. The Horowhenua District Council, as the local government authority for the region, played a particularly important role in indirectly influencing the success of the PHO establishment project because of its decision-making authority and power relationships with the primary health care stakeholders – particularly the DHB. The DHB Board, as the governing body for the funding of primary health care services in the region, and the District Council shared comparable authority and power over decisions made about community infrastructures and services. The Horowhenua District Councillor who is a MidCentral DHB member played a crucial role as advocate and informant for the PHO at these governance levels. This multi- level involvement of community leaders in planning for PHO establishment should

theoretically enhance the likelihood of meaningful community participation. Rifkin (1990) holds the view that if local leadership is ignored projects have a diminished chance of long- term success. However, from another perspective, these community representatives influenced decisions not to seek wider community input into the Steering Committee establishment and membership. In effect these decisions further diminished opportunity for new grassroots community representatives to come forward and be involved in PHO planning. Campbell and Jovchelovitch (2000) support the notion that the process of participation provides opportunity for dialogue between different representations. While this is the case for the community representatives at the different decision-making levels in this community, it also provided an avenue for patterns of dominance to be reinforced. Labonte (1997) concurs - communities are often involved but decision-making authority occurs within clearly determined parameters. The PHO planning process illustrated how control and exclusion can result from actions not only taken by individuals who have institutional power (for example, Funding Division Representatives and health professionals) but also by community representatives who, through their representation, have been accorded power and authority.

The process adopted for commencing PHO establishment was not the result of just one individual’s or one group’s effort to determine a pathway forward. Rather, it was the combined effort of members who were part of a number of established infrastructures within the community. They represented groups who held considerable decision-making power (local government and DHB governance), as well as the grassroots community committees. Throughout the planning process, the impact of these infrastructures was not always visible, particularly to external stakeholders. The benefits of these interrelationships for the Steering Committee were that often other committees and organisations fulfilled an advocacy and information sharing role for the Steering Committee within their separate networks. In effect, the Steering Committee was supported, albeit indirectly, by a range of community leaders and decision-makers all of whom were aligned to the Steering Committee’s goals and desired outcomes.

At another level, and occurring at the same time as the PHO Steering Committee was preparing to establish, the DHB Reference Group34 was formed, with a community representative appointed to the Group from the Horowhenua. This person later became the PHO Steering Committee Chairperson. This provided reciprocal opportunities; the Reference Group secured the expertise of a community representative who was actively involved in preparing for PHO establishment, and the Chairperson of the PHO Steering Committee benefited from the networking and access to information which resulted from her involvement in the Reference Group. The Chairperson considered these collegial associations, and the opportunity this membership provided her to access relevant information, to be of valuable assistance to her throughout the planning period (from an interview, 18 August, 2004).

An added dimension, not specifically relevant to PHO establishment but important when considering community infrastructures and partnerships, was the relationship between the Horowhenua District Council and the Health Services Review Steering Committee. These two groups were aligned in a collective effort to secure funds from an external agency (New Zealand Treasury via the Ministry of Health and the DHB) for their reconfigured local community health service. This illustrated a combined effort of two groups within the Horowhenua community: one which comprised predominantly community representatives working from the “bottom up” (Health Services Review Steering Committee) and another working from the “top down” (Horowhenua District Council). Both groups shared the same goal and brought to the partnership different, but valued kinds of knowledge, perceptions and skills to achieve a common goal: resourcing for a reconfigured health service. Labonte (1999), Laverack (2004) and Rifkin et al. (1988) all draw attention to the importance of established networks and relationships in communities which contribute to strengthen and support community participation. This case study illustrates their invisibility and influence. Stakeholders, particularly those external to the community, did not seem to fully appreciate their presence or their influence on process and outcome.

34 _{See Appendix A for Terms of Reference.}