The structures and processes
for interactions between services and civil groups also need
attention. The literature documents problems when there is inadequate
structural support, weak information access, limited authority
and vague roles. Community-service interactions are weaker when
there are too many poorly coordinated, poorly resourced, issue-specific
forums, with weak abilities and procedures for resolving conflict,
poorly supported by information, and with weak legitimacy. They
are undermined when managers and service providers have weak
incentives to respond to directions given by participatory structures
and are resistant to or poorly prepared for changes in authority
or for using non-medical inputs. Equally, weakened citizen interest,
paternalistic cultures, illteracy and weak civil capacities also
undermine these interactions (Kahassy
& Baum, 1996; Bennett
et al., 1995; Gilson
et al., 1994).
Hospital boards, for example,
are a particular form of participation in the management of services
that have suffered from ambiguity between their powers and responsibilities.
Bennett et al. (1995) noted that the power and roles allotted
to the board, and the degree of autonomy they were given by the
ministry of health, were important factors in their success.
Where boards have had little influence over capital investment
and financial and personnel policy, they have had limited impact
on efficiency or service provision. Given that referral hospitals
provide public services, central governments clearly need to
continue to exercise some control over their performance. It
would, however, appear that the best balance - between arm's
length measures providing legal and performance standards and
incentives and the more direct forms of control - has generally
not yet been found (Bennett
et al., 1995).