Integrating Community Health System Activities and Participation into the Primary Healthcare System for Ensuring Effective Community Participation and Achieving Health Goals in Nigeria

Contextual characteristics

Akwa Ibom State is the highest oil and gas producing state. Despite a high literacy rate (males 75.5%; females 80.6%) [20], a strong belief in witchcraft remains, which affects health‑seeking behaviour and shapes perceptions of health security [19]. Kano State still has a high rate (80.8%) of obstetric deliveries outside the health facility, and a very low female literacy rate (37.8%) compared to males (71.3%) [20]. Anambra State has the highest literacy rate of the three study states (males 89.1% and females 87%) and a high rate (90.4%) of facility‑based obstetric deliveries [20].

Healthcare across the three states is provided through primary, secondary, and tertiary facilities. At the PHC level, nurses, midwives, community health officers (CHOs), and community health extension workers (CHEWs) deliver services, although shortages and uneven distribution of these health workers remain a challenge. In Akwa Ibom, an assessment of PHC facilities found that none of the facilities studied met the recommended minimum staffing requirements, with key health workers unevenly distributed across facilities [21]. Similar workforce shortages have been reported in Kano State, where only 467 nurses and midwives were available against an estimated requirement of 3,082, alongside shortages in other key PHC cadres [22]. In Anambra, health workforce shortages have also been reported, with 82% of PHC facilities assessed in one study operating with less than 20% of the nationally recommended number of health workers [23]. These differences in the availability and organisation of formal healthcare are important to understanding how communities respond to local health needs and interact with PHC services.

Distribution of free drugs and medical supplies

In some communities, community members pay patent medicine vendors (PMVs) for certain medications (e.g., Vitamin A and antimalarial drugs) to ensure that those who cannot afford them receive them for free. Some private individuals also give out medical supplies to these vendors to share freely with their customers. There are also community PMVs who subsidise or offer free treatment to community members on occasion:

There are people who are sick; when they come to me and they don’t have money, I treat them for free. I sell drugs at a cheap rate, and during the Christmas period, I give my customers free drugs. I am also planning to buy a BP apparatus and blood sugar testing kits to test people for free (IDI, PMV, Anambra).

Some communities in Kano and Anambra States organised periodic health outreaches involving medical personnel, community volunteers, and health workers, providing free medicines, healthcare, and referrals. Although largely philanthropic, some activities already involved formal health providers and referral linkages. In Kano, one such activity was an annual outreach organised by a youth forum around Christmas.

… Community‑oriented health programme, the one I know and can say is usually done annually is the one the youth forum normally organises towards Christmas… they will bring a doctor, then drugs are given to sick patients. The people with serious issues will be referred to the hospital, then assistance will be sought on behalf of the person if the person cannot foot the bill. Assistance involved approaching community members who could contribute towards the cost of care (FGD, community member, Kano).

Health screening, health promotion, and education

Free health checks are organised by community elites for early diagnosis of ailments and to identify those who need care. Those in need of treatment are booked for care, and their bills are taken care of. These community‑based interventions are driven by indigenes of the respective communities and usually organised to take place annually at about the same time of the year, but other stakeholders are also involved. A formal healthcare provider in Anambra State reflected:

“Yes, when I newly came here …this is the man that welcomed me in this town. He is a doctor too at the eye hospital. The condition he gave me is that I must do a free medical check, which I did at the town hall. I did it myself. I did a free lab test for everybody for two weeks...”(IDI, med lab scientist, Anambra).

Health promotion and health education were enabled in these communities by leveraging various actions and activities. Town criers and outreaches were among the methods leveraged to create health and healthcare awareness. They were also used as a means to prevent infections, raise awareness about diseases, and promote health services available to the community.

… what the committee, in conjunction with the community leaders, do is, they make sure they create awareness to the members of the community by using town criers, by talking to people one on one on the benefits of health and to stay healthy…. there are people that are not well informed in the community. When the town crier makes announcements there begins to be vaccination… (FGD, community member, Akwa‑Ibom).

Religious leaders and school leaders, who are highly respected in the communities, also got involved in health education, promotion, and sensitisation. Community leaders in Kano also took actions to stop the spread of diseases in their community:

When there was an outbreak of cholera, one of us took action when they saw it, they quickly told the household that they have to go to the hospital. Through that they got our people to come to the hospital. When they come to the hospital, they will bring all their household so that it can’t be spread to anyone. That’s how we use to do it (IDI, WDC chairman, Kano)

The community leaders in Akwa‑Ibom also organised seminars on sex education to educate the populace. There were also initiatives implemented during the COVID‑19 pandemic in Akwa Ibom State to speak to the people on the benefits of healthcare.

Community‑based health insurance

Community health insurance was established as a way to fund healthcare, with healthy community members contributing towards the care of those who were ill.

Our people started what they called community health insurance and health financing scheme... They came and started a community healthcare and community financing scheme that enables the healthy ones to finance the health of those that are not healthy. As a result, if you pay one hundred Naira premium (100) monthly dues of one thousand two hundred Naira only (#1,200.00) per year, you will be entitled to enter the scheme with a card. So, they use the three health centres in Igboukwu as their base. Our people donate to finance (IDI, Director, Anambra).

This scheme was adopted by some other communities, and when the state health insurance was introduced, the community schemes were absorbed into the state scheme, and philanthropists continued to pay premiums for the less well‑off in their communities.

For instance, when O.(the governor) introduced ASHIA (Anambra State Health Insurance Agency), it went out of the community health financing scheme and governments now dominate. I will show you the cards for the local scheme. He funds it on his own as a way of giving back to the community. All these are delivered by philanthropic acts (IDI, community member, Anambra).

Provision of security

In most of the PHCs, the security guards were sponsored by community members. They were involved in appointing a security guard, usually a member of the community and also pay them a stipend. In one study state, this reportedly improved access to and utilisation of PHC services, as reflected by this respondent:

…in my area, there is a hospital where armed robbers always disturb them, but since we started working, all these have reduced drastically, and the staff can now go to work without fear and patients can easily visit the hospital for treatment any time. Also, when they (facility staff) go for programs to share medications and other medical products, we also try to ensure their protection so that these things do not get snatched or people interrupt or disturb them (FGD, security guard, Anambra).

The WDC in our community provide physical support, they provide security to the PHCs when there are health programs being carried out in the facility (IDI, OIC, Akwa‑Ibom)

Environmental sanitation

Enforcement of environmental sanitation and hygiene was the most common form of community activity addressing SDH. Community leaders mobilised their members to engage in sanitation, cleaning drains and their surroundings. This is mainly championed by the village heads and carried out by the youths. As one community member reflected:

“There’s what we call community sanitation in our community; I was part of it almost seven months ago in our area. They organized it under our village head at that time. They bring us out saying that those who are selling akara [beancake] in the street near the gutters should stop selling there, including the cooking and selling of food along the gutter” (FGD, Trader, Kano).

Community leaders took responsibility for ensuring that people adhered to environmental sanitation regulations in their communities;

We speak to them on the importance of seeing that the environment they live in is clean....In those days you know we use to have several diseases, they were thinking they were witches or their enemies, but now, they have realized that they are the architects of their own misfortune (IDI, village head, Akwa Ibom).

Community food empowerment

Groups of farmers in communities in Anambra State coalesced and produced a plan for enhanced food production. Although encouraged and eventually financially supported by the government, the communities initiated the design of contextually relevant plans to enhance food production during the COVID‑19 pandemic. A government stakeholder reflected:

It’s just for the poor members of the community. They have a community facilitator who gets information and guides them to meet up with the requirements…they form a cooperative of 40 – 100 persons…they organize themselves and once they meet the requirements through the community facilitator, they come forward for approval…..we can’t say that we have completely eradicated poverty, but I must say that we are proud of the results for now…..there is an increase in the number of poor people accessing the inputs. We now have two thousand, seven hundred and seventeen (2,717) of them scattered across fifteen local governments in Anambra State...the increased food security in the state contributed to increased yield…we can say that most of them may be feeding better than before, which may have in turn strengthened their health status. (Officer, Agriculture programme).

Training of informal providers and community leaders by formal providers

Training and retraining were provided to IHPs, including TBAs and PMVs, although the content varied by provider group. TBAs described training on delivery practices, recognition, and management of complications, prevention of communicable diseases, and appropriate referral to health facilities. Training reported by PMVs covered malaria, family planning, pneumonia, and patient management. Community intermediaries, including TBAs, also received training on household health education and community mobilisation.

Yes, and we’re really enjoying the retraining because the training is encouraging us, and like before most of the women when they give birth at home they don’t care to go to the hospital but now as a result of our work they do come to the hospital, and all happens as a result of the training, and all these are among our work, and now even giving birth at home is very rare and even now that we are talking there is a woman in labour room that is about to give birth (FGD, TBA, Kano).

Participants reported that training and retraining were provided by both government and non‑governmental organisations, although the frequency varied. Non‑governmental organisations were described as providing retraining more frequently in some settings, while trainees also received support for transportation and food during training. One participant explained:

Sometimes before the government calls us for a single retraining, the NGO has trained us more than 2 to 3 times. They give us money for transportation and food during the training… (IDI, PPMV, Kano).

Formal providers also included health talks for the community in their work schedule. They organised seminars at scheduled times for the community members in the health facility. Participants reported that these sessions increased their knowledge and informed the advice they gave to other community members about seeking care.

There was a seminar at the health center that required women to attend, so we were taught and advised on these things to do, and that was how I learned and knew them. So, I advise and encourage other women to check their blood pressure. I used to check my blood pressure on my own before the seminar, so it was additional knowledge for me. I advise women, especially those who go to markets or farms and are stressed after a long day’s work, to check their blood pressure frequently because stress causes an increase in blood pressure, which most women don’t realize and instead believe is witchcraft (IDI, Woman leader, Akwa‑Ibom).

Recruitment of community help during outreaches

There are assigned days for outreaches in every community, and in communities with few formal providers and CHEWs, community members were recruited to assist during outreaches. The roles of these recruited community members were not to vaccinate or perform healthcare duties but rather to support the outreach activities.

The OIC of each ward knows the people that she is working with in each of the communities; there are people in the community whom their leaders know can do the job well. Like crowd control and community mobilization. Yes, there are criteria because a village woman can’t be a vaccinator; the vaccinator must be a trained nurse or CHEW. The village people will be recruited as town criers, house‑to‑house mobilizers, or crowd control people. We recruit them according to their abilities (IDI, Civil Servant, Anambra).

Accountability structure for community philanthropy

Healthcare facilities in some communities established structures to foster and ensure accountability for funds donated by community philanthropists.

In every organization there is a leader. So, any donor will go through the hospital health committee leader and the two of them will come together and give the description of what he is giving to the hospital (FGD, Community member, Kano)

Another community had an environmental and health unit embedded in the formal health facility and tasked with health promotion. The community had also activated a yellow fever campaign to vaccinate community members.

Okay, currently the community is participating in this yellow fever because now we are, we are going to activate this yellow fever program in the state. So, the community are being selected so that those we want to participate fully… because most of the oldest (members of the team) are from the community. We use our health workers as vaccinators and the oldest who are from the community to encourage community members to participate fully in the yellow fever vaccination. Yes. The in‑charge of the facility is the vaccinator… vaccinator of that area because people know she is in charge of the committee (IDI, Primary Health Care Coordinator, Kano).