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Strengthening Community Participation to Improve Primary Health Care

Service Delivery in Rural Nigeria

Thesis · March 2016

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STRENGTHENING COMMUNITY PARTICIPATION
TO IMPROVE PRIMARY HEALTH CARE SERVICE
DELIVERY IN RURAL NIGERIA

Author:
Samuel Mayeden

Lecturers:

Dr. Olaf Horstick

Dr. Nasir Umar
Dr. Silvia Runge Ranzinger

Decision Making in Public Health (25th -29th April, 2016)

Master of Science International Health
University of Heidelberg

Submitted:

8th May, 2016

INTRODUCTION AND GENERAL OVERVIEW
Primary health care (PHC) is an integral part of the health care system that has been imported
into many developed and developing country’s health systems including Nigeria. Existing
literature reveals that, as a result of the short comings of the western medicine and its
attendant’s implications for health care in the developing countries particularly Nigeria, the
situation has not been favourable.

The global declaration of Alma-Ata urged governments to formulate national policies to

incorporate PHC into their national health systems. It was expected that, adopting such
initiative will help countries to meet four (4) basic conditions of viable health care plan of
accessibility, affordability, continuity and quality of services. It urged that attention be given
to community-based care that reflects a country’s political and economic realities. This model
would bring “health care as close as possible to where people live and work” by enabling them
to seek treatment as appropriate from trained community health workers, nurses and doctors.
Several studies have recommended community participation. It would also foster a spirit of
self-reliance among individuals within a community and encourage their participation in the
planning and execution of health-care programmes. Referral systems would complete the
spectrum of care by providing more comprehensive services to those who needed them most –
the poorest and the most marginalized.

A review of various studies revealed that the, the principle of community participation is the
hallmark to achieve Universal Health Coverage by ensuring everybody has access to quality of
health service and participate effectively in service delivery at the community level. How can
communities be engaged to improve PHC services in Nigeria? Is it feasible then?

This paper examines the role of community participation through the formation, training,
engagement and monitoring of Community Health Committees (CHC) to improve primary
health care delivery and raise other issues pertaining to community participations in rural
Nigeria. After the introduction of and overview presented earlier, the rest of the discussions
will focus on three elements of decision making in public health practice including; Assess,
Choose and Change and linked to evidence based or models in public health practice.
WHAT IS PRIMARY HEALTH CARE?
The World Health Organization (WHO) define PHC as the provision of essential healthcare
based on practical, scientifically sound and socially acceptable methods and technology made
universally accessible to individuals and families in the community through their participation
and at a cost that the community and country can afford to maintain at every stage of their
development in the spirit of self-reliance and self-determination.

CONCEPT OF PRIMARY HEALTH CARE

PHC is for all especially the needy. Regardless of social and economic status every individual
in the nation must have access to good health care. The services should be acceptable to the
community and there must be active involvement of the community. The health services must
be effective, preventive, promotive and curative. The services should form an integral part of
the country’s health system. Implementing PHC services therefore need to be efficient, multi-
sectorial because health does not exist in isolation.

PRINCIPLES OF PRIMARY HEALTH CARE

The concept and definition of PHC encapsulate its fundamental provides guidance on its
implementation. It includes the four key elements that characterise PHC as stated in the Global
Strategy for Health for all by the 34th World Health Assembly in 1981.
i) Equity
ii) Community Participation
iii) Inter-sectoral Coordination
iv) Appropriate Technology

i) Equity/Equitable Distribution

The first key principle in primary health care strategy is equity or equitable distribution
of health services. Health services must be shared equally by all people irrespective of
their ability to pay and all (rich or poor, urban or rural) must have access to health
services. Currently health services are mainly in towns and inaccessibility to majority
of population in the developing world not excluding Nigeria in the West Africa Sub-
region.

ii) Community Participation

Second principle of PHC is community participation. The overall responsibility is of
access to care and participation in health service delivery is on the state. The
 involvement of individuals, families, and communities in promotion of their own health
and welfare is an essential ingredient of primary health care. PHC coverage cannot be
achieved without the involvement of community in planning, implementation and
maintenance of health services.

iii) Inter-sectoral Coordination

The third principle of PHC is inter-sectoral coordination. The declaration of Alma –Ata states
that PHC involves in addition to the health sector all related sectors and aspects of national
and community development, in particular education, agriculture, animal husbandry, food,
industry, housing, public works and communication. To achieve cooperation, planning at
country level is required to involve all sectors. Taking a stakeholder analysis is very important
in the delivery of health services.

iv) Appropriate Technology

The fourth and last principle of PHC is having appropriate technology that is
scientifically sound, adaptable to the local needs, and acceptable to those who apply it
and those for whom it is used and can be maintained by the people themselves with the
resources of the community and country can afford.

WHAT ARE COMPONENT OF PRIMARY HEALTH CARE?

The component needed for implementation of PHC as stipulated in the Global Strategy for
Health by the 134th World Health Assembly in 1981 includes;

1. Education concerning prevailing health problems and the methods of identifying,

preventing and controlling them
2. Promotion of food supply and proper nutrition, an adequate supply of safe water
and basic sanitation
3. Maternal and child health care including family planning
4. Immunization against major infectious diseases
5. Prevention and control of locally endemic diseases
6. Treatment of common diseases and injuries
7. Promotion of mental health
8. Provision of essential drugs
OVERVIEW OF HEALTH SYSTEM IN NIGERIA
The (1999) Constitution of the Federal Republic of Nigeria, there are three tier system of health
care including;
a. Primary health care for local government
b. Secondary health care for state, local government
c. Tertiary health care for federal government

It is clearly stipulated in the constitution that, primary health care shall provide general health
service of preventive, promotive, curative and rehabilitative nature for the population as on the
entry point of the health care system.

REFORMATION OF HEALTH POLICIES IN NIGERIA

In 2003, the Federal Government of Nigeria undertook a purposeful reform of the National
Health Care delivery system in the context of the National Economic Empowerment and
Development Strategy, 2003-2007, along with it is an implementation framework. This paved
way for the development of several initiatives including the President’s 7-Point Agenda
implemented through two instruments: the Vision 20:2020 document, as well as the National
Strategic Health Investment Plan 2007/2008. This also facilitated the revision of the National
Health Bill, revitalization of the National Council on Health; formal launching of the National
Health Insurance Scheme and formulation of several subsectors policies, plans and
programmes.

In the 2009, the Government also launched the National Strategic Health and Development
Plan (NSHDP) 2010-2015, which aligned national development initiatives with various
international agreements, declarations and goals including the Millennium Development Goals
(MDGs), Ouagadougou Declaration, the Paris Declaration on Aid Effectiveness and Accra
Agenda for Action.

The NSHDP highlights eight priority areas including, Leadership and governance, Health
Service Delivery, Human Resource for Health, Financing for Health, National Health
Management Information System, and Partnership for Health, Community Participation and
Ownership, and Research for Health. A Presidential Summit held in Abuja in March 2014 on
Universal Health Coverage (UHC) declared and reaffirmed health as fundamental human right,
and made commitment to increase budgetary allocations in health; mandatory health insurance
and special funds to cover the poor and vulnerable population at the community level.

ALIGNMENT WITH THE GLOBAL HEALTH POLICY?

The first strategic priority of WHO country cooperation agenda (2014-2019) is “Strengthening
health systems based on a primary health care approach”. The Government of Nigeria also
recognises that, a strong primary health care system is critical to the future success and
sustainability of the entire health care system. These when adhered to, will contribute
significantly in attaining the Sustainable Development Goal (SDG) and subsequently improve
access to care through the universal health coverage (UHC) by the year 2030. This means that,
the role of communities in the delivery of care is essential in other to achieve both objectives
stipulated in the WHO and NSHDP. It requires the local government to mobilize communities
to participate in the provision and maintenance of health services, eliciting the support of
various formal and informal community leaders.

CHALLENGES OF PRIMARY HEALTH CARE SERVICE IN NIGERIA

The primary health care indicators particular those stipulated in the components of health care
delivery at the community have shown steady, albeit slow improvement coupled with porous
health systems. In 2013, Nigeria was certified free of indigenous transmission of Guinea worm.
Transmission of Wild Polio Virus was interrupted in the southern state and only two cases was
reported nationwide in 2014 (WHO global health outlook, 2014) with polio immunization
coverage improving even in security compromised areas.

Malaria contributes to 30% of the childhood mortality though the use of insecticide-treated
bed-ned increased from 8% in 2008 to 50% in 2013. AIDS, lower respiratory tract infections
and diarrheal diseases are among the leading causes of year’s life lost. Malnutrition is very
common and extent of stunting has stagnated at 40%. There is still an increase burden of non-
communicable diseases including hypertension, diabetes, neurological disorders and road
traffic injuries present a novel challenge for the health systems. Alcohol consumption and
tobacco use are increasingly high.

DEVELOPMENT AND GLOBAL HEALTH OUTCOME

Poverty is still pervasive in Nigeria, where recent figure indicates 68% of the population lives
on less than USD 1.25 a day (World Bank report, 2014). The goal concerning child mortality
and maternal mortality efforts by government and community participation. The most recent
record concerning maternal and under-5 child mortality are 630 per 100, 000 live births and
124 per 1000 live births respectively coupled with great disparities in health status across the
state and geopolitical zones. Disease aetiology is link to social determinants such as
socioeconomic status, education, gender and inequality, as well as poor access to water and
sanitation and hygiene. According to the Human Development Index, Nigeria was ranked 153
out of 186 countries cross the world (2012).

SUMMARY OF KEY CHALLENGES

1. Inequitable access to quality of health between rural and urban population
2. Lack of basic amenities to execute preventive services and refer complicated ones to
the secondary or tertiary level.
3. Limited involvement of the communities, hence leading to low utilization of service at
the PHC facilities
4. Historical financial dependence on development partners (multi and bilateral agencies).

THE CHOICE FOR CHANGE (INTERVENTION)

Nigeria’s primary health care system faces significant challenges due to low community
involvement, general weaknesses in health system, poor quality delivery of services at the PHC
facilities, and historical dependence on development partners. Compounding with these
challenges, primary health care in Nigeria has tended to operate without meeting the basic
needs of the poor and most vulnerable population. This has made if complex for the health
system to meet global target of improving maternal and child health services.

However, the choice for change is to improve community participation and involvement
through the formation of Community Health Committees (CHC). These concept of CHC has
been used in Ghana’s PHC services and has proven very successful in the delivery of basic
services at the community for poor population. Adopting this initiative will be vital in order to
improve PHC services in rural communities. This policy priority will focus on key intervention
such as improving quality of health service and strengthen community participation and will
contribute significantly in Nigeria’s health outcome by the year 2020.
THE FUTURE (CHANGE IMPLEMENTATION)
A strong, responsive and cost-effective primary health care systems to meet the current
challenges. Key to the future having a community participation and ownership within a national
framework and can better respond to the needs and priority of local communities.

WHAT IS COMMUNITY HEALTH COMMITTEE (CHC) AND WHAT WILL BE

THEIR ROLE IN PHC?
A Community Health Committee (CHC) consist of between six to ten respectable persons in a
community. They are selected and approved by the traditional leaderships to serve as the link
between the community and a primary health care facility (health systems). Their main
responsibility is to supervise village health volunteers whom they assist in selecting. They also
advocate for community health needs and ensure welfare of the staff at the primary health care
facility.

CRITERIA FOR SELECTING CHC MEMBERS

Once someone meets the criteria endorsed by the community, they go through a process of
approval. The following is a flow chart simplified version of the process a person must go
through to get approval.
COMMUNITY HEALTH AND INTERVENTION LOGIC: OUR THEORY OF
CHANGE
There are five basic parts to this model including;
1) Community context and planning
2) Community action and intervention
3) Community and system change
4) Risk and protective factors and widespread
behaviour change
5) Improving more distant outcomes (the long-
term goals)

1. Community Context and Collaborative

Planning

The first step is understanding the context in which

people act. By that you explore people's
experiences, their dreams for a better life, and
what makes them do what they do. The context is
influenced by many things, such as: People's
hopes and expectations--for example, the belief
Source: Community Tool Box
that things can change, problems, especially death
of children and pregnant mothers.

2. Community Action and Intervention

The planning process is always followed by action--going out and doing what was outlined.
If the plan of action was thorough, this part should generally go fairly smoothly within the
process of change.

3. Community and System Change

Third in the circle is community and system change. The goal of the action plan is to bring
about community and system changes. Bringing about these changes is an important step
towards achieving the goal set by the group.
4. Risk and Protective Factors and Widespread Behaviour Change

At this stage of the change theory, the belief is that when these community and system changes occur,
they should, taken together, change the environment in which a person behaves.
5. More Distant Outcomes
Improvements in more distant outcomes, such as reducing violence or immunization status of
children in the community, become an ultimate goal of the committee. The belief is that by
reducing the risk factors (and enhancing the protective factors) for the issue you are trying to
address, you will affect the bottom line. That's true whether your bottom line is lower rates of
teen pregnancy, higher rates of immunization for small children, or any other topic.

This five steps (process) will be an interactive and continuous cycle. The community context
affects the committee’s planning and guided by ongoing planning, the committee generates
community action and implements interventions.

CRITERIA FOR SELECTING INTERVENTION

The intervention was derive from the theory of change as explained earlier. The will be
delivered through the formation of CHC. A systematic review of literature showed evidence of
health facility committee in low-middle income countries found some evidence that, health
facility committee (Community members) can be effective in terms of improving the quality
of and coverage of health care as well impacting on health outcomes. However, the external
validity of these studies is inevitably limited (McCoay et al, 2011).
A rapid Appraisal of Health Extension study, concludes that, “The health extension program is
one of the most innovative community-based programme in Ethiopia. Is is based on the
assumption that, access to and quality of primary health care in rural communities can be
improved through transfer of health knowledge and skills to households. Is has enable Ethiopia
to increase primary health care coverage from 76.9% in 2005 to 90% in 2010. (Banteyerga,
2011)
Lastly, systematic review conducted in LMICs, 48 RCTs were assessed. The results show that,
community or lay health workers interventions programme that use health workers who are
trained in the context of the intervention but have no formal professional certificate or degree
or tertiary education in primary health care, generated promising benefits compared to usual
care in increasing uptake of immunization and TB treatment outcomes. The findings were
consistent across all the studies done in LMCS. Improving transferability of community based
intervention (Lewin et. al, 2008)
2 KEY PRIORITY INTERVENTION
To address the shortcomings of current situation which has a direct impact on the community
and health system, we need actions to implement key priority interventions within policy
framework. These includes;
1. Improving quality and reducing inequality
2. Strengthen community participation and accountability

IMPLEMENTATION PLAN
A detailed implementation plan is outline in the link as attached for your review.

Implementation
Plan_PHC_CHC.xlsx

STAKEHOLDER ANALYSIS
An analysis of the stakeholder is provided in the outline of the link below

Stakeholder
Analysis_PHC_CHC.xlsx

FORCE FIELD ANALYSIS

PERFORMANCE MONITORING AND EVALUATION
The introduction of a performance management system with different types of measures (i.e.,
core performance, program and target group) is another vital evaluation activity. These
measures will not only assist each PHC site in improving performance, but also aid in
identifying resources needed to improve the health and participation of community members
at various levels of PHC services. The logical framework (theory of change) for community
participation and engagement will ensure appropriate indicators that best align with national
regulations of outcomes, support feasibility of data collection and lessen the reporting burden
on operations, and provide evidence for which new and necessary services can be tailored for
each PHC site.

Depicted here is the decision framework

which guides the selection of the three
types of measures: core, program, and
target group. The continuum of
indicators is shown, which includes five
different types of indicators beginning
with inputs, moving through activities
and outputs, and culminating in
outcomes and impacts. Underlying
principles and rationale, such as
indicators representing a “gold
standard”, are central to the decision-
making process. The measures will be
reviewed on an annual basis in order to
comply with best practices and to
determine whether or not they require
modification or replacement.

Source: PHC Evaluation Framework, 2013

 KEY REFERENCE

1. Primary Health Care Evaluation Framework, 2013, Base of Alberta

Primary Health Care services
2. WHO Country cooperation strategic agenda at a glance for Nigeria, 2012
3. Implementing change in public health practice, lectures of decision making
in public health
4. Operational Manual for community Based Health Planning and Service,
Ghana Health Serve, 2008
5. Field operational manual for training Community health committee (CHC)
and village health volunteers in primary health care facilities, 2008,
Published by population council
6. Community tool box (Theory of change) (website)
7. Community medicine in the tropics (website)

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