Introduction:
In contrast to the curative, top-bottom, vertical approach to health care delivery adopted by sub-Saharan countries, including Nigeria, China had moved in a rather opposite direction, adopting a preventive, bottom-up structure that was community-based. It order to enhance access to health care it became necessary to streamline the various, divergent approaches globally. Consequently, an International Conference on Primary Health Care, was convened in Alma Ata, Kazakhstan, in September, 1978, at which 134 countries advocated and endorsed the ‘health for all’ programme through the Alma Ata Declaration, to be driven by the Primary Health Care (PHC) system.
The PHC concept stands on five principles, designed to work together and be implemented simultaneously to bring about better health outcomes for the entire population. These are: accessibility; health promotion; appropriate technology; inter-sectoral collaboration; and community participation.
The emphasis of this paper is on community participation, which is one of the domains of governance in primary health care delivery. It entails the meaningful involvement of the community in planning, implementing and management of their health services. It is envisaged that through the involvement of the community, maximum utilisation of local resources, such as manpower, money and materials, can be utilised to fulfil the goals of PHC.
However, because of their cross-cutting nature, some components of other principles are embedded in the principle of community participation. These include its emphasis on rural communities (accessibility); and health education and sanitation (health promotion). Our objective is determine the role of community participation in the PHC system in Delta State.
Conceptual Clarification
The study deployed and interrogated two concepts, namely: governance and community participation. Governance is the dynamic political process through which decisions are made, conflicts are resolved, diverse interests are negotiated and collective action is undertaken. It is “the effective participatory, transparent, equitable and accountable management of public affairs guided by agreed procedures and principles, to achieve the goals of sustainable poverty reduction and social justice”.(1) Among other attributes of governance is the building of the capacity of government so as to facilitate effective policy making and implementation (2), the exercise of economic, political and administrative authority to manage affairs at any level of jurisdiction (3) and the ability to develop an effective, efficient and accountable public management process which is open to the participation and inclusive of all stakeholders and which also strengthens rather than weaken the democratic structure.(4) In other words, governance emphasises not only the efficiency and effectiveness of the public administration system, but also the imperative of ensuring that popular participation (inclusive representativeness) is strengthened so as to ensure the accountability of service delivery.(5)
With particular regards to the health sector, governance provides the framework within which to establish systems of mutual accountability that are participatory, equitable and accountable, and that support interactions between and among communities, health facilities and the government. It improves health care delivery by providing the platform for bringing together communities, health care providers (both public and private), the government and other stakeholders in participatory systems that enable them to collaborate, negotiate, act, build consensus and take action to improve service delivery.
Strengthened governance produces results including: more functional and responsive health systems; improved quality and service delivery; improved staff attitude; reduced discrimination; improved coverage and access, particularly in reaching vulnerable groups like isolated, remote, rural and wet land communities. Other include the removal of barriers to health care seekers; improved oversight and management of health facilities, in terms of budgeting and provision of supplies; mutual trust and accountability; feeling of a sense of ownership of, and responsibility for, their own health and health systems; as well as holding governments and heath systems accountable for their responsibilities and commitments.(1)
There, therefore, appears to be a seamless relationship between primary health care governance and community participation. This is because without local communities there would be no primary health care. In fact, the primary health care system is tailor-made for the community level.(6) It is now almost universally acknowledged by health care planners that community participation is central to the successful implementation of the primary health care system.(7) As embedded in Article 44 of the 1978 Declaration of Alma Ata, community participation is: “The process by which individuals and families assume responsibility for their own health and welfare and for those of the community, and develop the capacity to contribute to their own and the community’s development”.(8) Article 46 of the Declaration further elaborated that: “There are many ways in which the community can participate in every stage of primary health care. It must first be involved in the assessment of the situation, the definition of problems and the setting of priorities. Then, it helps to plan primary health care activities and subsequently it cooperates fully when these activities are carried out”.(8)
Community mobilization and participation facilitate the common ownership of the project by the researcher, decision-makers and end-users, by encouraging the community, through their credibly accredited representatives, to take part in their health care planning, development and implementation.(9) These enhance the integrity and enrich the quality of the work by: injecting grassroots information; integrating the indigenous knowledge system (IKS), or appropriate technology, that are in harmony with local beliefs, cultures and traditions; as well as monitoring the quality of service provided. Indeed, it is for the purpose of community participation that the National Health Policy in Nigeria emphases community engagement in the provision of PHCs, pursuant to the spirit of the Bamako Initiative of 1987.(10) Community participation was institutionalized in Nigeria in 2003, through the creation of District Development Committee (DDC) and the Village Development Committee (VDC).(7) In spite of their strategic importance to the actualization of the goal of equitable access to, and utilization of PHC services, community mobilization and participation have not been strong components of the PHC system.
The Delta State PHC research project provided for the integration of community participation, by involving all stakeholders, particularly rural health care seekers and end-users of PHC services, in the implementation of the project. This involvement is achieved through membership of the project management committee, on the one hand, and attendance and participation at all briefing and information-sharing meetings at which felt needs are articulated and prioritized, on the other. This enabled local communities to assume responsibility for their health and welfare, as well as build their capacities to contribute to policy on health through involvement in planning, implementing, monitoring, evaluating and above all, ensuring the sustainability of health interventions.
Methodology
The study is an aspect of the larger research project titled: “Strengthening the health care system in Nigeria through improved equitable access to Primary Health Care (PHC) : The case of Delta State, Niger Delta region”, jointly funded by the International Development Research Centre (IDRC) and the West African Health Organization (WAHO).
The gathering of quantitative information adopted the multi-stage sampling procedure. Accordingly, nine local government areas were selected; three each from the three senatorial districts. The emphasis of the larger study was to look at the challenges of accessibility in health care delivery. Consequently, the selection of local government areas was purposive and designed to capture rural, isolated and wetland communities that are characteristically inaccessible, marginalised and usually underserved. The choice of communities was further justified by the fact that more than 90 per cent of the region is rural, with 94 per cent of the 13,329 settlements having less than 5,000 population.(11)
The study sought to know the nature of the participation of key stakeholders, particularly local communities and health seekers/users in the primary health care delivery in Delta State. The study was, therefore, participatory and inclusive, with the objective making the research results the joint product of researchers, decision makers and the communities. The expectation is that the ‘co-ownership’ of the research findings will facilitate their eventual translation into policy.
The platform adopted in the study for integrating research and policy was to set up two strategic committees, namely: the State Steering Committee (SSC) and the Project Management Committee (PMC). The State Steering Committee (SSC) was constituted of key policymakers that are statutorily linked with policies and the implementation of projects designed to pursue and address issues of primary health care delivery. Therefore, pursuant to this objective, SSC was constituted to include the supervising Permanent Secretary of the Ministry of Health (MoH), other Permanent Secretaries and all the Directors (of Departments) in the ministry. On the other hand, the Project Management Committee (PMC) was composed of representatives of researchers; representatives o fpolicymakers; representatives of care providers; representatives of health care seekers/users; advocacy experts; activists; accredited representatives of such vulnerable groups as the poor, the women. The SSCs and SPMCs provided the framework for knowledge transfer from, and knowledge brokerage by, the core research team to other stakeholders.
The instrument used to elicit information was the users’ survey, designed to determine the degree and quality of public participation in the governance and management of primary health care. Among the issues that were interrogated were: communities’ participation in health management committees; the frequency of meetings of health management committees; reasons why people are not interested in participating in committees; and perceived solutions to the problems observed. Research assistants were recruited from eligible members of the communities in which the facilities are located. They were trained on the administration of the survey instruments. A pilot test was conducted after which the questionnaires were further fine-tuned for final production. Supervisors were also recruited and trained separately to monitor the research assistants and resolve all challenges that the latter might encounter. The field data were cleaned up and exported to SPSS for analysis and are presented in percentages.
In addition to the quantitative data, there was also a qualitative component. This component was implemented through focus group discussions (FGDs) and key informant interviews (KIIs). The population of the qualitative survey comprised PHC staff, and randomly selected key stakeholders in the localities, such as community leaders, users of primary health services, women and youths. The FGDs and KIIs were conducted in all the nine local government areas. The objective of the qualitative survey was to determine the integrity of the quantitative data, particularly from the perspective of primary health care users and communities.
Because the study is entirely participatory, the involvement of local communities and key stakeholders did not end with the giving of information to researchers. Rather, the findings were presented to the representatives of the local communities for their review and feedback. Specifically, their perception of the major findings was canvassed. In addition, their opinion was sought as to what they considered to be the solutions to the perceived problems. In order to make them represent the opinion of all stakeholders, these assessments, reviews and feedbacks were further discussed with the Project Management Committee as well as the State Steering Committee for their perspectives on the findings and their suggestions for going forward. The final results were, therefore, the systematic integration of the inputs of all stakeholders. This is to ensure that the results were policy-ready and implementable.
Findings
The emphasis on community participation in health care delivery is a recognition of the need for a rights-based health system that addresses the systemic challenges encountered by vulnerable groups, particularly isolated and rural communities. Consequently, successful implementation of a bottom-up health policy requires the ability to work with local communities and health care seekers/users in taking actions that are not only representative but also responsive. Below, are some perspectives on health care governance and management of the PHC system in Delta State. The emphasis is on the involvement and participation of the local people in the various aspects of the management of PHCs in the localities in which they are located.
The types of committees involved in health related activities
The PHC system is dynamic. Consequently, the effectiveness of its activities depends on, among others, the diversity of the sub-structures that provide the support base for the management and operations of its health and related activities. A number of committees have been designed to provide this support, through regular meetings for the purpose of enriching local content, by supplying information and sharing of ideas from the health-seeking public and other stakeholders. Usually, the more diversified the committees, or the broader and more varied the involvement and input of the public/stakeholders, the greater the priorities and interests of the health care seekers will be captured and reflected. Consequently, the more responsive the PHC services will be to the health needs of the public. Three committees are particularly relevant. These are: community/village health management committees, ward health committees and youth/women committees, as outlined in the Bamako Initiative, 1987. Their distribution is presented in Table 1.
The study shows that community/village health management committees were the most common, accounting for more than half (54 per cent) of all the committees. This was followed by ward health committees (24 per cent). PHC facilities that had no committees and those that had youth/women committees, each accounted for 11 per cent. Among the committees, there were quite remarkable differences. For instance, while community/village health management committees accounted for 95 per cent of all the committees in Ndokwa East, they were none in the PHCs in Bomadi. With respect to ward health committees, while on the average, they accounted for 24 per cent of all the committees, they varied from an overwhelming 93 per cent of all the committees in Udu to a total absence in Bomadi. Two other remarkable observations on Table 2 are that: in Ughelli South, the most common type of committees were the youth/women committees, which accounted for 43 per cent of all and that Bomadi had no type of committees whatsoever, at the time of the survey. Conversely, there were more diverse and balanced outlets for community participation in Ika South because it had more the average of each of the committees; followed by Aniocha North which was above average in two of the three types of committees.
Table 1: Percentage distribution of the committees engaged in health-related activities. |
| LGA |
None |
Community/
Village
Health
Management
Committees |
Ward
Health
Committees |
Youth/
Women
Committees |
Total |
Aniocha North |
0 |
41 |
37 |
22 |
100 |
Bomadi |
100 |
0 |
0 |
0 |
100 |
Ika South |
0 |
53 |
28 |
19 |
100 |
Isoko North |
0 |
86 |
11 |
3 |
100 |
Ndokwa East |
0 |
95 |
5 |
0 |
100 |
Okpe |
0 |
88 |
4 |
8 |
100 |
Udu |
0 |
7 |
93 |
0 |
100 |
Ughelli South |
0 |
41 |
16 |
43 |
100 |
Warri North |
0 |
72 |
21 |
7 |
100 |
Average |
11 |
54 |
24 |
11 |
100 |
| Source: Fieldwork, 2014. |
Frequency of meetings of PHC management committees in 2013
It is one thing to have health management committees but quite another for the committees to be functional. A dormant committee is not better than having no committee. The functionality of the committees was determined by how frequently they met in the year preceding the survey (2013). It was considered that quarterly meetings were ideal in order to keep abreast of, and evaluate all developments for timely interventions. The responses are presented in Table 2.
Perhaps the most remarkable observation from the study was that on the whole, in almost one-third (30.33 per cent) of the PHC centres surveyed, no health management committee meetings were held in 2013. Particularly noteworthy was the observation that almost one-half (48 per cent) of the centres in Ndokwa East, Okpe and Ughelli South held no health management committee meetings in the year preceding the study. The survey showed that only 22.56 per cent of PHC centres performed optimally, having held health management committee meeting four times in 2013. However, this average masked the great variations that existed between and among the LGAs. Thus, while 57 per cent of the centres in Udu health such meetings, in the centres surveyed in Ndokwa East, none (0.0 per cent) held such meetings.
The studies also showed that 10 per cent of the surveyed centres held meetings thrice in 2013, with the details varying from 22 per cent of the centres in Ika South, to Warri North, where none (0.0 per cent) of the centres held such meetings.
Also the study showed that while across the target LGAs 19.44 per cent of the centres held biannual committee meetings, the details varied from as high as 56 per cent in Bomadi, to Aniocha North where no such meetings (0.0 per cent) were held.
Table 2: Percentage distribution of health management committee meetings in 2013 in PHC centres |
| LGA |
Once |
Twice |
Thrice |
Four
Times |
None |
Total |
Anioca North |
46 |
0 |
8 |
33 |
13 |
100 |
Bomadi |
0 |
56 |
11 |
11 |
22 |
100 |
Ika South |
26 |
22 |
22 |
22 |
8 |
100 |
Isoko North |
26 |
5 |
11 |
32 |
26 |
100 |
Ndokwa East |
38 |
10 |
4 |
0 |
48 |
100 |
Okpe |
12 |
17 |
17 |
6 |
48 |
100 |
Udu |
0 |
10 |
10 |
57 |
23 |
100 |
Ughelli South |
11 |
17 |
7 |
17 |
48 |
100 |
Warri North |
0 |
38 |
0 |
25 |
37 |
100 |
Average |
17.67 |
19.44 |
10 |
22.56 |
30.33 |
100 |
| Source: Fieldwork, 2014. |
Finally, Table 2 shows that although 17.67 per cent of the PHC centres held committee meetings once in 2013, none (0.0 per cent) of the centres in Bomadi, Udu and Warri North held such meetings, while in Aniocha North 46 per cent of the centres held such meetings.
Major reasons inhibiting adequate participation of communities in committee meetings
Recognizing their significance in the governance of PHCs, the survey sought determine the factors militating against adequate public participation in health management committee meetings of PHCs; thereby making them either dormant or inactive. This will point to the policy issues that should be addressed. The responses by the respondents are summarised in Table 3.
The most major reason for the poor community participation in health committee meetings was lack of awareness, which accounted for 55 per cent of all responses. PHC staff claimed that many community members did not know what roles they were expected to play in the health management committees. The severity of this factor varied from a vast majority of 81 per cent of the responses in Isoko North, to 32 per cent in Aniocha North. Other LGAs where lack of knowledge severely hampered the participation of local communities were Ughelli South (73 per cent) and Udu (66 per cent). The study also showed that across the target LGAs, illiteracy/ignorance accounted for 23 per cent as the major reason for poor community participation in committee meetings. However, the details showed that this factor was cited by 36 per cent, 33 per cent and 32 per cent of the facilities in Warri North, Bomadi and Ndokwa East, respectively.
Table 3: Percentage distribution of the major factors that inhibit the committees from being active |
| LGA |
Lack of adequate finance |
Lack of awareness |
Illiteracy/
ignorance |
Total |
Aniocha North |
39 |
32 |
29 |
100 |
Bomadi |
11 |
56 |
33 |
100 |
Ika South |
28 |
53 |
19 |
100 |
Isoko North |
5 |
81 |
19 |
100 |
Ndokwa East |
23 |
45 |
32 |
100 |
Okpe |
50 |
38 |
12 |
100 |
Udu |
20 |
66 |
14 |
100 |
Ughelli South |
7 |
73 |
20 |
100 |
Warri North |
14 |
50 |
36 |
100 |
Average |
22 |
55 |
23 |
100 |
| Source: Fieldwork, 2014 |
The LGAs where illiteracy/ignorance had low affect on community participation were Udu (14 per cent) and Okpe (12 per cent). The third major cause of poor participation committee meetings was lack of adequate finance. Generally, attendance at committee meetings implies sacrifice of time that the rural poor could have been used for some income-yielding activities. When this sacrifice is consistently uncompensated, attendance becomes unattractive after one or two meetings. On the whole, the problem of lack of financial incentives for attending committee meetings accounted for 22 per cent of all responses, varying in details a high of 50 per cent in Okpe, to as low as five per cent and seven per cent in Isoko North and Ughelli South, respectively. Finally, apart from Okpe, (where lack of finance accounted for 50 per cent of all responses) the lack of awareness is the single most major reason for poor community participation in all other LGAs.
Percentage distribution of what could be done to make health management committees more active
In consonance with the inclusive and participatory methodology of the study, stakeholders (users, providers, key informants, focus groups and others) were required to share their perceived solutions to the indicated governance challenges of the system. This was the qualitative confirmation or otherwise of the reasons given above for the inadequate community participation in the governance and management of primary health care system. The responses are summarised in Table 4.
Although couched in different combinations and titles, the perceived solutions in Table 4, correspond largely with the major factors that inhibit community participation identified in Table 3. For instance, financial reward, awareness/enlightenment and mobilization in Table 4 correspond largely with lack of adequate finance, lack of awareness and illiteracy/ignorance, respectively, in Table 3. However, Table 4 shows that the distribution of the responses is more uniform than was the case in the other indicators that were characterised by very remarkable differences. This is a confirmation of the veracity of the perceived solutions. The outstanding exception is Ughelli South and Ndokwa East. Thus, compared with the average of 47 per cent, financial reward accounted for between 49 per cent to 22 per cent of the perceived solution in Aniocha North and Warri North, respectively.
Table 4: Percentage distribution of perception of what could be done to enhance community participation |
| LGA |
Create awareness and enlightenment |
Financial reward |
Mobilization of community members |
Total |
Aniocha North |
32 |
49 |
19 |
100 |
Bomadi |
45 |
33 |
22 |
100 |
Ika South |
40 |
32 |
28 |
100 |
Isoko North |
36 |
44 |
20 |
100 |
Ndokwa East |
16 |
66 |
18 |
100 |
Okpe |
33 |
38 |
29 |
100 |
Udu |
32 |
50 |
18 |
100 |
Ughelli South |
2 |
93 |
5 |
100 |
Warri North |
57 |
22 |
21 |
100 |
Average |
33 |
47 |
20 |
100 |
| Source: Fieldwork, 2014 |
Similarly, the respondents who perceived the creation of awareness and increased enlightenment as the needed solution, varied from 57 per cent to 32 per cent in Aniocha North and Udu, respectively. Finally, mobilization of community members accounted for between 29 per cent 18 per cent in Okpe and Udu, respectively.
Policy Implications
Two major policy implications flow from the major findings of the study, as presented above.
Increased funding of the primary health care system
The need for increased and sustained funding has implications for all areas of operation of the PHC system. However, with particular reference to community participation, increased funding will enhance its activities in at least the following ways: It will facilitate the convening of quarterly meetings of health committees. Committee meetings could be expensive. Therefore quarterly meetings could be a major financial burden on PHCs. They are very expensive to organize, considering the need for space rental (where the facility(ies) do(es) not have enough, as is most commonly the case). Secondly, for meetings that last hours, refreshment may have to be provided, because participants may have forgone a meal (breakfast) to attend early, and another (lunch) before the meeting ends. Thirdly and more importantly, ‘a sitting allowance/transportation allowance’ should be given to attendees, so as to compensate for the sacrifice of time and the cost of travelling to the meeting venue, so as to encourage them to continue to attend. This is particularly so for the rural poor who will have to forego their livelihood on meeting days. Otherwise, after one or at most two stressful and costly trips to meetings, they will cease to attend. This was indicated as the reason why almost one-third of all the facilities surveyed did not hold any committee meetings in the year preceding the survey. Because attendance at meetings are unattractive due to their opportunity costs to the poor communities, funds are needed to encourage members to participate.
Awareness and enlightenment
In order to create awareness and promote enlightenment, there is the need for health education, campaign, awareness mobilization and sensitization. The present dismal level of awareness is a strong indictment of the health educators in the surveyed facilities. The level of ignorance must be reduced. As matter of urgency, therefore, the health education departments in the PHCs in Delta State, should be overhauled, with a view to ensuring that they are equipped to aggressively disseminate health information to their host communities. A number of outlets already exist in our communities which could leveraged on. These include the ubiquitous town/village crier, as well as age-grade and special-interest meetings (such as youth women’s, traders’ groups). Special general meetings could be convened for whole groups, or in the alternative, their leaders could be trained, who in turn train their members. Formal information dissemination structures, such as schools, churches and mosques should be explored maximally. Accordingly, not only should students and pupils, as well as church and mosque congregations be equipped with knowledge on their importance, but more importantly, they should be encouraged to spread information on the varied services that PHC facilities offer and the need for local communities to participate in the design for the policies by attending health management committee meetings and participate in project monitoring and other activities. Primary health care services should be a mandatory plank for political manifestoes and campaigns. This will commit public office holders to the implementation of policies on primary health care service delivery to communities.
Conclusion
The primary health care (PHC) system was conceived and designed to meet the health needs at the basic level. It is meant to be the health seeker’s first entry point into the health care delivery system. This makes the local community its primary target and clientele, because it is customised for the community level. Indeed, the community is the raison d’être for the PHC system. The efficacy of the system should, therefore, be judged by the degree to which it responds to the health needs of the local people. One of the factors that determines the degree of its responsiveness is the quality of community participation in the governance and management of the system and its facilities. It is through community participation that individuals and families assume responsibility for their own health. It also helps the community to develop its capacity to contribute to its overall development. Community participation enhances the quality of service delivery by attending health management committee meetings and contributing their inputs and suggestions at the village, ward and special interest group levels.
However, the study of Delta State showed that the participation of local communities in the governance of primary health care delivery has not been satisfactory. Consequently, their contribution to the provision of basic infrastructure, such as toilets, is minimal and their attendance at health management committee meetings has been poor. Indeed almost one-third of the facilities surveyed did not hold a single committee meeting in the year preceding the study. Two major reasons were adduced for poor community participation in primary health care governance in the Delta State, namely: inadequate funding and ignorance. Consequently, it has been proffered that the funding of the PHC system should be significantly improved and sustained and that there should be massive health education, campaign and sensitization of the communities, concerning the importance of health and the need for them to participate in primary health care activities in their localities.
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