Our chairman is very efficient: community participation in the delivery of primary health care in Ibadan, Southwest Nigeria

Introduction Community participation is rapidly being viewed as a requirement for the successful acceptance of health services; it integrates a complicated process which involves customs, beliefs, culture and power relations, not only structures and policies. Yet, there is a wide knowledge gap and changes favouring community participation in primary health care is still minimal. This study aims to assess the process indicators and other factors influencing community participation in the delivery of primary health care. Methods This descriptive cross-sectional study using qualitative methods was conducted in Ibadan South East Local Government Area of Oyo State, Nigeria between July and September, 2015. The interview and Focus Group Discussion guides centred around five participation indicators of needs assessment, leadership, resource mobilization, organization and management was used to collect data. A total of 12 in-depth interviews and four FGDs were conducted among male and female respondents consisting PHC service providers and community members purposively selected from four wards of the LGA. Spidergrams were constructed to visualize the levels of community participation from respondents' opinions. Results About 51.1% of the 45 respondents (with mean age 45.5 ± 8.09 years) were males. The respondents view community participation in the delivery of PHC in the LGA as being wide (open). Majority of the service users believe and agree that the level of community participation in their wards is about average while the service providers believed that participation was very high. However, respondents identified female representation, collaboration with pre-existing community structures, top-down and bottom-up approach to service delivery as factors affecting community participation in PHC delivery. Conclusion This study provides a baseline data on community participation in the delivery of primary health care. Community participation is still an important principle in the delivery of primary health care and it guarantees the positive changes desired in the uptake and sustainability of primary health care programmes.


Introduction
Primary health care is a grassroots approach towards universal and equitable health care for all as conceptualized by the Alma-Ata declaration of 1978 [1]. Several years later, its implementation is still below the optimum level in most Sub-Saharan African countries where access to health interventions remains a major problem for a large percentage of the populations [2]. Prior to the declaration, Nigeria had begun the implementation of Basic Health Services Scheme (BHSS) which was part of the Third National Development Plan from 1975-1980 [3,4]. The BHSS however paid minimal attention to community participation, inter-sectoral collaboration and the use of appropriate technology; it was solely on the provision of health facilities and training of health workers [5]. The declaration at the Alma-Ata identified community participation, one of the pillars of primary health care; as the process by which individuals and families assume responsibility for the health and welfare of both themselves and the community thereby developing capacity to contribute to the growth of their community [1]. It is widely interpreted as the collective involvement of indigenous people in assessing their needs and strategizing to meet those needs [6]. For many decades, several advocacies have been made to support community participation in health as a strategy to improving health [7]. More than three decades ago, countries like Sri Lanka who had adopted the concept of primary health care showed obvious improvements in their health status and quality of life due to committed community participation among other reasons; in-spite of their under development as compared to the United Kingdom [8]. A study conducted in South Africa on tuberculosis treatment delivery and community participation in primary health care identified that community participation should be encouraged as better outcomes were recorded where communities participated [9]. Community participation is rapidly being viewed as a precondition for the successful acceptance of health services [10]. It integrates a complicated process which involves customs, belief, culture and power relations, not only structures and policies [11].
Community participation and community ownership is engendered by community mobilization to ensure the sustenance of health programs [12]. It is still crucial to the success of primary health care interventions as communities agree to this fact and desires greater involvement [2] which is likely to facilitate "needs-based and demand driving" provision of health services thereby promoting sustainability and ownership [13]. Recent studies have re-iterated the message that community participation is key to the delivery of health care [13], its importance cannot be over-emphasized. It is the combined participation of community members, their representatives and PHC personnel, to enhance their collective effort in eradicating health problems [14]. The PHC is specifically made to suit people at the community level. Gideon [15] submitted that "without the communities there would be no primary health care and without primary health care, communities will experience health problems". A large and growing body of evidence exists that some forms of service delivery are improved when the communities they serve participate actively [16]. When the community members participate in defining problems, planning, implementation and evaluation of community resources, it gives them a sense of responsibility for their own health and also that of others [17].
Community participation was institutionalized in Nigeria through the creation of District Development Committee (DDC) and the Village/Community Development Committee (VDC) which are mandated to work in close proximity with local governments [17], to enhance the delivery and uptake of primary health care services.
Despite this, reports have shown Nigeria's consistent underperformance in all health indices [18], however, some health care interventions such as nutritional programs, treatment of diarrhoea and Acute Respiratory Infections (ARI) symptoms have improved in the last few years; attributable to the incorporation of community participation and some of the principles of PHC for the strategic implementation of these programs [19]. This study provides a baseline data on community participation in the delivery of primary health care. LGA, the Chief matron of the LGA and the head of facility (n = 5), at least one Community Development Committee member per selected ward (n=6), male and female PHC service users who reside in the selected wards (n=33).

Study design and sampling method:
The study was descriptive cross-sectional in nature using qualitative methods: Key Informant Interview (KII), In-depth Interview (IDI) and Focus Group Discussion (FGD). Purposive sampling was employed based on the inclusion criteria and willingness to participate; availability and ability to provide relevant information on the research questions [21]. Deliberate effort was made to recruit both male and female participants so as to explore the gender dimension of community participation. The FGD was conducted in the community, it involved male and female respondents and the discussions held separately. A moderator facilitated the discussions and ensured that every member of each group participated actively. A digital voice recorder was used for storing the data obtained from the interviews and FGDs and notes were also taken on paper to assist in the transcription process and for back up purposes. Four FGDs were conducted and each had 6-13 respondents.

Spidergram:
The spidergram provides a simple, practical yet powerful way of illustrating the extent of community participation in important areas in a visual way as presented in Figure 1. The methodology identified five indicators from over 200 studies that can be used to measure, visualize and locate levels of community participation on a continuum, the indicators are; needs assessment, leadership, organization, resource mobilization and management [22]. The spidergram can also be used as an approach by health planners and program managers in assessing the reflection of changes in community participation showed via health outcomes and program impacts [23]. It has been used across several programs in several nations of the world [24] including Ghana where it was used in assessing participation in a community-based health planning and services program [10]. could be obtained [26]. The spidergram of the extent of community participation in the wards and from the PHC service providers' perspective is constructed to visualize the present level of community participation [10,22] as inferred from the results obtained. A score of 1-5 using the community participation assessment tool developed by Lehman, (1999) is placed on each process indicator located on a continuum on the spidergram to show how narrow or broad participation is in each of the selected wards.
A score of 1 represents mobilization, 3-collaboration, 5empowerment while 2 and 4 are intermediate values [23]. Ethical approval was obtained from the Oyo State Ministry of Health Research Ethics Review Committee before the commencement of the study. Permission to interview community members was sought from the Head of Local Government Administration, written informed consent authenticated with a thumb print/signature was obtained from each participant before the commencement of the interviews/ discussions and participants were assured of confidentiality. All interviews and discussions were conducted at a convenient time and place as chosen by the participants.

Results
Participants' characteristics: A total of 45 persons participated in the interviews and focus group discussion sessions and each interview and discussion lasted for an average of 20-55 minutes.
Majority of the participants were from the Yoruba tribe, which is the dominant tribe in the South west region of Nigeria. Table 1 shows the participants' characteristics while Table 2 provides the description of focus groups.

Needs assessment
Importance of needs assessment: Respondents agree that community participation is important in community needs assessment and in the delivery of PHC and community members have been responsive to the PHC professionals in assessing some of their needs. According to a female community development committee member; community participation is very important in needs assessment as community members are the ones directly involved whenever a need arises' (IDI 2, female, W1). Another respondent opined that; Community participation cannot be overemphasized because PHC services is a healthcare service that is close to the grassroots and the community members have to be involved if not, they will not have a sense of belonging for that particular program (IDI 1, DSNO, male). was not well treated, yet, they tell us to sensitize our people that health care is free, still they make us pay heavily to assess care" (FGD1, female 5).  Figure 4. Figure 5 shows the collective opinion of both service providers and community members revealing wide participation in the empowerment end.

Discussion
This study aims to assess community participation, as a major principle in the delivery of Primary Health Care and it uses the Spidergram as a methodological tool to visualize participation levels.
All the study participants admitted that PHC has fared well in Nigeria since the Alma-Ata declaration and the importance of community participation in its delivery cannot be over emphasized. This agrees with Makaula and colleagues' [2] view that community participation participation for health [6,11]. This study revealed that community members through their representatives supported the delivery of PHC by contributing lands/ buildings; the results from the survey of PHC facilities by Gupta et al [27] which showed that community health committees were the major source of support for building maintenance in majority of the selected PHC facilities agrees with this finding. Although, some community members belief that their requirements to mobilizing resources for PHC services is a way of diverting the responsibilities of the government; this aligns with the findings of McCoy et al [7] findings that governments may use community participation in health to divert their responsibilities to communities. In some wards, it was observed that female participation was very minimal; consistent with findings from the assessment of participation in a community-based health planning and services program in Ghana [10]. Male dominance, from the results of this study has a negligible effect on whether the community members will participate or not, this is however inconsistent with the findings of Baatiema and colleagues [10] and Sepheri and Pettigrew [28] that male dominance hindered community participation and prevented community health committees from effectively representing the interest of the community as a whole thereby preventing total community participation in PHC delivery. A number of factors were inferred from respondents' discussions and interviews as favoring or hindering community participation in Primary Health Care delivery.
The general opinion of respondents, particularly community members is that inadequate mobilization and advocacy for programs is a major factor hindering their participation; this is corroborated by Alenoghena et al view [29]. The results of this study revealed the desire of community members for monetary incentives; especially those who participate in mobilization and advocacy, some even noted their desire to be on a regular payroll of the PHC professionals which agrees with the findings of Kironde and Klaasen [9] on the desire of volunteers in the community for remuneration in developing countries as a major hindrance to community participation. This is also corroborated by the findings of McCoy et al [7] that communities are expected to participate through their health committees on an unpaid basis.
The present economic state of the country and the literacy level of the community members however might be a contributing factor to this finding. This study also revealed that PHC staff-responsiveness and accountability was substantial where communities participated in PHC delivery; this is corroborated by findings of Gupta et al [27].
Community members view Primary Health Care programs in which they participate as beneficial to them and they sometimes completely ignore the uptake of services in which they feel they have minimal participation; this agrees with the submission of Preston et al [30] that community participation can increase the uptake of services and yield favorable health outcomes. The opinions of PHC professionals and those of community members (CDC members inclusive) differed slightly from each other in a few instances which may be due to reporting bias as postulated by Baatiema and colleagues [10]. This study also revealed that community participation is a complex process as opined by Mosquera [11]   Top-down approach to primary health care by some service providers impedes community participation.    Harare, Zimbabwe: regional network on Equity in Health in