Integrating Community Health System Activities and Participation into the Primary Healthcare System for Ensuring...

Introduction: In Nigeria, communities have long organised health and social actions that address local needs but remain weakly integrated into the formal primary healthcare (PHC) system. Understanding these approaches and how they interface with PHC is important for advancing universal health coverage (UHC). Objective: This study examined community-driven health and social actions and explored pathways for their integration into the formal PHC system. Method: A qualitative study was conducted in three purposively selected Nigerian states: Anambra, Akwa Ibom, and Kano. Data were collected through face-to-face in-depth interviews with 11 formal healthcare providers, 31 informal healthcare providers, and 19 traditional and religious leaders, and 12 focus group discussions with community members. Data were analysed deductively using the Expanded Health System Building Blocks and the World Health Organization Operational Framework for Primary Health Care. Results: Communities across the study sites had established diverse, self-organised health and social actions that filled gaps in primary healthcare delivery. These included community-financed drug distribution and insurance schemes, subsidised care by informal providers, health education, sanitation, food support, and community safety initiatives. Led by local leadership structures, these activities were sustained through collective responsibility. Interfaces with the PHC system had emerged in several settings, including PHC-led training of traditional birth attendants and informal providers, revealing a community-generated layer of healthcare delivery with potential for systematic integration. Conclusion: Our findings highlight opportunities to strengthen linkages between existing community initiatives and PHC governance, financing, and accountability structures to better harness community contributions to health and its social determinants and support progress towards UHC.