Strengthening the effectiveness of community health system: assessing the factors that enhance or constrain the delivery of health services within communities in Nigeria

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This paper examined the key factors that either enhance or constrain CHSD in Nigeria at individual, community/facility and governmental levels while recommending evidence-based solutions for sustaining and improving CHSD within the framework of CHS. Methods Data was collected through a qualitative study undertaken in three states (Anambra, Akwa-Ibom and Kano) in Nigeria. Respondents were formal/informal health providers; community leaders and representatives of civil society organizations all purposively sampled. There were 90 in-depth interviews and 12 focus group discussions, which were audio-recorded, transcribed verbatim, and analyzed thematically using codes to identify key themes. Results Factors constraining CHSD at the individual level were: poor health seeking behavior and male dominance. At the community/facility level: superstitious/cultural beliefs and poor attitude of facility workers; at the governmental level were: inadequate financial support, embezzlement of funds, inadequate social amenities... Conversely, the enabling factors at the individual level were: community members participation, compassionate attitude of informal providers… At the community/facility level were: synergy between formal and informal providers; and support from community-based organizations and structures. At the governmental level were: government’s support to community-based formal/informal providers and clear line of communication. Conclusions CHSD through functional CHS can improve overall health systems strengthening and lead to improved community health. Policymakers should integrate CHSD in all program implementation and ultimately work with CHS as a veritable platform for effective community health service delivery. Community health service delivery Community health systems CHS CHSD Universal health coverage Multisectoral collaboration Introduction Poor community healthcare service delivery has adverse effect both on the individual and economy of the state [ 1 , 2 ], while improved community healthcare service delivery has been shown to relate to more productivity in people [ 3 ]. Therefore, ensuring an efficient community health service delivery does not only have implication for improving the health of the citizens but also the economy of the country. Achieving the Universal Health Coverage (UCH) and the Sustainable Development Goals (SDGs), for any country relies on how effective health services are delivered to communities which in turn is dependent on how well factors that constrain health service delivery are able to be identified and addressed as well as sustaining those factors that enhance it [ 4 ]. The promotion of an effective community health service delivery that would enhance community health system in Nigeria has been a key policy objective of the Nigerian government as contained in the Nigerian 2016 National Health Policy document [ 5 ]. This is because, ensuring an efficient community health system has been a major global issue for countries across the globe [ 6 , 7 ]. According the Nigerian 2016 National Health Policy document, the improvement of health service delivery at the community level has been identified as one of the key strategies towards improving CHS. Although there is no general consensus for defining the concept of community health system due to the fact that it is still evolving, Schneider and Lehmann in 2016 defined it as the set of local actors, relationships, and processes engaged in producing, advocating for, and supporting health in communities and households outside of, but existing in relationship to, formal health structures [ 8 ]. Despite Nigeria’s establishment of the primary health care (PHC) system in 1976 which designated the local government areas (LGAs), the second smallest administrative level in the country, the responsibility to manage and implement health services at the community level and the establishment of the National PHC Development Agency to ensure sustainability of previous gains and better manage the PHC system in the country with the agency revising PHC system in 1993 [ 9 ], Nigeria ranks 157th out of 167 countries in a 2023 world health and health system ranking [ 10 ]. With this ranking, it is uncommon to see the CHS plunging. Studies [ 11 , 12 ] have shown that the CHS in the country has been deteriorating and needs to be enhanced as a way of improving the overall health system as well as boosting the country’s health profile. For example, [ 12 ] linked the deterioration to lack of enough community health workers and lack of re-training for the few available workers while [ 11 ] linked the deterioration to poor female representation, poor collaboration with pre-existing community structures, the poor approach to service delivery as factors affecting community participation in PHC delivery which in turn affects the CHS. However, in order to improve community health system delivery in Nigeria within the construct of community health system, it is important to assess the factors that constrain and as well as promote healthcare service delivery at different levels across communities with the goal of identifying and addressing the constraining factors while ensuring the sustenance of the promoting factors. Identifying and addressing the key factors that impede community health service delivery in Nigeria have strong implication for the improvement of community health systems in the country as well as the attainment of the universal health coverage (UHC) and the Sustainable Development Goals (SDGs). It is therefore possible that identifying and rewarding exceptional community members that contribute to improving health service delivery in the communities by the leaders of the community and other stakeholders can encourage the sustenance of the identified enabling factors especially at the individual level since studies have shown that reinforcements can help sustain positive attitudes [ 13 – 15 ]. This paper examined the key factors that either enhance or constrain CHSD in Nigeria at individual, community/facility and governmental levels while recommending evidence-based solutions for sustaining and improving CHSD within the framework of CHS. The findings will be useful for decision makers on possible solutions to tap into the latent resources of communities, especially within the context of CHS to significantly improve community health. Methods Study area and design: This study was conducted in three States across three geopolitical zones in Nigeria namely: Akwa-Ibom (south-southern zone), Anambra (south-eastern zone) and Kano (located at the north-western region). The areas were purposively chosen to achieve a geographical representation of the country and ensure more spread of the result findings. The study employed a qualitative design in which data was collected through face-to-face semi-structured interviews and focus group discussion (FGD) with open-ended questions and prompts. Purposive sampling was used to select two Local Governments Areas (LGAs) in each of the three states. The sampled LGAs comprised of one rural and one urban area. For Akwa-Ibom State, the urban LGA was Uyo, while the rural LGA was Itu. For Anambra State, the urban LGA was Awka South LGA, while the rural LGA was Aguata. For Kano State, the urban LGA was Nasarawa Local Government Area while the rural LGA was Kumbotso. The purposive sampling technique was used to select respondents for the study. The factors considered in their identification and selection were: their level of participation and involvement in health-related activities in the communities, their occupation, leadership roles and length of service to the community or the government. The respondents cut across different groups – policymakers, Civil Society Organizations (CSOs), Non-Governmental Organizations (NGOs), Traditional, Religious and Community leaders, community groups, formal health providers and informal health providers. A total of 90 in -depth interviews (IDIs) and 12 focus group discussions (FGDs) were conducted (Table 1). Data was collected between October to November 2022. Table I - Summary of respondent categories and number of interviews Respondent category Akwa Ibom Anambra Kano Health sector policymakers 3 2 3 Health program managers 2 2 1 Formal healthcare providers 4 3 4 Informal healthcare providers 13 7 11 Intermediary health workers ---- ----- 3 Private health sector ---- 4 ---- CSO/NGO 2 4 3 Community or Religous leader 7 5 7 (FGD) Community groups/ Service users (Women) 2 2 2 (FGD)Community groups /Service sers(Men) 2 2 2 Total (Males) 18 18 25 Total (Females) 17 13 11 Total per state 35 31 36 Grand Total 102 Data Analysis: The analysis followed a systematic approach, including familiarization with the data, coding, identification of themes, and interpretation. Regular meetings were held to discuss the coding and resolve any discrepancies among the researchers. Analyses focused on exploring the factors that both encourage as well as hinder community health service delivery in three sub-themes or levels _individual, community/facility and governmental. The analysis process involved double coding of each of the transcripts to ensure the relevance and comprehensiveness of the findings. Ethical considerations: Ethical approval for this study was obtained from the Health Research Ethics Committee of the University of Nigeria Teaching Hospital, Ituku-Ozalla Enugu State. Permission to conduct the study was sought and obtained from the respondents and traditional leaders of the communities. Written informed consents were obtained from all study participants after they have demonstrated understanding of study procedures, and voluntariness. The confidentiality of all the participants was assured and maintained during and after the study by assigning unique identifiers to each participant during data analysis and reporting. Results The result of the analysis is presented in two main themes which are: Factors that (1) Enable or (2) Constrain community health service delivery. Each of the main theme is further broken down to three sub-themes or levels: individual, community/facility and governmental. Factors that promote CHSD The following factors were found in the study to enhance community health service delivery at different levels: Individual Level Selfless participation of community members We found that one of the factors encouraging health service delivery in the communities is community members’ selfless participation in activities that improve CHSD. The members of the community were found to engage in personal activities such as carrying out sanitary activities in the primary healthcare centers as well as providing health equipment such as handwashes, gloves etc. in a bid to improve the quality of health service provision in the communities. For example, a respondent in Kano State during the interview noted: We carry out many services in the society like cleaning gutters and sweeping our surroundings, washing and disinfecting hospital etc. All of this are done voluntarily by the people without expecting any payment at the end. (Civil Servant, Kano, IDI). Synergy between formal and informal providers with community members At the individual level, informal providers expressed that they were in constant interaction with the formal providers in order to ensure adequate health service delivery for the community members. This interaction involves informal providers individually referring cases they cannot handle to formal providers in order to ensure maximum treatment output. The informal providers acknowledged that some cases they encounter are sometimes beyond them and that the best practice is to refer immediately to the formal providers and that this has helped in ensuring adequate health service delivery output. While trying to buttress this point, a Herbalist in Akwa Ibom noted: “Yes, I do refer some injuries that are beyond my ability to a health center because I believe there are some injuries that I can cure and others that I cannot and must refer to health centers.” (Herbalist, Akwa Ibom, IDI) Compassionate attitude of informal providers Another factor found to aid health service delivery in the communities at the individual level was the informal provider’s compassion and willingness to help the patients at little or no cost. These providers noted that their priority is ensuring that the patients recover from their illness and not necessarily about making monetary gains. This ensured that the patients kept coming to receive services at reduced rate. A Bonesetter in Akwa Ibom in a bid to elucidate this noted: "I'm not sure, but according to information I received from one of the clients referred to me, he should pay the hospital 650,000naira. I was also considerate with him, and I didn't take much from him because he was poor. I only charged him 130,000 naira because I was being considerate……. "The majority of them stay because I have a large house and I don't mind them staying until they finish their treatment, and while at my place, they feed themselves out of their pockets, while the majority of them come from their homes for their treatment and then return"." [10_AK_UB_IDI_IP_Bonesetter] Another respondent in Kano, recounts that it is the passion that the providers have for the job that keeps them going and not the amount they get since the amount they are paid is little compared to the work they do. The respondent noted: Most of them have passion for it because the little they get from it is really helping them [IHW Kano, IDI] Community/Facility Level Synergy between formal and informal providers At this level a key factor we identified to be aiding health service delivery in the communities was cooperation between the formal and informal providers. Informal providers were found to cooperate with formal provider to the extent of having a union in the community that serves to regulate their practices. In these meetings, it was found that they share ideas about how to promote their services. The informal providers were also reported to help in preparing patients for the formal providers to administer treatments. One of the respondents during an interview in Kano while trying to elucidate this synergy among the providers said: “During disease outbreak, our members help the health workers in managing patients, for instance we help in moving patients to their respective wards, putting them on beds and getting drips ready so that by the time the health worker comes to them all is set he/she is just going to start administering treatment” [32_KN_UB_IDI_CL]. “All the health workers in the hospital including the in-charge respect and give us their maximum cooperation” [32_KN_UB_IDI_CL]. Another respondent in kano noted: “As you can see we (TBAs) are in the antenatal station so we work with them” [TBA, Kano,IDI]. An FGD respondent in Kano also added: " Yes, we have linkage and from the ward head up to the district head. We the VCM, normally hold a meeting every month with district heads, to discuss about the health-related problems and if there is need for further assistance the ward head will also report to district head." (CGW-R5, Kano, FGD). Support from Community-based Organizations and structures Support from community-based organizations was also found to aid CHSD at the community/facility level. The existing community structures were found to facilitate the provision of service delivery through directly/indirectly influencing community participation or the provision of health service delivery. These community structures were: Faith Based Organizations (FBOs), Ward Development Commission (WDC), Health Facility Committees (HFCs), and broader community leadership. These groups were found to be involved in various health activities and other non-health activities in the communities, ranging from capital projects like erection of new health centres, after which they hand over to the government to manage. They organise community empowerment programs, sensitization, health education activities through regular meetings, convening at community ceremonies like weddings and church/mosque. For example, in one of the interviews in Anambra, one of the respondents noted: “For us to achieve our objectives in the communities, we engage the services of the President Generals of the communities; CHEWs, Traditional leaders, faith-based organizations, the Market Women Association, the youths, etc.” [25_AN_UB_IDI_PM]. “We normally draw the attention of the community representatives such as the TR, PG, youth leaders, market women leaders, etc. of the need to gather the community members for awareness creation” [25_AN_UB_IDI_PM]. Governmental Level Government/partner’s support to community-based formal and informal providers At this level, the support from both government and non-governmental organizations to community-based formal and informal providers were seen to aid CHSD. For example, informal providers were trained, supported, and incentivized by NGOs that provide formal services to identify and refer illness cases to a central facility for treatment in Kano. Also, the TBAs noted that they receive items such as gloves, cleaning agents, etc., from the local government health authorities, as a way to support them in attending to cases within their capacities and incentivizing them to make quick referrals to the formal providers. A respondent in Anambra noted: “My organization trained CHEWs and community volunteers on how to handle compassion fatigue… Yes of course, we have to educate them on what to do in the community before they start, this will help to guide them against abuse” [08_AN_RU_IDI_FP]. Another respondent also said: We organize training, we train the CORPs, we train the CVs- the community volunteers and the community resource persons [25_AN_UB_IDI_PM]. Speaking during an FGD in Kano, a TBA reflects: “...we’re really enjoying the training 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...” (CGW-R6, Kano,FGD) Clear line of communication We also found that another factor that enhances CHSD at the governmental level is ensuring a clear line of communication among the health partners, the government and the community. This was made it easy to ensure that interventions are directed to the right people. A respondent in Anambra during the IDI threw more light on this when the respondent said: “If any partner is coming to the state to support the state, for family planning programme, they will come through me. En, and then we go down to the LGAs, the LGA have the RA supervisor at the LGA level, and then we move down to the community, then we have facilities where we implement all these programmes” [25_AN_UB_IDI_PM]. Factors that constrain CHSD These factors were found to impede efficient community health service delivery at different levels. Individual level Poor health seeking behaviors/quack patronage The result of the study revealed that one of the factors impeding CHSD was the inability of the community members to seek health advice from experts; poor health seeking behavior, quack patronage, tendency to receive services from people that are proximal to their homes and people they know rather than professionals, and the inability to go to the hospital on time to access care until the illness worsens. One of the respondents during the interview said: “That has been a challenge, honestly, we need to work on that actually. Even at that, people are still patronizing the quack…There is a PHC there, but they prefer to go to the quack and to the TBAs to deliver...” [25_AN_UB_IDI_PM]. In Akwa-Ibom, a healthcare provider noted that after visiting quacks, the patients would then come to them when the illness gets worst and the quack may no longer handle it. below is an excerpt from the interview with the respondent. “They go to Chemist and treatment will fail, then they return to us. Some go to the Chemist with the name of the drugs and the chemist will hardly ask them questions” [OIC, Akwa Ibom, IDI]. Male Dominance Male dominance was found to be a problem especially in Kano. This factor involved males refusing to comply with health workers and providers in the community, hence making effective service delivery difficult to attain. These males were also found to prevent their wives from receiving care such as going for antenatal and having their children immunized. A respondent in Kano elucidated this problem when she noted: “The main problem is noncompliance from the men in the community, in many cases the women give their full support to us but their husbands prevent them from attending ante-natal or accepting immunizations for their babies" (IP, Kano, IDI). Community/facility level Superstitious/Cultural belief The result also revealed that superstitious belief/cultural belief was a factor impeding CHSD at this level. The belief was found to revolve around local and religious perceptions about different aspects of health such as birthing and illnesses. These beliefs were observed to cut across societal spiritual stereotypes attached to health, political and fetish interferences and lack of community awareness. This belief was captured by one of the respondents during the interview in Akwa-Ibom when the respondent said: “You know our people believe prophesy, that woman can see well if the person will not be able to deliver, she used to pray, so many TBAs have prayer houses which our women can live there for one month before the delivery time” [OIC, Akwa Ibom, IDI]. While reacting to the issue of the cultural belief, a respondent in Anambra also noted: " Again, is what people say about ntutu (a native malicious charm characterized by the mysterious injection of tiny metal pin like objects into the victim’s body)- all these things contribute to the disruption of health care. Because when someone has serious typhoid and malaria, or serious illness inside the person, the person will focus on going to remove the ntutu. By the time they will come to hospital, things have gotten worst [Public Servant, Anambra, IDI]” Poor attitude of facility workers Another factor found to be constraining service delivery in the communities at this level is the poor attitude of the formal providers in the facility which mostly reflected in absenteeism. This was elucidated by a community leader in Anambra when he noted: When you get there, you will only see a nurse there and the doctor might be working in Awka. He won’t be coming all the time. When you get there the nurse will be giving you first aid treatment while waiting for the doctor. Will you say that they are not there? The nurse will press you water while you wait for the doctor and the doctor might end up not coming that day while the person keep waiting. So that is the challenge [Anambra, Community Leader, IDI] During an FGD in Akwa Ibom, a respondent also noted: This patronage to PMVs happen because there aren't enough workers at the health centers and the health centers are closed early or not even open sometimes especially during weekends. Most people use the PMVs and TBAs when they have no other option because there aren't enough workers at the health center. This means that there should be enough staff at the health center and people will see reasons to visit the health center instead of using the PMVs [Akwa Ibom, CGMR9, FGD] Governmental level Lack of adequate financial support from the government The result revealed that one of the major factors constraining health service delivery was lack of adequate financial support to healthcare providers to carry out their activities. This lack of funds was for example seen in poor remuneration for the field workers, problem of owing health workers by the government, delay in payment of monthly salary, lack of funds for nutrition officers, lack of a CMAM center (Community-based Management of Acute Malnutrition) in Akwa Ibom where acute malnutrition can be managed etc. One of the respondents in Kano while trying to buttress on the issue noted: “Yes, our biggest challenge is finance. We have the zeal to do many things but our constraint is finance. We are able to achieve some of our aims” [32_KN_UB_IDI_CL]. The problem of finance was also narrowed to the government’s inability to adequately support the health providers financially. For example, a respondent from Kano said: “The biggest challenge we face so far is lack of financial support from the government” [32_KN_UB_IDI_CL]. Embezzlement of funds Another major problem we found in the study constraining CHSD at the governmental level was the embezzlement of funds budgeted for healthcare in the communities. This corrupt practice cuts across the whole health system down to government officials and elites in the society. To elucidate this problem, a formal provider in Anambra noted that: “There was one man that came here, that time was like they are doing sickle cell program for the State. It is government funded or foreign government funded. During the Mr. X's governorship regime, they brought the money, but a sitting government official took it” [08_AN_RU_IDI_FP] Lack of social amenities From the result, we found that another governmental level factor limiting the progress of community health service delivery is lack of social amenities in the communities such as water, electricity, and security etc. The lack of electricity was emphasized on particularly, as it prevents pregnant women from accessing the health center at night. An example of how this constrains service delivery was captured by one of the respondents during the interview in Kano by saying: “These sectors can because if there is no water in the hospital, there is a big problem, you see, water is very important because whatever that you are going to take, you have to use water, in conducting delivery, in the lab, because you have to wash some items before use or after use, in the hospital environment even the toilet, the staff toilet, outpatient toilet, everything, you have to use water. Water is very essential for the community health” [07_KN_RU_IDI_FP]. While reacting to the issue of security, a respondent in Akwa Ibom noted: “But the fear is when you do all these things without security, something can happen cos when I came in here. I had a little experience, thieves came and removed all the fans that were here, about 8 fans and picked all the drugs” [14_AK_UB_IDI_FP_OIC]. The lack of accommodation or living quarters inside the healthcare facilities for healthcare workers was also buttressed on by a respondent in Akwa Ibom: “...but we are still praying that one faithful day, those ones they have not been giving us, they will give, because here now, we are supposed to have a quarters” [OIC, Akwa Ibom, IDI]. “... one thing is the quarters here, the space is very big, they supposed to build quarters here and they are complaining, they supposed to build quarters, the community gave the government this land to build of which they have not” [OIC, Akwa Ibom, IDI]. Poor data record/data management The result also revealed that problem with health data collection and management was another factor constraining CHSD by affecting the utilization of health data for planning and decision-making. This problem was found to accrue from limited human resource and lack of training of data officers by the government. In a bid to elucidate this problem, a respondent said: “We have issue with data; we have issue with data collection because we don’t have enough human resource for health. So, data collection has been a problem, you know, they are trying, but need training; at times they will lack the tools to collect data, but we are trying to address it; because if we have enough human resources for health, we will, know, deploy them to these facilities to help to generate every data and assign that role to them” [25_AN_UB_IDI_PM]. Result Summary Table II shows the identified factors enhancing CHSD in the communities respectively at individual, community/facility and governmental levels. Table II: Factors enhancing CHSD Individual Level Community/Facility Level Governmental Level Selfless participation of community members Synergy between formal and informal providers Government’s support to community based formal and informal providers Synergy between formal and informal providers with community members Support from Community based Organizations and structures Clear line of communication Compassionate attitude of informal providers Table III shows a summary of identified factors constraining CHSD in the communities respectively at individual, community/facility and governmental levels. Table III: Factors constraining CHSD Individual Level Community/Facility Level Governmental Level Poor health seeking behaviors/quack patronage Superstitious/Cultural belief Lack of adequate financial support from the government. Male dominance Poor attitude of facility workers Embezzlement of funds Lack of social amenities Poor data record/data management Discussion The findings from the present study revealed that although CHSD within Nigerian communities are plagued with multi-level challenges, there are also multi-level factors playing roles in enhancing CHSD. This underscores that efforts are still being made to ensure an improved CHSD within the communities at different levels. The underlining argument therefore could be that these efforts are not substantial to produce the significant improvement needed for an optimal CHSD within the communities thereby drawing attention to the possible need of a joint approach that ensures the sustenance of the enabling factors while simultaneously addressing the identified challenges. This study’s findings also revealed that some of the factors impeding CHSD within Nigerian such as lack of funding and basic amenities from government, are also those reported by the Nigerian national population commission [ 16 ] to affect health service delivery in other African countries thus calling to attention the possibility that some of these challenges are continental and would require a joint regional effort from African leaders to effectively address. The findings from the present study are also consistent with the work of other researchers within Nigeria. For example, the current study supports the findings from the works of Amedari and Ejidike [ 17 ], Obansa and Orimisan [ 18 ], Okereke et al., [ 12 ] and Welcome [ 19 ] which identified factors affecting health service delivery in Nigerian communities as centering on, corruption across health system, poor management of human resources and lack of funding from government. This raises the concern that these problems may have lingered because of negligence or enough not being done to curtail it by relevant stakeholders hence, pointing to the urgent need to create more awareness on the dangers of these constraining factors on CHSD and CHS as well as calling for more concerted effort to address these challenges. This also highlights the need for possibly adopting a different approach in addressing these challenges. Although there are multi-level factors identified to be impeding CHSD in Nigeria by the present study, majority of the factors were identified to stem from the governmental level. lack of adequate financial support, embezzlement of funds, lack of social amenities etc. were among the factors found to be impeding the progress of health services in the communities. By adequately addressing the issue of embezzlement of public fund, the issues of inadequate financial support and lack of amenities can invariably be resolved to a reasonable extent, this is because, the reason for lack of social amenities and other financial support could be because the funds provided for such are embezzled or mismanaged. Therefore, by setting up functional accountability structures involving the community members where every fund coming into the communities for health be it as donation or government funding are clearly accounted for, there is a possibility that this will also increase community participation in health as well as enable the communities to serve as “accountability police” for health projects, thus ensuring that funds are efficiently utilized in the execution and delivery of community health services. The findings show that a major reason why the constraining factors have lingered in the first instance is due to over dependence on the government to tackle the challenges. Hence, involving more hands was seen as a key solution. The introduction of a multi-sectoral action where different health and non-health sectors can collectively work towards addressing these challenges may be more effective than expecting the government to do it all alone. This is because since the challenges occur at different levels, different sectors that function at different levels can focus on addressing challenges within their level of operation. Evidences [ 20 , 21 ] have also shown that multi-sectorial collaboration is an effective approach in addressing different health challenges. Conclusion Achieving an enhanced CHS is possible. However, this is largely dependent on how well actors in both health and non-health sectors prioritize and adequately address the multi-level challenges constraining CHSD while sustaining the factors that promote it. CHSD through functional CHS can help improve overall health systems strengthening and lead to improved health at the community level while ensuring the achievement of the Universal health coverage. Decision makers should integrate CHSD in all program implementation that involves communities and ultimately work with CHS as a veritable platform for effective health service delivery. Abbreviations CHS Community Health System CHSD Community Health Service Delivery TBAs Traditional Birth Attendants IDI In Depth Interview OIC Officer-in-Charge CMAM Community-based Management of Acute Malnutrition FGD Focus Group Discussion PMVs Patent Medicine Vendors UCH Universal Health Coverage SDGs Sustainable Development Goals PHC Primary Health Care CSOs Civil Society Organizations NGOs Non-Governmental Organizations LGA Local Government Area CVs Community Volunteers FBOs Faith-Based Organizations WDC Ward Development Commission HFCs Health Facility Committees. Declarations Ethics Approval and consent to participate This study received ethics approval from the Health Research Ethics Committee of University of Nigeria Teaching Hospital Enugu with reference number NHRECAS/01/2008-WA00002458-IRB00002323. All methods were conducted according to relevant guidelines and regulations. All participants were informed of the purpose of the research, rights of participants and measures to protect them and their data. Written, signed and verbal informed consent was also obtained from all the participants. Participation in the study was voluntary and confidentiality was ensured. Consent for publication Not Applicable Availability of data and materials The dataset used for this study is available and can be obtained from the corresponding author upon request. Competing interest There is no competing interest. We confirm that the manuscript has been read and approved by all named authors. We confirm that the order of authors listed in the manuscript has been approved by all named authors. Funding The research project which led to the results included in this manuscript received funding from the Bill and Melinda Gates Foundation. However, the funding does not cover publications. The funders did not participate in designing the study, collecting and analyzing data, or writing and reviewing the manuscript. The views expressed in this manuscript belong exclusively to the authors and do not necessarily represent the funders’ opinions. Authors’ contributions Enyi Etiaba and Obinna Onwujekwe conceptualized and designed the study. Okechukwu Ozor and Enyi Etiaba participated in data collection. All authors took part in data analysis. Okechukwu Ozor wrote the first draft of the manuscript. All authors reviewed and approved the final version of the manuscript. Acknowledgements We wish to acknowledge the Bill and Melinda Gates Foundation as well as the African Health Observatory Platform (AHOP) for their support in helping to ensure the completion of this study. Author’s information Okechukwu Ozor - BSc, MSc - Clinical Psychology; Enyi Etiaba - MBBS, MPH; Obinna Onwujekwe - MBBS, PhD-Health economics. References De Nardi, M., Pashchenko, S., & Porapakkarm, P. (2017). The lifetime costs of bad health. Technical report, National Bureau of Economic Research. Dobkin, C., Finkelstein, A., Kluender, R., & Notowidigdo, M. J. (2018). The economic consequences of hospital admissions. American Economic Review, 108(2):308–52. Mitchell, R. J., Ozminkowski, R. J., & Serxner, S. (2013). Improving employee productivity through improved health. Journal of occupational and environmental medicine, 55 (10), 1142–1148. https://doi.org/10.1097/JOM.0b013e3182a50037 Effiong, F. B., Ogbonna, C. P., Agughalam, P. I., Okwukwu, M. O., Dike, I. C., Elebesunu, E. E., & Uwishema, O. (2023). The role of community-based approaches in achieving universal health coverage: addressing the Nigerian narrative. Annals of medicine and surgery (2012), 85 (5), 1769–1773. https://doi.org/10.1097/MS9.0000000000000443 Federal Ministry of Health (2016). National Health Policy 2016: Promoting the Health of Nigerians to Accelerate Socio-Economic Development. Federal Ministry of Health, Abuja. https://naca.gov.ng/wp-content/uploads/2019/10/National-Health-Policy-Final-copy.pdf Rawat, A., Pun, A., Ashish, K. C., Tamang, I. K., Karlström, J., Hsu, K., & Rasanathan, K. (2023). The contribution of community health systems to resilience: Case study of the response to the 2015 earthquake in Nepal. Journal of global health, 13 , 04048. https://doi.org/10.7189/jogh.13.04048 Kruk, M. E., Gage, A. D., Arsenault, C., Jordan, K., Leslie, H. H., Roder-DeWan, S., Adeyi, O., Barker, P., Daelmans, B., Doubova, S. V., English, M., García-Elorrio, E., Guanais, F., Gureje, O., Hirschhorn, L. R., Jiang, L., Kelley, E., Lemango, E. T., Liljestrand, J., Malata, A., … Pate, M. (2018). High-quality health systems in the Sustainable Development Goals era: time for a revolution. The lancet. Global health, 6(11), e1196-e1252. https://doi.org/10.1016/S2214-109X(18)30386-3 Schneider, H., & Lehmann, U. (2016). From community health workers to community health systems: time to widen the horizon? Health Systems & Reform, 2(2), 112–118. Egan, K. F., Devlin, K., & Pandit-Rajani, T., (2017). Community Health Systems Catalog Country Profile: Nigeria. Arlington, VA: Advancing Partners & Communities. Vankar, P. (2023, April, 12). Ranking of Health and Health Systems of Countries Worldwide in 2023. Statista. https://www.statista.com/statistics/1376359/health-and-health-system-ranking-of-countries-worldwide/ Iyanda, O. F., & Akinyemi, O. O. (2017). Our chairman is very efficient: community participation in the delivery of primary health care in Ibadan, Southwest Nigeria. The Pan African medical journal, 27 , 258. https://doi.org/10.11604/pamj.2017.27.258.12892 Okereke, E., Ishaku, S.M., Unumeri, G. et al. (2019). Reducing maternal and newborn mortality in Nigeria—a qualitative study of stakeholders’ perceptions about the performance of community health workers and the introduction of community midwifery at primary healthcare level. Human Resource for Health 17, 102. https://doi.org/10.1186/s12960-019-0430-0 Adam, P., Greg, R., Sasan, S., & Alan, W. (2023). Small sample field study: The effects of team-based recognition on employee engagement and effort. Management Accounting Research, 59,1044–5005. https://doi.org/10.1016/j.mar.2022.100829 . Alkandi, I. G., Khan, M. A., Fallatah, M., Alabdulhadi, A., Alanizan, S., Alharbi, J. (2023). The Impact of Incentive and Reward Systems on Employee Performance in the Saudi Primary, Secondary, and Tertiary Industrial Sectors: A Mediating Influence of Employee Job Satisfaction. Sustainability. 15(4):3415. https://doi.org/10.3390/su15043415 Mohsin, B., Bradley, E., Wright, E., & Shahidul, H. (2021). The interactive influence of public service motivation, perceived reward equity, and prosocial impact on employee engagement: a panel study in Pakistan. 1213–1237. https://doi.org/10.1080/14719037.2021.2013069 Nigeria NPC. Nigeria demographic and health survey 2018. Abuja: National Population Commission and ICF Macro; 2018. Amedari, M. I. & Ejidike, I. C. (2021). Improving access, quality and efficiency in health care delivery in Nigeria: a perspective. PAMJ – One health. 5:3. Doi: 10.11604/pamj-oh.2021.5.3.28204 Obansa, S. A., & Orimisan, A. (2013). Health care financing in Nigeria: prospects and challenges. Mediterranean Journal of Social Sciences. 4(1):221–236. Doi: 10.5901/mjss.2013.v4n1p221 Welcome M. O. (2011). The Nigerian health care system: Need for integrating adequate medical intelligence and surveillance systems. Journal of pharmacy & bioallied sciences, 3 (4), 470–478. https://doi.org/10.4103/0975-7406.90100 Rasanathan, K., Atkins, V., Mwansambo, C., Soucat, A., & Bennett, S. (2018). Governing multisectoral action for health in low-income and middle-income countries: an agenda for the way forward. BMJ Global Health, 10 (3) (Suppl 4):e000890. doi: 10.1136/bmjgh-2018-000890 . PMID: 30364321; PMCID: PMC6195143. Bennett. S., Glandon, D., & Rasanathan, K., (2018). Governing multisectoral action for health in low-income and middle-income countries: unpacking the problem and rising to the challenge. BMJ Glob Health, 10(3) (Suppl 4):e000880. doi: 10.1136/bmjgh-2018-000880 . PMID: 30364411; PMCID: PMC6195144. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 05 Sep, 2024 Read the published version in Health Research Policy and Systems → Version 1 posted Editorial decision: Revision requested 12 Jun, 2024 Reviews received at journal 09 Jun, 2024 Reviews received at journal 06 Jun, 2024 Reviewers agreed at journal 01 Jun, 2024 Reviewers agreed at journal 31 May, 2024 Reviewers invited by journal 31 May, 2024 Editor assigned by journal 27 May, 2024 Submission checks completed at journal 27 May, 2024 First submitted to journal 22 May, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4460913","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":312347255,"identity":"5981f4a7-2290-4b73-b2f2-95cc917ba147","order_by":0,"name":"Okechukwu Ozor","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA70lEQVRIiWNgGAWjYPCCBAYGCQZmIMMGiBkbD5CiJQ2kpYEkLYfBXLxa+PkPH/vAUJEmxz+7x9iYt+283dr2w0BbamyicWmRbDiWPIPhTI6xxJ0zxsm8bbeTt51JBGo5lpbbgEOLwcEeYwbGtorEDRI5xodzgVrMDgC1MDYcxq3lMA9YSz1Uy7lks/MPCWg5BtaSk2AA1JKc23bAzuwGAVske9iSGRLOpBnOuJFWbPznXHKC2Q2gLQl4/AIMscMMHyqS5flnJG+WnFFmZ292Pv3hgw81Nji1gEECEjuxAV2EILAnRfEoGAWjYBSMDAAAxEldmUpVGFwAAAAASUVORK5CYII=","orcid":"","institution":"University of Nigeria","correspondingAuthor":true,"prefix":"","firstName":"Okechukwu","middleName":"","lastName":"Ozor","suffix":""},{"id":312347256,"identity":"a772ea8b-9f29-4202-bd5b-2d5bd7aecba7","order_by":1,"name":"Enyi Etiaba","email":"","orcid":"","institution":"University of Nigeria","correspondingAuthor":false,"prefix":"","firstName":"Enyi","middleName":"","lastName":"Etiaba","suffix":""},{"id":312347257,"identity":"540876a9-4b46-4e8c-9816-a04804ee15fc","order_by":2,"name":"Obinna Onwujekwe","email":"","orcid":"","institution":"University of Nigeria","correspondingAuthor":false,"prefix":"","firstName":"Obinna","middleName":"","lastName":"Onwujekwe","suffix":""}],"badges":[],"createdAt":"2024-05-22 12:31:27","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4460913/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4460913/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12961-024-01204-9","type":"published","date":"2024-09-05T16:05:13+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":64186243,"identity":"c3cddda8-0e20-44ed-864b-794058e1bbf8","added_by":"auto","created_at":"2024-09-09 16:26:09","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":583872,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4460913/v1/7cc45828-449d-453f-a13d-bad373249d54.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Strengthening the effectiveness of community health system: assessing the factors that enhance or constrain the delivery of health services within communities in Nigeria","fulltext":[{"header":"Introduction","content":"\u003cp\u003ePoor community healthcare service delivery has adverse effect both on the individual and economy of the state [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e], while improved community healthcare service delivery has been shown to relate to more productivity in people [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Therefore, ensuring an efficient community health service delivery does not only have implication for improving the health of the citizens but also the economy of the country.\u003c/p\u003e \u003cp\u003eAchieving the Universal Health Coverage (UCH) and the Sustainable Development Goals (SDGs), for any country relies on how effective health services are delivered to communities which in turn is dependent on how well factors that constrain health service delivery are able to be identified and addressed as well as sustaining those factors that enhance it [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe promotion of an effective community health service delivery that would enhance community health system in Nigeria has been a key policy objective of the Nigerian government as contained in the Nigerian 2016 National Health Policy document [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. This is because, ensuring an efficient community health system has been a major global issue for countries across the globe [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. According the Nigerian 2016 National Health Policy document, the improvement of health service delivery at the community level has been identified as one of the key strategies towards improving CHS.\u003c/p\u003e \u003cp\u003eAlthough there is no general consensus for defining the concept of community health system due to the fact that it is still evolving, Schneider and Lehmann in 2016 defined it as the set of local actors, relationships, and processes engaged in producing, advocating for, and supporting health in communities and households outside of, but existing in relationship to, formal health structures [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eDespite Nigeria\u0026rsquo;s establishment of the primary health care (PHC) system in 1976 which designated the local government areas (LGAs), the second smallest administrative level in the country, the responsibility to manage and implement health services at the community level and the establishment of the National PHC Development Agency to ensure sustainability of previous gains and better manage the PHC system in the country with the agency revising PHC system in 1993 [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e], Nigeria ranks 157th out of 167 countries in a 2023 world health and health system ranking [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. With this ranking, it is uncommon to see the CHS plunging.\u003c/p\u003e \u003cp\u003eStudies [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e] have shown that the CHS in the country has been deteriorating and needs to be enhanced as a way of improving the overall health system as well as boosting the country\u0026rsquo;s health profile. For example, [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e] linked the deterioration to lack of enough community health workers and lack of re-training for the few available workers while [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e] linked the deterioration to poor female representation, poor collaboration with pre-existing community structures, the poor approach to service delivery as factors affecting community participation in PHC delivery which in turn affects the CHS.\u003c/p\u003e \u003cp\u003eHowever, in order to improve community health system delivery in Nigeria within the construct of community health system, it is important to assess the factors that constrain and as well as promote healthcare service delivery at different levels across communities with the goal of identifying and addressing the constraining factors while ensuring the sustenance of the promoting factors.\u003c/p\u003e \u003cp\u003eIdentifying and addressing the key factors that impede community health service delivery in Nigeria have strong implication for the improvement of community health systems in the country as well as the attainment of the universal health coverage (UHC) and the Sustainable Development Goals (SDGs). It is therefore possible that identifying and rewarding exceptional community members that contribute to improving health service delivery in the communities by the leaders of the community and other stakeholders can encourage the sustenance of the identified enabling factors especially at the individual level since studies have shown that reinforcements can help sustain positive attitudes [\u003cspan additionalcitationids=\"CR14\" citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThis paper examined the key factors that either enhance or constrain CHSD in Nigeria at individual, community/facility and governmental levels while recommending evidence-based solutions for sustaining and improving CHSD within the framework of CHS. The findings will be useful for decision makers on possible solutions to tap into the latent resources of communities, especially within the context of CHS to significantly improve community health.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy area and design:\u003c/h2\u003e \u003cp\u003eThis study was conducted in three States across three geopolitical zones in Nigeria namely: Akwa-Ibom (south-southern zone), Anambra (south-eastern zone) and Kano (located at the north-western region). The areas were purposively chosen to achieve a geographical representation of the country and ensure more spread of the result findings.\u003c/p\u003e \u003cp\u003eThe study employed a qualitative design in which data was collected through face-to-face semi-structured interviews and focus group discussion (FGD) with open-ended questions and prompts. Purposive sampling was used to select two Local Governments Areas (LGAs) in each of the three states. The sampled LGAs comprised of one rural and one urban area. For Akwa-Ibom State, the urban LGA was Uyo, while the rural LGA was Itu. For Anambra State, the urban LGA was Awka South LGA, while the rural LGA was Aguata. For Kano State, the urban LGA was Nasarawa Local Government Area while the rural LGA was Kumbotso.\u003c/p\u003e \u003cp\u003eThe purposive sampling technique was used to select respondents for the study. The factors considered in their identification and selection were: their level of participation and involvement in health-related activities in the communities, their occupation, leadership roles and length of service to the community or the government. The respondents cut across different groups \u0026ndash; policymakers, Civil Society Organizations (CSOs), Non-Governmental Organizations (NGOs), Traditional, Religious and Community leaders, community groups, formal health providers and informal health providers. A total of 90 in -depth interviews (IDIs) and 12 focus group discussions (FGDs) were conducted (Table\u0026nbsp;1). Data was collected between October to November 2022.\u003c/p\u003e \u003cp\u003eTable I - Summary of respondent categories and number of interviews\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Taba\" border=\"1\"\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRespondent category\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAkwa Ibom\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAnambra\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eKano\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHealth sector policymakers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHealth program managers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFormal healthcare providers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInformal healthcare providers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIntermediary health workers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e----\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-----\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrivate health sector\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e----\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e----\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCSO/NGO\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCommunity or Religous leader\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e(FGD) Community groups/ Service users (Women)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e(FGD)Community groups /Service sers(Men)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eTotal (Males)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003e18\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003e18\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003e25\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eTotal (Females)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003e17\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003e13\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003e11\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTotal per state\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e35\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e31\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e36\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eGrand Total\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e \u003cp\u003e\u003cb\u003e102\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eData Analysis:\u003c/h2\u003e \u003cp\u003eThe analysis followed a systematic approach, including familiarization with the data, coding, identification of themes, and interpretation. Regular meetings were held to discuss the coding and resolve any discrepancies among the researchers. Analyses focused on exploring the factors that both encourage as well as hinder community health service delivery in three sub-themes or levels _individual, community/facility and governmental. The analysis process involved double coding of each of the transcripts to ensure the relevance and comprehensiveness of the findings.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eEthical considerations:\u003c/h2\u003e \u003cp\u003eEthical approval for this study was obtained from the Health Research Ethics Committee of the University of Nigeria Teaching Hospital, Ituku-Ozalla Enugu State. Permission to conduct the study was sought and obtained from the respondents and traditional leaders of the communities. Written informed consents were obtained from all study participants after they have demonstrated understanding of study procedures, and voluntariness. The confidentiality of all the participants was assured and maintained during and after the study by assigning unique identifiers to each participant during data analysis and reporting.\u003c/p\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eThe result of the analysis is presented in two main themes which are: Factors that (1) Enable or (2) Constrain community health service delivery. Each of the main theme is further broken down to three sub-themes or levels: individual, community/facility and governmental.\u003c/p\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eFactors that promote CHSD\u003c/h2\u003e \u003cp\u003eThe following factors were found in the study to enhance community health service delivery at different levels:\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eIndividual Level\u003c/h2\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eSelfless participation of community members\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003e We found that one of the factors encouraging health service delivery in the communities is community members\u0026rsquo; selfless participation in activities that improve CHSD. The members of the community were found to engage in personal activities such as carrying out sanitary activities in the primary healthcare centers as well as providing health equipment such as handwashes, gloves etc. in a bid to improve the quality of health service provision in the communities. For example, a respondent in Kano State during the interview noted:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003eWe carry out many services in the society like cleaning gutters and sweeping our surroundings, washing and disinfecting hospital etc. All of this are done voluntarily by the people without expecting any payment at the end. (Civil Servant, Kano, IDI).\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eSynergy between formal and informal providers with community members\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eAt the individual level, informal providers expressed that they were in constant interaction with the formal providers in order to ensure adequate health service delivery for the community members. This interaction involves informal providers individually referring cases they cannot handle to formal providers in order to ensure maximum treatment output. The informal providers acknowledged that some cases they encounter are sometimes beyond them and that the best practice is to refer immediately to the formal providers and that this has helped in ensuring adequate health service delivery output. While trying to buttress this point, a Herbalist in Akwa Ibom noted:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;Yes, I do refer some injuries that are beyond my ability to a health center because I believe there are some injuries that I can cure and others that I cannot and must refer to health centers.\u0026rdquo; (Herbalist, Akwa Ibom, IDI)\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eCompassionate attitude of informal providers\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eAnother factor found to aid health service delivery in the communities at the individual level was the informal provider\u0026rsquo;s compassion and willingness to help the patients at little or no cost. These providers noted that their priority is ensuring that the patients recover from their illness and not necessarily about making monetary gains. This ensured that the patients kept coming to receive services at reduced rate. A Bonesetter in Akwa Ibom in a bid to elucidate this noted:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\"I'm not sure, but according to information I received from one of the clients referred to me, he should pay the hospital 650,000naira. I was also considerate with him, and I didn't take much from him because he was poor. I only charged him 130,000 naira because I was being considerate\u0026hellip;\u0026hellip;. \"The majority of them stay because I have a large house and I don't mind them staying until they finish their treatment, and while at my place, they feed themselves out of their pockets, while the majority of them come from their homes for their treatment and then return\".\" [10_AK_UB_IDI_IP_Bonesetter]\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eAnother respondent in Kano, recounts that it is the passion that the providers have for the job that keeps them going and not the amount they get since the amount they are paid is little compared to the work they do. The respondent noted:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eMost of them have passion for it because the little they get from it is really helping them [IHW Kano, IDI]\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eCommunity/Facility Level\u003c/h2\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eSynergy between formal and informal providers\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eAt this level a key factor we identified to be aiding health service delivery in the communities was cooperation between the formal and informal providers. Informal providers were found to cooperate with formal provider to the extent of having a union in the community that serves to regulate their practices. In these meetings, it was found that they share ideas about how to promote their services. The informal providers were also reported to help in preparing patients for the formal providers to administer treatments. One of the respondents during an interview in Kano while trying to elucidate this synergy among the providers said:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;During disease outbreak, our members help the health workers in managing patients, for instance we help in moving patients to their respective wards, putting them on beds and getting drips ready so that by the time the health worker comes to them all is set he/she is just going to start administering treatment\u0026rdquo; [32_KN_UB_IDI_CL].\u003c/em\u003e \u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;All the health workers in the hospital including the in-charge respect and give us their maximum cooperation\u0026rdquo; [32_KN_UB_IDI_CL].\u003c/em\u003e \u003c/p\u003e\u003cp\u003eAnother respondent in kano noted:\u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;As you can see we (TBAs) are in the antenatal station so we work with them\u0026rdquo; [TBA, Kano,IDI].\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eAn FGD respondent in Kano also added:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\" Yes, we have linkage and from the ward head up to the district head. We the VCM, normally hold a meeting every month with district heads, to discuss about the health-related problems and if there is need for further assistance the ward head will also report to district head.\" (CGW-R5, Kano, FGD).\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eSupport from Community-based Organizations and structures\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eSupport from community-based organizations was also found to aid CHSD at the community/facility level. The existing community structures were found to facilitate the provision of service delivery through directly/indirectly influencing community participation or the provision of health service delivery. These community structures were: Faith Based Organizations (FBOs), Ward Development Commission (WDC), Health Facility Committees (HFCs), and broader community leadership. These groups were found to be involved in various health activities and other non-health activities in the communities, ranging from capital projects like erection of new health centres, after which they hand over to the government to manage. They organise community empowerment programs, sensitization, health education activities through regular meetings, convening at community ceremonies like weddings and church/mosque. For example, in one of the interviews in Anambra, one of the respondents noted:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;For us to achieve our objectives in the communities, we engage the services of the President Generals of the communities; CHEWs, Traditional leaders, faith-based organizations, the Market Women Association, the youths, etc.\u0026rdquo; [25_AN_UB_IDI_PM].\u003c/em\u003e \u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;We normally draw the attention of the community representatives such as the TR, PG, youth leaders, market women leaders, etc. of the need to gather the community members for awareness creation\u0026rdquo; [25_AN_UB_IDI_PM].\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eGovernmental Level\u003c/h2\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eGovernment/partner\u0026rsquo;s support to community-based formal and informal providers\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eAt this level, the support from both government and non-governmental organizations to community-based formal and informal providers were seen to aid CHSD. For example, informal providers were trained, supported, and incentivized by NGOs that provide formal services to identify and refer illness cases to a central facility for treatment in Kano. Also, the TBAs noted that they receive items such as gloves, cleaning agents, etc., from the local government health authorities, as a way to support them in attending to cases within their capacities and incentivizing them to make quick referrals to the formal providers. A respondent in Anambra noted:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;My organization trained CHEWs and community volunteers on how to handle compassion fatigue\u0026hellip; Yes of course, we have to educate them on what to do in the community before they start, this will help to guide them against abuse\u0026rdquo; [08_AN_RU_IDI_FP].\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eAnother respondent also said:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eWe organize training, we train the CORPs, we train the CVs- the community volunteers and the community resource persons [25_AN_UB_IDI_PM].\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eSpeaking during an FGD in Kano, a TBA reflects:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;...we\u0026rsquo;re really enjoying the training because the training is encouraging us, and like before most of the women, when they give birth at home they don\u0026rsquo;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...\u0026rdquo; (CGW-R6, Kano,FGD)\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eClear line of communication\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eWe also found that another factor that enhances CHSD at the governmental level is ensuring a clear line of communication among the health partners, the government and the community. This was made it easy to ensure that interventions are directed to the right people. A respondent in Anambra during the IDI threw more light on this when the respondent said:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;If any partner is coming to the state to support the state, for family planning programme, they will come through me. En, and then we go down to the LGAs, the LGA have the RA supervisor at the LGA level, and then we move down to the community, then we have facilities where we implement all these programmes\u0026rdquo; [25_AN_UB_IDI_PM].\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eFactors that constrain CHSD\u003c/h2\u003e \u003cp\u003eThese factors were found to impede efficient community health service delivery at different levels.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eIndividual level\u003c/h2\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003ePoor health seeking behaviors/quack patronage\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eThe result of the study revealed that one of the factors impeding CHSD was the inability of the community members to seek health advice from experts; poor health seeking behavior, quack patronage, tendency to receive services from people that are proximal to their homes and people they know rather than professionals, and the inability to go to the hospital on time to access care until the illness worsens. One of the respondents during the interview said:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;That has been a challenge, honestly, we need to work on that actually. Even at that, people are still patronizing the quack\u0026hellip;There is a PHC there, but they prefer to go to the quack and to the TBAs to deliver...\u0026rdquo; [25_AN_UB_IDI_PM].\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eIn Akwa-Ibom, a healthcare provider noted that after visiting quacks, the patients would then come to them when the illness gets worst and the quack may no longer handle it. below is an excerpt from the interview with the respondent.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;They go to Chemist and treatment will fail, then they return to us. Some go to the Chemist with the name of the drugs and the chemist will hardly ask them questions\u0026rdquo; [OIC, Akwa Ibom, IDI].\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eMale Dominance\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eMale dominance was found to be a problem especially in Kano. This factor involved males refusing to comply with health workers and providers in the community, hence making effective service delivery difficult to attain. These males were also found to prevent their wives from receiving care such as going for antenatal and having their children immunized. A respondent in Kano elucidated this problem when she noted:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;The main problem is noncompliance from the men in the community, in many cases the women give their full support to us but their husbands prevent them from attending ante-natal or accepting immunizations for their babies\" (IP, Kano, IDI).\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eCommunity/facility level\u003c/h2\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eSuperstitious/Cultural belief\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eThe result also revealed that superstitious belief/cultural belief was a factor impeding CHSD at this level. The belief was found to revolve around local and religious perceptions about different aspects of health such as birthing and illnesses. These beliefs were observed to cut across societal spiritual stereotypes attached to health, political and fetish interferences and lack of community awareness. This belief was captured by one of the respondents during the interview in Akwa-Ibom when the respondent said:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;You know our people believe prophesy, that woman can see well if the person will not be able to deliver, she used to pray, so many TBAs have prayer houses which our women can live there for one month before the delivery time\u0026rdquo; [OIC, Akwa Ibom, IDI].\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eWhile reacting to the issue of the cultural belief, a respondent in Anambra also noted:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\"\u003cem\u003eAgain, is what people say about ntutu (a native malicious charm characterized by the mysterious injection of tiny metal pin like objects into the victim\u0026rsquo;s body)- all these things contribute to the disruption of health care. Because when someone has serious typhoid and malaria, or serious illness inside the person, the person will focus on going to remove the ntutu. By the time they will come to hospital, things have gotten worst [Public Servant, Anambra, IDI]\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003ePoor attitude of facility workers\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eAnother factor found to be constraining service delivery in the communities at this level is the poor attitude of the formal providers in the facility which mostly reflected in absenteeism. This was elucidated by a community leader in Anambra when he noted:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eWhen you get there, you will only see a nurse there and the doctor might be working in Awka. He won\u0026rsquo;t be coming all the time. When you get there the nurse will be giving you first aid treatment while waiting for the doctor. Will you say that they are not there? The nurse will press you water while you wait for the doctor and the doctor might end up not coming that day while the person keep waiting. So that is the challenge [Anambra, Community Leader, IDI]\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eDuring an FGD in Akwa Ibom, a respondent also noted:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eThis patronage to PMVs happen because there aren't enough workers at the health centers and the health centers are closed early or not even open sometimes especially during weekends. Most people use the PMVs and TBAs when they have no other option because there aren't enough workers at the health center. This means that there should be enough staff at the health center and people will see reasons to visit the health center instead of using the PMVs [Akwa Ibom, CGMR9, FGD]\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eGovernmental level\u003c/h2\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eLack of adequate financial support from the government\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eThe result revealed that one of the major factors constraining health service delivery was lack of adequate financial support to healthcare providers to carry out their activities. This lack of funds was for example seen in poor remuneration for the field workers, problem of owing health workers by the government, delay in payment of monthly salary, lack of funds for nutrition officers, lack of a CMAM center (Community-based Management of Acute Malnutrition) in Akwa Ibom where acute malnutrition can be managed etc. One of the respondents in Kano while trying to buttress on the issue noted:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;Yes, our biggest challenge is finance. We have the zeal to do many things but our constraint is finance. We are able to achieve some of our aims\u0026rdquo; [32_KN_UB_IDI_CL].\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThe problem of finance was also narrowed to the government\u0026rsquo;s inability to adequately support the health providers financially. For example, a respondent from Kano said:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;The biggest challenge we face so far is lack of financial support from the government\u0026rdquo; [32_KN_UB_IDI_CL].\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eEmbezzlement of funds\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eAnother major problem we found in the study constraining CHSD at the governmental level was the embezzlement of funds budgeted for healthcare in the communities. This corrupt practice cuts across the whole health system down to government officials and elites in the society. To elucidate this problem, a formal provider in Anambra noted that:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;There was one man that came here, that time was like they are doing sickle cell program for the State. It is government funded or foreign government funded. During the Mr. X's governorship regime, they brought the money, but a sitting government official took it\u0026rdquo; [08_AN_RU_IDI_FP]\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eLack of social amenities\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eFrom the result, we found that another governmental level factor limiting the progress of community health service delivery is lack of social amenities in the communities such as water, electricity, and security etc. The lack of electricity was emphasized on particularly, as it prevents pregnant women from accessing the health center at night. An example of how this constrains service delivery was captured by one of the respondents during the interview in Kano by saying:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;These sectors can because if there is no water in the hospital, there is a big problem, you see, water is very important because whatever that you are going to take, you have to use water, in conducting delivery, in the lab, because you have to wash some items before use or after use, in the hospital environment even the toilet, the staff toilet, outpatient toilet, everything, you have to use water. Water is very essential for the community health\u0026rdquo; [07_KN_RU_IDI_FP].\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eWhile reacting to the issue of security, a respondent in Akwa Ibom noted:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;But the fear is when you do all these things without security, something can happen cos when I came in here. I had a little experience, thieves came and removed all the fans that were here, about 8 fans and picked all the drugs\u0026rdquo; [14_AK_UB_IDI_FP_OIC].\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThe lack of accommodation or living quarters inside the healthcare facilities for healthcare workers was also buttressed on by a respondent in Akwa Ibom:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;...but we are still praying that one faithful day, those ones they have not been giving us, they will give, because here now, we are supposed to have a quarters\u0026rdquo; [OIC, Akwa Ibom, IDI].\u003c/em\u003e \u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;... one thing is the quarters here, the space is very big, they supposed to build quarters here and they are complaining, they supposed to build quarters, the community gave the government this land to build of which they have not\u0026rdquo; [OIC, Akwa Ibom, IDI].\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003ePoor data record/data management\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eThe result also revealed that problem with health data collection and management was another factor constraining CHSD by affecting the utilization of health data for planning and decision-making. This problem was found to accrue from limited human resource and lack of training of data officers by the government. In a bid to elucidate this problem, a respondent said:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;We have issue with data; we have issue with data collection because we don\u0026rsquo;t have enough human resource for health. So, data collection has been a problem, you know, they are trying, but need training; at times they will lack the tools to collect data, but we are trying to address it; because if we have enough human resources for health, we will, know, deploy them to these facilities to help to generate every data and assign that role to them\u0026rdquo; [25_AN_UB_IDI_PM].\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eResult Summary\u003c/strong\u003e \u003cp\u003eTable II shows the identified factors enhancing CHSD in the communities respectively at individual, community/facility and governmental levels.\u003c/p\u003e \u003c/p\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"3\"\u003e\u003cb\u003eTable II: Factors enhancing CHSD\u003c/b\u003e\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e\u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Tabb\" border=\"1\"\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIndividual Level\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCommunity/Facility Level\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGovernmental Level\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSelfless participation of community members\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSynergy between formal and informal providers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGovernment\u0026rsquo;s support to community based formal and informal providers\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSynergy between formal and informal providers with community members\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSupport from Community based Organizations and structures\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eClear line of communication\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCompassionate attitude of informal providers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eTable III shows a summary of identified factors constraining CHSD in the communities respectively at individual, community/facility and governmental levels.\u003c/p\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"3\"\u003e\u003cb\u003eTable III: Factors constraining CHSD\u003c/b\u003e\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e\u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Tabc\" border=\"1\"\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIndividual Level\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCommunity/Facility Level\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGovernmental Level\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePoor health seeking behaviors/quack patronage\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSuperstitious/Cultural belief\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eLack of adequate financial support from the government.\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale dominance\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePoor attitude of facility workers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eEmbezzlement of funds\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eLack of social amenities\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePoor data record/data management\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe findings from the present study revealed that although CHSD within Nigerian communities are plagued with multi-level challenges, there are also multi-level factors playing roles in enhancing CHSD. This underscores that efforts are still being made to ensure an improved CHSD within the communities at different levels. The underlining argument therefore could be that these efforts are not substantial to produce the significant improvement needed for an optimal CHSD within the communities thereby drawing attention to the possible need of a joint approach that ensures the sustenance of the enabling factors while simultaneously addressing the identified challenges.\u003c/p\u003e \u003cp\u003eThis study\u0026rsquo;s findings also revealed that some of the factors impeding CHSD within Nigerian such as lack of funding and basic amenities from government, are also those reported by the Nigerian national population commission [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e] to affect health service delivery in other African countries thus calling to attention the possibility that some of these challenges are continental and would require a joint regional effort from African leaders to effectively address.\u003c/p\u003e \u003cp\u003eThe findings from the present study are also consistent with the work of other researchers within Nigeria. For example, the current study supports the findings from the works of Amedari and Ejidike [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e], Obansa and Orimisan [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e], Okereke et al., [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e] and Welcome [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e] which identified factors affecting health service delivery in Nigerian communities as centering on, corruption across health system, poor management of human resources and lack of funding from government. This raises the concern that these problems may have lingered because of negligence or enough not being done to curtail it by relevant stakeholders hence, pointing to the urgent need to create more awareness on the dangers of these constraining factors on CHSD and CHS as well as calling for more concerted effort to address these challenges. This also highlights the need for possibly adopting a different approach in addressing these challenges.\u003c/p\u003e \u003cp\u003eAlthough there are multi-level factors identified to be impeding CHSD in Nigeria by the present study, majority of the factors were identified to stem from the governmental level. lack of adequate financial support, embezzlement of funds, lack of social amenities etc. were among the factors found to be impeding the progress of health services in the communities. By adequately addressing the issue of embezzlement of public fund, the issues of inadequate financial support and lack of amenities can invariably be resolved to a reasonable extent, this is because, the reason for lack of social amenities and other financial support could be because the funds provided for such are embezzled or mismanaged. Therefore, by setting up functional accountability structures involving the community members where every fund coming into the communities for health be it as donation or government funding are clearly accounted for, there is a possibility that this will also increase community participation in health as well as enable the communities to serve as \u0026ldquo;accountability police\u0026rdquo; for health projects, thus ensuring that funds are efficiently utilized in the execution and delivery of community health services.\u003c/p\u003e \u003cp\u003eThe findings show that a major reason why the constraining factors have lingered in the first instance is due to over dependence on the government to tackle the challenges. Hence, involving more hands was seen as a key solution. The introduction of a multi-sectoral action where different health and non-health sectors can collectively work towards addressing these challenges may be more effective than expecting the government to do it all alone. This is because since the challenges occur at different levels, different sectors that function at different levels can focus on addressing challenges within their level of operation. Evidences [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e] have also shown that multi-sectorial collaboration is an effective approach in addressing different health challenges.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eAchieving an enhanced CHS is possible. However, this is largely dependent on how well actors in both health and non-health sectors prioritize and adequately address the multi-level challenges constraining CHSD while sustaining the factors that promote it. CHSD through functional CHS can help improve overall health systems strengthening and lead to improved health at the community level while ensuring the achievement of the Universal health coverage. Decision makers should integrate CHSD in all program implementation that involves communities and ultimately work with CHS as a veritable platform for effective health service delivery.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCHS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eCommunity Health System\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCHSD\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eCommunity Health Service Delivery\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eTBAs\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eTraditional Birth Attendants\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eIDI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eIn Depth Interview\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eOIC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eOfficer-in-Charge\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCMAM\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eCommunity-based Management of Acute Malnutrition\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eFGD\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eFocus Group Discussion\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePMVs\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePatent Medicine Vendors\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eUCH\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eUniversal Health Coverage\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSDGs\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eSustainable Development Goals\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePHC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePrimary Health Care\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCSOs\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eCivil Society Organizations\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eNGOs\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eNon-Governmental Organizations\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eLGA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eLocal Government Area\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCVs\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eCommunity Volunteers\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eFBOs\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eFaith-Based Organizations\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eWDC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eWard Development Commission\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eHFCs\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eHealth Facility Committees.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics Approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study received ethics approval from the Health Research Ethics Committee of University of Nigeria Teaching Hospital Enugu with reference number NHRECAS/01/2008-WA00002458-IRB00002323. All methods were conducted according to relevant guidelines and regulations. All participants were informed of the purpose of the research, rights of participants and measures to protect them and their data. Written, signed and verbal informed consent was also obtained from all the participants. Participation in the study was voluntary and confidentiality was ensured.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot Applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe dataset used for this study is available and can be obtained from the corresponding author upon request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interest\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThere is no competing interest. We confirm that the manuscript has been read and approved by all named authors. We confirm that the order of authors listed in the manuscript has been approved by all named authors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe research project which led to the results included in this manuscript received funding from the Bill and Melinda Gates Foundation. \u0026nbsp;However, the funding does not cover publications. The funders did not participate in designing the study, collecting and analyzing data, or writing and reviewing the manuscript. The views expressed in this manuscript belong exclusively to the authors and do not necessarily represent the funders\u0026rsquo; opinions.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEnyi Etiaba and Obinna Onwujekwe conceptualized and designed the study. Okechukwu Ozor and Enyi Etiaba participated in data collection. All authors took part in data analysis. Okechukwu Ozor wrote the first draft of the manuscript. All authors reviewed and approved the final version of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe wish to acknowledge the Bill and Melinda Gates Foundation as well as the African Health Observatory Platform (AHOP) for their support in helping to ensure the completion of this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor\u0026rsquo;s information\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOkechukwu Ozor - BSc, MSc - Clinical Psychology; Enyi Etiaba - MBBS, MPH; Obinna Onwujekwe - MBBS, PhD-Health economics.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eDe Nardi, M., Pashchenko, S., \u0026amp; Porapakkarm, P. (2017). The lifetime costs of bad health. Technical report, National Bureau of Economic Research.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDobkin, C., Finkelstein, A., Kluender, R., \u0026amp; Notowidigdo, M. J. (2018). The economic consequences of hospital admissions. American Economic Review, 108(2):308\u0026ndash;52.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMitchell, R. J., Ozminkowski, R. J., \u0026amp; Serxner, S. (2013). Improving employee productivity through improved health. Journal of occupational and environmental medicine, \u003cem\u003e55\u003c/em\u003e(10), 1142\u0026ndash;1148. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1097/JOM.0b013e3182a50037\u003c/span\u003e\u003cspan address=\"10.1097/JOM.0b013e3182a50037\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEffiong, F. B., Ogbonna, C. P., Agughalam, P. I., Okwukwu, M. O., Dike, I. C., Elebesunu, E. E., \u0026amp; Uwishema, O. (2023). The role of community-based approaches in achieving universal health coverage: addressing the Nigerian narrative. Annals of medicine and surgery (2012), \u003cem\u003e85\u003c/em\u003e(5), 1769\u0026ndash;1773. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1097/MS9.0000000000000443\u003c/span\u003e\u003cspan address=\"10.1097/MS9.0000000000000443\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFederal Ministry of Health (2016). National Health Policy 2016: Promoting the Health of Nigerians to Accelerate Socio-Economic Development. Federal Ministry of Health, Abuja. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://naca.gov.ng/wp-content/uploads/2019/10/National-Health-Policy-Final-copy.pdf\u003c/span\u003e\u003cspan address=\"https://naca.gov.ng/wp-content/uploads/2019/10/National-Health-Policy-Final-copy.pdf\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRawat, A., Pun, A., Ashish, K. C., Tamang, I. K., Karlstr\u0026ouml;m, J., Hsu, K., \u0026amp; Rasanathan, K. (2023). The contribution of community health systems to resilience: Case study of the response to the 2015 earthquake in Nepal. Journal of global health, \u003cem\u003e13\u003c/em\u003e, 04048. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.7189/jogh.13.04048\u003c/span\u003e\u003cspan address=\"10.7189/jogh.13.04048\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKruk, M. E., Gage, A. D., Arsenault, C., Jordan, K., Leslie, H. H., Roder-DeWan, S., Adeyi, O., Barker, P., Daelmans, B., Doubova, S. V., English, M., Garc\u0026iacute;a-Elorrio, E., Guanais, F., Gureje, O., Hirschhorn, L. R., Jiang, L., Kelley, E., Lemango, E. T., Liljestrand, J., Malata, A., \u0026hellip; Pate, M. (2018). High-quality health systems in the Sustainable Development Goals era: time for a revolution. The lancet. Global health, 6(11), e1196-e1252. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/S2214-109X(18)30386-3\u003c/span\u003e\u003cspan address=\"10.1016/S2214-109X(18)30386-3\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSchneider, H., \u0026amp; Lehmann, U. (2016). From community health workers to community health systems: time to widen the horizon? Health Systems \u0026amp; Reform, 2(2), 112\u0026ndash;118.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEgan, K. F., Devlin, K., \u0026amp; Pandit-Rajani, T., (2017). Community Health Systems Catalog Country Profile: Nigeria. Arlington, VA: Advancing Partners \u0026amp; Communities.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVankar, P. (2023, April, 12). \u003cem\u003eRanking of Health and Health Systems of Countries Worldwide in 2023.\u003c/em\u003e Statista. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.statista.com/statistics/1376359/health-and-health-system-ranking-of-countries-worldwide/\u003c/span\u003e\u003cspan address=\"https://www.statista.com/statistics/1376359/health-and-health-system-ranking-of-countries-worldwide/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eIyanda, O. F., \u0026amp; Akinyemi, O. O. (2017). Our chairman is very efficient: community participation in the delivery of primary health care in Ibadan, Southwest Nigeria. The Pan African medical journal, \u003cem\u003e27\u003c/em\u003e, 258. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.11604/pamj.2017.27.258.12892\u003c/span\u003e\u003cspan address=\"10.11604/pamj.2017.27.258.12892\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOkereke, E., Ishaku, S.M., Unumeri, G. \u003cem\u003eet al.\u003c/em\u003e (2019). Reducing maternal and newborn mortality in Nigeria\u0026mdash;a qualitative study of stakeholders\u0026rsquo; perceptions about the performance of community health workers and the introduction of community midwifery at primary healthcare level. Human Resource for Health 17, 102. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/s12960-019-0430-0\u003c/span\u003e\u003cspan address=\"10.1186/s12960-019-0430-0\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAdam, P., Greg, R., Sasan, S., \u0026amp; Alan, W. (2023). Small sample field study: The effects of team-based recognition on employee engagement and effort. Management Accounting Research, 59,1044\u0026ndash;5005. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.mar.2022.100829\u003c/span\u003e\u003cspan address=\"10.1016/j.mar.2022.100829\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAlkandi, I. G., Khan, M. A., Fallatah, M., Alabdulhadi, A., Alanizan, S., Alharbi, J. (2023). The Impact of Incentive and Reward Systems on Employee Performance in the Saudi Primary, Secondary, and Tertiary Industrial Sectors: A Mediating Influence of Employee Job Satisfaction. Sustainability. 15(4):3415. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.3390/su15043415\u003c/span\u003e\u003cspan address=\"10.3390/su15043415\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMohsin, B., Bradley, E., Wright, E., \u0026amp; Shahidul, H. (2021). The interactive influence of public service motivation, perceived reward equity, and prosocial impact on employee engagement: a panel study in Pakistan. 1213\u0026ndash;1237. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1080/14719037.2021.2013069\u003c/span\u003e\u003cspan address=\"10.1080/14719037.2021.2013069\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNigeria NPC. Nigeria demographic and health survey 2018. Abuja: National Population Commission and ICF Macro; 2018.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAmedari, M. I. \u0026amp; Ejidike, I. C. (2021). Improving access, quality and efficiency in health care delivery in Nigeria: a perspective. PAMJ \u0026ndash; One health. 5:3. Doi:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.11604/pamj-oh.2021.5.3.28204\u003c/span\u003e\u003cspan address=\"10.11604/pamj-oh.2021.5.3.28204\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eObansa, S. A., \u0026amp; Orimisan, A. (2013). Health care financing in Nigeria: prospects and challenges. Mediterranean Journal of Social Sciences. 4(1):221\u0026ndash;236. Doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.5901/mjss.2013.v4n1p221\u003c/span\u003e\u003cspan address=\"10.5901/mjss.2013.v4n1p221\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWelcome M. O. (2011). The Nigerian health care system: Need for integrating adequate medical intelligence and surveillance systems. Journal of pharmacy \u0026amp; bioallied sciences, \u003cem\u003e3\u003c/em\u003e(4), 470\u0026ndash;478. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.4103/0975-7406.90100\u003c/span\u003e\u003cspan address=\"10.4103/0975-7406.90100\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRasanathan, K., Atkins, V., Mwansambo, C., Soucat, A., \u0026amp; Bennett, S. (2018). Governing multisectoral action for health in low-income and middle-income countries: an agenda for the way forward. BMJ Global Health, 10 (3) (Suppl 4):e000890. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1136/bmjgh-2018-000890\u003c/span\u003e\u003cspan address=\"10.1136/bmjgh-2018-000890\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. PMID: 30364321; PMCID: PMC6195143.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBennett. S., Glandon, D., \u0026amp; Rasanathan, K., (2018). Governing multisectoral action for health in low-income and middle-income countries: unpacking the problem and rising to the challenge. BMJ Glob Health, 10(3) (Suppl 4):e000880. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1136/bmjgh-2018-000880\u003c/span\u003e\u003cspan address=\"10.1136/bmjgh-2018-000880\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. PMID: 30364411; PMCID: PMC6195144.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"health-research-policy-and-systems","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"hrps","sideBox":"Learn more about [Health Research Policy and Systems](http://health-policy-systems.biomedcentral.com/)","snPcode":"12961","submissionUrl":"https://submission.nature.com/new-submission/12961/3","title":"Health Research Policy and Systems","twitterHandle":"@HarpsJournal","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Community health service delivery, Community health systems, CHS, CHSD, Universal health coverage, Multisectoral collaboration","lastPublishedDoi":"10.21203/rs.3.rs-4460913/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4460913/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eIntroduction:\u003c/h2\u003e \u003cp\u003eSub-optimal community health service delivery (CHSD) has been a challenge constraining community health system (CHS) globally, especially in underdeveloped countries like Nigeria. This paper examined the key factors that either enhance or constrain CHSD in Nigeria at individual, community/facility and governmental levels while recommending evidence-based solutions for sustaining and improving CHSD within the framework of CHS.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eData was collected through a qualitative study undertaken in three states (Anambra, Akwa-Ibom and Kano) in Nigeria. Respondents were formal/informal health providers; community leaders and representatives of civil society organizations all purposively sampled. There were 90 in-depth interviews and 12 focus group discussions, which were audio-recorded, transcribed verbatim, and analyzed thematically using codes to identify key themes.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eFactors constraining CHSD at the individual level were: poor health seeking behavior and male dominance. At the community/facility level: superstitious/cultural beliefs and poor attitude of facility workers; at the governmental level were: inadequate financial support, embezzlement of funds, inadequate social amenities... Conversely, the enabling factors at the individual level were: community members participation, compassionate attitude of informal providers\u0026hellip; At the community/facility level were: synergy between formal and informal providers; and support from community-based organizations and structures. At the governmental level were: government\u0026rsquo;s support to community-based formal/informal providers and clear line of communication.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eCHSD through functional CHS can improve overall health systems strengthening and lead to improved community health. Policymakers should integrate CHSD in all program implementation and ultimately work with CHS as a veritable platform for effective community health service delivery.\u003c/p\u003e","manuscriptTitle":"Strengthening the effectiveness of community health system: assessing the factors that enhance or constrain the delivery of health services within communities in Nigeria","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-06-10 10:17:33","doi":"10.21203/rs.3.rs-4460913/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-06-12T04:49:34+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-06-09T19:39:00+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-06-06T17:06:22+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"38634069620576793151051423267638364730","date":"2024-06-01T13:31:12+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"121391478696998954234973916748079272257","date":"2024-06-01T00:18:47+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-05-31T22:14:48+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-05-27T16:59:40+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-05-27T16:59:39+00:00","index":"","fulltext":""},{"type":"submitted","content":"Health Research Policy and Systems","date":"2024-05-22T12:30:13+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"health-research-policy-and-systems","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"hrps","sideBox":"Learn more about [Health Research Policy and Systems](http://health-policy-systems.biomedcentral.com/)","snPcode":"12961","submissionUrl":"https://submission.nature.com/new-submission/12961/3","title":"Health Research Policy and Systems","twitterHandle":"@HarpsJournal","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"0cb1e183-44e2-4c52-b4dd-c946b7779b1b","owner":[],"postedDate":"June 10th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-09-09T16:18:29+00:00","versionOfRecord":{"articleIdentity":"rs-4460913","link":"https://doi.org/10.1186/s12961-024-01204-9","journal":{"identity":"health-research-policy-and-systems","isVorOnly":false,"title":"Health Research Policy and Systems"},"publishedOn":"2024-09-05 16:05:13","publishedOnDateReadable":"September 5th, 2024"},"versionCreatedAt":"2024-06-10 10:17:33","video":"","vorDoi":"10.1186/s12961-024-01204-9","vorDoiUrl":"https://doi.org/10.1186/s12961-024-01204-9","workflowStages":[]},"version":"v1","identity":"rs-4460913","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4460913","identity":"rs-4460913","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}