Examining the roles and relationships of actors in community health systems in Nigeria through the lens of the expanded health systems framework

Abstract

Background Community health system (CHS) exists through the actions and activities of different actors within and outside communities. However, these actors, their roles and their relationships with one another have not been properly explored to understand their dynamics in facilitating the effectiveness of CHS. This study identified the actors in CHS, described their roles and their relationships with one another using the expanded health systems framework (EHSF).Methodology Data were collected using qualitative tools in three states located in three geographical zones in Nigeria. A total of 102 in-depth interviews and focus group discussions sessions were conducted, recorded and transcribed. The respondents were categorised into policy-makers, programme managers, formal health providers, informal health providers (IHPs), civil society organisations/non-governmental organisations, community leaders and community groups. The data were analysed using a thematic data analysis approach.Findings The study identified numerous informal health actors (IHA) within the CHS and certain actors—such as community leaders, ward development committees, IHPs and local health representatives—exhibited more pronounced actions. They were active across the EHSF, especially in leadership and governance, health workforce, service delivery and supply of medical products. The relationships and interdependencies of these actors manifest as intricately complex, united by the shared goal of enhancing health at both the household and community levels. Although their roles may not be distinctly defined, instances of active and pronounced engagement reveal the strong commitment of IHA to advocate for and facilitate health programmes at the community level.Conclusion There is a broad spectrum of actors whose contributions are critical to the effectiveness and full functioning of CHS. Continuous engagement and defining clear roles and responsibilities for these actors could contribute to improved community health.