A Theoretical and Empirical Investigation of Community Participation in Primary Healthcare Governance in Nigeria

Community participation in primary healthcare governance is a foundational principle of the Alma-Ata Declaration and its successors, but its theoretical operationalisation and empirical effectiveness in Nigerian PHC governance contexts remains inadequately characterised. This study conducted an original theoretical and empirical investigation of community participation in PHC governance in Nigeria. The theoretical investigation reviewed 48 publications on community participation in health governance from 2015 to 2024, systematically evaluating how participation is conceptualised, measured, and theoretically linked to health system outcomes in the Nigerian and comparable sub-Saharan African contexts. The empirical investigation was a multi-state comparative study across six geopolitical zones, assessing participation quality in Ward Development Committees (the formal community PHC governance structure in Nigeria) in 60 wards across 12 LGAs. Participation quality was measured using a validated 32-item Community Participation Assessment Tool covering representation inclusiveness, deliberative quality, power sharing, accountability mechanisms, and feedback effectiveness. Association between participation quality and PHC service delivery outcomes was assessed through correlation analysis using routinely collected DHIS2 service output data. Results showed that adequate participation quality was achieved in only 28.3 percent of assessed WDCs. Female representation was below 30 percent in 71.7 percent of WDCs. Participation quality was significantly positively correlated with facility immunisation coverage (r = 0.54; p < 0.001) and skilled delivery rates (r = 0.41; p < 0.01). The study develops an original Nigerian PHC Community Participation Theory specifying enabling conditions, participation quality dimensions, and health system outcome pathways.