Community and Primary Health Care

2.8.1 Public Health Issue

Communities make significant contributions to the development of health systems around the world particularly at the PHC or community level (Milton et al., 2011). The concept of ‘community participation’ in primary care therefore refers to the process by which individuals/families take responsibility for improving their own health through collaboration with health providers. In other words, community participation requires willingness and commitment of community members to take part in health-based research as well as decision-making in healthcare organizations (Marston et al., 2016). Community participation gained wide acceptance after the 1978 Alma Ata Declaration, which identified communities as key to the planning, organizing, operation and control of PHC systems. Community participation in recent years has also emerged as a priority area in global health management following the implementation of SDGs. Accordingly, the SDGs emphasized integration of people-centred health services as the major solution to actualizing WHO’s universal health coverage (Ewan et al., 2005; Martin., 2008; Milton et al., 2011).

However, every country needs to adapt suitable participatory approaches in order to achieve national health objects as chronic diseases, political crisis, economic and socio-cultural issues ravage global PHC systems (Sheikh et al., 2013). Intersectoral approaches that encourage participation and engagement of communities in health care delivery are, thus, part of the key solutions for an effective and efficient implementation of health care strategies geared towards the control and prevention of communicable/chronic diseases (Narain., 2011; Moreno-Serra & Smith., 2012)

But despite the benefits of community participation in healthcare management, there is need to consider demographic changes and the impact of individual/community-based factors that affect overall health outcomes (Manion., 2005). This underscores the importance of analysing people’s social-cultural environment and the implications to governance and policymaking in health institutions. Studies in health care show that community participation helps to improve health practices and quality of care through meaningful contributions in the development, implementation and evaluation of health services. But the structural and practical challenges successful and sustainable community involvement cannot be ignored although studies on the effect of community participation in the primary health care of developed countries—in terms of benefits at both community and individual levels—have not been subjected to empirical reviews (Morgan., 2001; Rifkin., 2009a; Rifkin., 2014b; Ewan et al., 2005).

2.6.2 Types of Community Participation in Primary Health Care

Some systematic studies on the outcomes of community participation in primary care focused on rural health whereas few others examined mother and child health (Marston et al., 2016). Preston et al (2010) and Evans et al (2010) explored health and social outcomes of participatory PHC approaches in Britain. Crawford et al (2002) conducted a systematic review of relevant studies published between 1966 to 2000 on the impact of engaging patients in the planning and development of healthcare. However, the researchers neglected outcomes of community involvement in health service governance (i.e. planning, implementation, monitoring, and evaluation of health management policies) (Boerma., 2006).

To understand the various types of community participation in primary health care, it is pertinent to recognize that different terminologies/concepts may reflect different perspectives or degrees of participation (Freeman et al., 2016). Although many scholars have constructed various structures or typologies to highlight the differences in community-level participation (Shi et al., 2002), Arnstein’s (1969) framework is considered an ideal concept due to its comprehensive analysis and presentation of structural power distribution as explained below.

Figure 2.2 The Community Participation Concept

Source: Arnstein (1969)

Oakley’s (1989) book titled ‘Participatory action research’ argued that community participation can be seen either as a mean or as an end itself. Defining community participation as means, the researcher asserted that ‘input from communities’ helps to improve service quality, with emphasis that the parameters are controlled by health providers. According to Oakley, community participation is often a short-term exercise with a defined goal and tasks. On the other hand, he viewed participation as an end, describing it as a dynamic and unpredictable responsibility that provides community members with firmer control of their health outcomes—as well as the scope and ability to effect changes (Koppel et al., 2013).

However, Baum et al (2008a) reviewed Oakley’s assertions and modified them to include contemporary typologies of participation as explained below:

• Structural participation: This concept of participation views community participation as an engaging developmental process under the control of communities. Structural participation is an ongoing, potentially empowering health care activity involving a large population (Agass et al., 1991).
• Substantive participation: This concept of community participation emphasises the active involvement in major decision-making process such as the setting of priorities and implementation of health policies. However, substantive participation does not allow the control wielded by communities under structural participation. Basically, external control remains under substantive participation—with a chance for power shift after a period of time (Crawford et al., 2002).
• Participation as a means: This implies using participation to achieve certain health care objectives. For example, health providers engage services of community members to increase attendance during meetings and to enforce compliance to regulations guiding implementation of community health programmes. There is no shift in power except delegated authority/role. Leadership activities are driven by health organisations (Kotter., 2003).
• Consultation: The concept of consultation refers to the act of seeking opinions from communities. This includes providing platforms for people to criticise policies or make suggestions to be considered during policy formulation and implementation. Examples of strategies used during consultative activities are feedback surveys, interviews and questionnaires. Consultation may be a one-off exercise controlled by health organisation (Freeman et al., 2016).

An analysis of the listed community participation concepts/typologies show the scholars focused on purpose and degree of power control between health providers and communities (Baum., 2006b). But the involvement of community members in primary care is a cumbersome activity mainly because healthcare institutions hardly find people who are passionate about the job. Even when volunteers are found, another challenge becomes how to keep them motivated (Martin., 2008). Moreover, participants are not always an accurate representative of the total patient population, thus, health care professionals are most likely to question the relevance of contributions/activities from these participants.

Additionally, the imbalanced representation tends to neglect/underrepresent women, young adults (aged between 16–29) and people from less-privileged and/or low-income classes (Marston et al., 2016). For example, the drive for community participation in primary care is increasing in the UK and many parts of the world (Martin., 2008). But there’s dearth of systematic studies on the characteristics or circumstances that can motivate community members to willingly participate in primary care (Agass et al., 1991; Neuwelt., 2012; Petsoulas et al., 2015).