In-Depth Comparative Studies

The AHOP comparative study is a collection of complementary peer reviewed manuscripts focused on a topic decided by consensus across AHOP National Centres having consulted their national policy makers. 

In our inaugural AHOP comparative study we investigate the interface between Community Health Systems (CHS) and Primary Health Care from the perspective of Ethiopia, Kenya, Nigeria, Rwanda, and Senegal. The multicounty analysis aims to help understand how community level structures and influences from the health sector and beyond, both formal and informal, improve the health of their local populations.

The term ‘Community Health Systems’ has emerged to capture community led efforts to improve health. In this series of papers, AHOP explore in greater depth the interface between CHS, the primary health system and the broader environment. Using a variety of entry points, we present a series of papers designed to better understand how community health systems are defined, operationalised and provide opportunities to further improve the health of the communities they serve.   

We encourage you to read our findings.

Papers published to date:

Led by Nigerian AHOP National Centre: 

1. Community involvement in healthcare relies on collaborative efforts to improve access and use of services. Obi et al’s study in rural and urban areas of three Nigerian states identified horizontal collaborations, including community-led, facility-led, and individual-led initiatives, focusing on advocacy, facility upgrades, and health education. These efforts have enhanced the use of primary healthcare centers, demonstrating the value of local actors in improving access to primary healthcare services.
2. Ungoverned spaces in health systems emerge when healthcare providers evade government regulation, posing risks to health security. In their study, Agwu and colleagues highlight Informal Health Providers (IHPs) like Patent Medicine Vendors, Herbalists, and Traditional Birth Attendants as key examples in Nigeria. While some IHPs interact with health authorities, many operate without oversight, and their unions may act parallel to formal systems. Though IHPs fill gaps in underserved areas, their unregulated practices threaten quality healthcare. Future research should focus on developing policies to integrate IHPs into governed health systems.
3. Sub-optimal community health service delivery (CHSD) remains a challenge globally. Ozor and colleagues, undertake a qualitative study in three Nigerian states (Anambra, Akwa-Ibom and Kano) to examined the key factors that were reported to either enhance or constrain CHSD in Nigeria at the individual, community/facility and governmental levels while recommending evidence-based solutions.  Poor health-seeking behavior, cultural beliefs, inadequate funding, and corruption are all identified as constraints. Enabling factors such as community participation, synergy between providers, and government support were reported as critical. Strengthening CHSD through a functional community health system, integrating it into program implementation, and fostering collaboration with communities can improve health outcomes and overall health system performance.
4. Community health systems involve various actors whose roles and relationships significantly impact their effectiveness.  Odii et al set out to identify the actors in CHS, describe their roles and their relationships with one another using the expanded health systems framework (EHSF). The study identified key actors, including community leaders, ward development committees, informal health providers (IHPs), and local health representatives, who actively contribute to leadership, governance, service delivery, and medical supplies. Despite the complexity and overlapping roles, their shared goal of enhancing community health drives collaboration. They conclude that defining clear roles and fostering continuous engagement could strengthen CHS functionality and outcomes further.
5. The level of Community participation in health programmes and how this involvement facilitates programme implementation. Ojielo et al here highlight how inclusion of community members and groups improved willingness to access immunization services amongst others, and encourages programme planners to additionally involve communities earlier, in the conceptualization and planning phases.  
6. Demand and supply side factors that drive delayed referrals from traditional birth attendants to public primary healthcare facilities. Okeke and co-authors present findings from across three Nigerian states showing that, on the demand-side community preference for TBAs, along with cultural and religious beliefs, hinders referrals. On the supply side, infrastructural deficits, staff shortages, and weak enforcement of PHC standards discourage timely transfers. Addressing these challenges requires innovative interventions, such as incentivizing TBAs to encourage early referrals, fostering stronger linkages between informal and formal health systems, and improving PHC infrastructure and staffing.
7. Multisectoral plans at the community level are key to improving health and addressing social determinants in Nigeria’s primary healthcare (PHC) system.Etiaba et al explore multisectoral collaborations across health and non-health sectors in Kano, Akwa Ibom, and Anambra states, guided by the Expanded Health Systems and WHO PHC frameworks. Data from 103 interviews, 12 focus groups, and policy reviews highlight various community-level activities led by both health and non-health sectors. Strengthening coordination, capacity, and policy integration is essential to enhance these efforts and advance universal health coverage (UHC) in Nigeria.
8. Communicating Health Information at the Community Level in Nigeria: Examining Common Practices and Challenges. Abah et al. argues that there are unsystematic and sub-optimal communications of health information at the community level, which can militate against such information and hinder the effective delivery of health programmes to communities.

Led by the Kenya AHOP National Centre:

1. The community-based health information system (CBHIS) is integral to community health systems, enabling data-driven planning, monitoring, and evaluation of healthcare services. It supports evidence-based policy development, resource allocation, and priority setting while fostering community empowerment through health dialogues and data accessibility. In this scoping review the Kenyan AHOP National Centre review 55 studies across 27 African countries revealed predominant use of paper-based systems, though some have adopted digital tools. Kuvuna and colleagues find that while investments have focused on digitisation and data quality, greater emphasis is needed on leveraging CBHIS data for community empowerment and utilisation at the grassroots level.

Forthcoming (in preparation and under review): 

Led by LSE:

1. ‘Community Health System’ – definitional challenges and varying policy environments lead to the term CHS being operationalised and formalised differently across countries. In their scoping review Conteh et al reflect on the use of CHS terminology in the literature and a range of AHOP country experiences.  The paper explores the extent the CHS is already an integral part of primary care, or a novel, contrasting perspective worthy of specific attention.
2. Community-based healthcare, grounded in community participation and ownership, is a cost-effective way to deliver last-mile healthcare and advance universal health coverage in sub-Saharan Africa. In this paper Kanya et al11 make the case that understanding effective financing approaches for community healthcare systems is essential to achieve long-term success and equity in healthcare delivery. A review of 30 studies and 17 policy documents highlight reliance on government budgets, community-based insurance, external funding, private contributions, and out-of-pocket payments. Mandatory insurance enrolment, increased domestic investments, and tailored financing strategies aligned with national policies and robust community engagement are essential for sustainable progress.

Led by Nigerian AHOP National Centre:

1. Catalyzing community ownership and engagement approaches to functional primary healthcare facilities in Nigeria: Lessons and strategies. This paper explores the ‘whole of Community’ approach for PHC. They present evidence on the Community Ownership and Engagement (COE) approach to functionality of PHC facilities and practical insights that will strengthen its effectiveness in Nigeria.
2. How are health data and information generated and managed for addressing community health   in Nigeria? This study by Ojiakor et al assesses the types of health data that are collected in communities and the overall data and information system practices within communities, as part of the community health system, in Nigeria.
3. Pathways to integrating community-led activities that contextually address health and other social determinants of health with formal PHC system in Nigeria– towards universal health coverage . This paper highlights community initiated contextual approaches to health that have contributed to improved community health and explores if and how these activities have been integrated into the formal PHC system. It also explores what more activities could further be integrated.
4. One Health: Non-health sector activities for improving health at the community level towards the One Health Plan in Nigeria.The One Health approach enables multisectoral collaboration in designing and implementing programs, policies, legislations and research, to achieve better public health outcomes for the human, animal, and environment sectors. Nigeria developed a One health plan between the Ministries of Health, Environment and Agriculture & Rural development in 2019. This paper explores what multisectoral activities exist at community levels to improve citizens’ health in alignment with this plan.

Led by the Rwandan AHOP National Centre: