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Introduction: Community participation is central to primary health care (PHC). However, there remains limited research on the practices of community involvement in PHC. This study aimed to inform the Zambian PHC agenda, by documenting key actors, their roles, interactions and available spaces or interfaces for engaging in community participation, as well as to identify the enabling conditions/mechanisms, and barriers underpinning community participation.

Methods: We used exploratory qualitative methods consisting semi-structured interviews with Community Health Assistants (CHAs) (n=10), healthcare workers (n=7) and traditional leaders (n=7). Additionally, focus group discussions were conducted with Neighbourhood Health Committees (NHCS) members (n=53) and community members (n=57). Data were analysed using thematic analysis.

Results: The CHAs, health workers and traditional leaders acted as the key intermediaries between health facilities and communities, driving co-production and social accountability processes. Traditional leaders and civil society organizations often served as initial catalysts of community participation, enabling the subsequent roles of the CHAs, while health centres and NHCs provided the spaces and platforms for community members to shape their involvement in participatory activities. Co-production entailed community contributions such as labour and participation in decision-making at health facilities. Social accountability took the form of suggestion boxes and informal feedback from traditional leaders. Several contextual barriers limited participation, including undefined roles for processes of community engagement, the lack of a comprehensive engagement strategy, and the exclusion of CHAs in health facility processes.

Conclusion: The CHAs and their roles, alongside those of other actors, were pivotal in supporting both co-production and social accountability processes. Strengthening community participation in primary health requires clearly defining the roles of various actors through the development of comprehensive community engagement strategies.