PHC resilience capabilities of positive deviants and comparator LGAs
| Capabilities identified by KIIs | Comparison of PDs and comparators | PD Examples | Comparator Examples |
| Integrated—coordinating across actors, sectors and engaging communities | |||
| Senior LGA leadership was engaged in managing and/or supporting the response | Large difference, more frequently cited by PDs | 10/12 cited this capability ‘[The] local government chairmen, [he] tried his best funding our movement, giving us money for data, the local government provided enabling environment. If we go for village mobilization they provided. The chairman of the local government will now call the town criers; they will bring out people. They did a lot for us.’ LGA official, PD | 2/12 cited this capability ‘The first and foremost it has to be the support from the political leadership, the response was satisfactory, actually the chairman gave us support both financially and morally during the pandemic, so that helps us’ LGA Official, Comparator |
| Specific local coordination structures were developed for the COVID-19 response | Large difference, more frequently cited by PDs | 9/12 cited this capability ‘During the pandemic, the honorable chairman constituted a COVID-19 monitoring committee headed by the supervisory counsellor special duties, supervisory counsellor for health, head of department health is the secretary of that committee, the disease notification officer, our office and some relevant key holder, SSS, DPO and some representatives of CAN chairman and Chief Imam were members of this committee that we have at the area council. We went to places of worship, schools, some companies,(…)That committee really help during that time. We were even giving recommendation from FCT area council secretariat, [this LGA] was the first to constitute that committee in [a state in Nigeria).’ LGA official, PD | 2/12 cited this capability ‘The LGA team comprises of all the secondary facilities and the local government team, so we work as a team(…)inaugurated by the chairperson of the local government as a task force. This task force works seriously towards helping the spread of COVID-19 in the local government.’ LGA official, Comparator |
| Dialogue with communities focused on generating continued demand for and awareness of essential health services | Moderate difference, more frequently cited by PDs | 8/12 cited this capability ‘The facility has gone out of the catchment area to health educate the women of age of childbearing age on the importance of coming to the health facility despite the COVID-19 pandemic, and they assure them that they are going to use all preventive measures to ensure that nobody comes to the facility and goes back infected with the COVID-19.’ Facility OIC, PD | 3/12 cited this capability ‘After the engagement with the community, we have [increases in] utilizing our services because they became(…)more reassured that one, the services are still available, and two, that if they come around, there won’t be any risk of exposure or contracting the COVID.’ LGA official, Comparator |
| Increasing the frequency of community engagement and outreach activities during the COVID-19 pandemic | No difference between PDs and comparators | 11/12 cited this capability ‘During the Covid period, we really needed community mobilization, community dialogue, trying to sensitize the people on the risk factors for contracting Covid and the safety profile of the health facilities.(…)We do our ward development community meetings once a month and that was enough to pass the message across. But during the Covid, it had to be almost routine because we needed to get the message presented to the people.’ LGA official, PD | 11/12 cited this capability ‘There is increase social mobilization, there is increase mobilization of the people. We increase our dialogue with the community.’ LGA official, Comparator |
| Existing platforms were leveraged and strengthened to engage with community leaders | Minor difference between PDs and comparators | 12/12 cited this capability ‘The existing community relationship help(ed] by ensuring community dialogue and sensitization(…). We work hand in hand with them.’ Facility Officer in Charge, PD | 11/12 cited this capability ‘The lesson learned? strengthening of the already existing relationship with the community members(…)this COVID-19 has brought(…)us close together, we have been working as a team’ LGA official, Comparator |
| A ‘teamwork’ mentality was strengthened across the health system | No difference between PDs and comparators | 11/12 cited this capability ‘We worked as a team(…)we also come back to review our activities and deliberates on our challenges, our strengths, our weaknesses, the opportunities we had and threats to the opportunities.’ LGA official, PD | 11/12 cited this capability ‘The local government chairman, all the heads of departments were all involved. So it was a, it was a team thing in all in the whole local government. So everyone was available, everyone was ready.’ LGA official, Comparator |
| Aware—understanding of resources to draw from, with data to identify threats | |||
| Local funding sources were leveraged to fill resource gaps in the response | Large difference, more frequently cited by PDs | 10/12 cited this capability ‘The facility management have made it mandatory every week to remove money from its account to support the COVID-19 response and the facility have tag some staff to ensure that there is strict maintenance of those preventive measures.’ PHC facility staff, PD | 1/12 cited this capability ‘We would join hands to see that we found a solution to the problem that arose or may arise. They [the LGA] even provide batteries for megaphone, refreshment etc.’ LGA official, Comparator |
| Adaptive—transforming processes in the short and long term in the face of threats | |||
| Incentives for service use were increased | Small difference, more frequently cited by PDs, but not reflected by a large number of sampled LGAs in either category. | 5/12 cited this capability ‘(Pregnant women] were given free ANC drugs and a mama kit. So, you find out that since they knew that if they come for or registered for antenatal, they will be given free nets, free drugs and delivery items. It motivated them to come.’ LGA official, PD | 2/12 cited this capability ‘One major thing we did was [we] made delivery free of charge,(…)we also declared registration for ANC free—which was not there [before]—to win people to continue to access our facilities.’ LGA official, Comparator |
| Home visits were used | Small difference, more frequently cited by PDs, but not reflected by a large number of sampled LGAs in either category. | 5/12 cited this capability ‘Before we go for outreach, we go to the people, [on this] date we will be coming for an outreach, since they no longer come to us, we are now going to them.(…)Yes it was not easy because you don’t sit at home or use your phone, you must have to go looking for them and for you to go, at times you dip your hands in your pocket to… that is why if you are not really committed to this job, you cannot do all these approaches because for you to talk to them, you go looking for them.’ LGA official, PD | 1/12 cited this capability ‘Home visiting, some don’t like coming to the facility, they say if they come to the facility, they will check them, they will take them for Covid, so we will meet them at their homes.’ LGA official, Comparator |
| Reduced appointments to prevent overcrowding of PHCs | Small difference, more frequently cited by comparators, but not reflected by a large number of sampled LGAs in either category. | 1/12 cited this capability ‘If you have gone through our health centres you will see they are small buildings, so putting people clustered in one place was not what we were trying to encourage during the COVID-19 pandemic. So, we had to do more, lesser numbers of persons in the facilities per time just to prevent the spread among the health care workers.’ LGA official, PD | 5/12 cited this capability ‘With these top services [MNCH), we continue but we try to reduce the number of people inside the health facility to prevent the spread since we already know that COVID virus was airborne. We are using physical distancing, and we reduce the number of the sessions, number of persons that attend to every vaccination session and in some cases, we had to schedule dates for mothers to bring their children and babies for vaccination’ LGA official, Comparator |
| Human resources were re-allocated via task shifting or changes in duty schedules | Small difference, more frequently cited by comparators, but not reflected by a large number of sampled LGAs in either category. | 2/12 cited this capability ‘One person can manage 2 or 3 services, because some service providers cannot transport themselves from where they are residing to the facility(so] you see 1 person has to manage 2 units in the facility’ PHC facility staff, PD | 4/12 cited this capability ‘Of course, that’s the strategy we used, since all the health workers won’t come at the same time, in the initial stages, there was an overall staff shifting, the midwives too could offer routine immunization services, not necessary health care workers and the pharmacy technician too could assist in vaccination and a lab scientist too could be deployed for record purposes, we did this task shifting to be able to cope.’ LGA official, Comparator |
| Self-regulating—contain threats while continuing core operations | |||
| Accessed reserve human resource capacity via voluntary, contract or other temporary health workers | Small difference, more frequently cited by comparators | 4/12 cited this capability ‘I don’t think there is another clinic that has a complete component of staff. That is why we formed the health development team to complement what the facilities needed.(…)there are staff on voluntary services, some are casual, so we used them based on their qualification to fill that gap’ LGA official, PD | 7/12 cited this capability ‘Retired matrons, retired health workers came to assist us during the COVID pandemic, and we were able to benefit from their experience and add [to] our workforce, but after the pandemic started declining, they all disengaged.’ LGA official, Comparator |
Note: Tabulations displayed in this table are derived from qualitative findings and should be interpreted as descriptive in nature. Informants from the LGA, PHC facility and community levels within a single LGA are considered a ‘case’ and represented jointly in the numerical tabulation of LGAs. Diverse capabilities were described in a small number of LGAs and did not rise to a level of sufficient saturation for inclusion in the results.
KIIs, key informant interviews; LGA, local government area; PDs, positive deviants; PHC, primary health care.