What made primary health care resilient against COVID-19? A mixed-methods positive deviance study in Nigeria.

INTRODUCTION: The SARS-CoV-2 (COVID-19) pandemic overwhelmed some primary health care (PHC) systems, while others adapted and recovered. In Nigeria, large, within-state variations existed in the ability to maintain PHC service volumes. Identifying characteristics of high-performing local government areas (LGAs) can improve understanding of subnational health systems resilience. METHODS: Employing a sequential explanatory mixed-methods design, we quantitatively identified 'positive deviant' LGAs based on their speed of recovery of outpatient and antenatal care services to prepandemic levels using service volume data from Nigeria's health management information system and matched them to comparators with similar baseline characteristics and slower recoveries. 70 semistructured interviews were conducted with LGA officials, facility officers and community leaders in sampled LGAs to analyse comparisons based on Kruk's resilience framework. RESULTS: A total of 57 LGAs were identified as positive deviants out of 490 eligible LGAs that experienced a temporary decrease in PHC-level outpatient and antenatal care service volumes. Positive deviants had an average of 8.6% higher outpatient service volume than expected, and comparators had 27.1% lower outpatient volume than expected after the initial disruption to services. Informants in 12 positive deviants described health systems that were more integrated, aware and self-regulating than comparator LGAs. Positive deviants were more likely to employ demand-side adaptations, whereas comparators primarily focused on supply-side adaptations. Barriers included long-standing financing and PHC workforce gaps. CONCLUSION: Sufficient flexible financing, adequate PHC staffing and local leadership enabled health systems to recover service volumes during COVID-19. Resilient PHC requires simultaneous attention to bottom-up and top-down capabilities connected by strong leadership.

Vaccination Utilization and Subnational Inequities during the COVID-19 Pandemic: An Interrupted Time-Series Analysis of Administrative Data across 12 Low- and Middle-Income Countries.

BACKGROUND: During and after the SARS-CoV-2 (COVID-19) pandemic, many countries experienced declines in immunization that have not fully recovered to pre-pandemic levels. This study uses routine health facility immunization data to estimate variability between and within countries in post-pandemic immunization service recovery for BCG, DPT1, and DPT3. METHODS: After adjusting for data reporting completeness and outliers, interrupted time series regression was used to estimate the expected immunization service volume for each subnational unit, using an interruption point of March 2020. We assessed and compared the percent deviation of observed immunizations from the expected service volume for March 2020 between and within countries. RESULTS: Six countries experienced significant service volume declines for at least one vaccine as of October 2022. The shortfall in BCG service volume was ~6% (95% CI -1.2%, -9.8%) in Guinea and ~19% (95% CI -16%, 22%) in Liberia. Significant cumulative shortfalls in DPT1 service volume are observed in Afghanistan (-4%, 95% CI -1%, -7%), Ghana (-3%, 95% CI -1%, -5%), Haiti (-7%, 95% CI -1%, -12%), and Kenya (-3%, 95% CI -1%, -4%). Afghanistan has the highest percentage of subnational units reporting a shortfall of 5% or higher in DPT1 service volume (85% in 2021 Q1 and 79% in 2020 Q4), followed by Bangladesh (2020 Q1, 83%), Haiti (80% in 2020 Q2), and Ghana (2022 Q2, 75%). All subnational units in Bangladesh experienced a 5% or higher shortfall in DPT3 service volume in the second quarter of 2020. In Haiti, 80% of the subnational units experienced a 5% or higher reduction in DPT3 service volume in the second quarter of 2020 and the third quarter of 2022. CONCLUSIONS: At least one region in every country has a significantly lower-than-expected post-pandemic cumulative volume for at least one of the three vaccines. Subnational monitoring of immunization service volumes using disaggregated routine health facility information data should be conducted routinely to target the limited vaccination resources to subnational units with the highest inequities.

Resilience of front-line facilities during COVID-19: evidence from cross-sectional rapid surveys in eight low- and middle-income countries.

Responsive primary health-care facilities are the foundation of resilient health systems, yet little is known about facility-level processes that contribute to the continuity of essential services during a crisis. This paper describes the aspects of primary health-care facility resilience to coronavirus disease 2019 (COVID-19) in eight countries. Rapid-cycle phone surveys were conducted with health facility managers in Bangladesh, Burkina Faso, Chad, Guatemala, Guinea, Liberia, Malawi and Nigeria between August 2020 and December 2021. Responses were mapped to a validated health facility resilience framework and coded as binary variables for whether a facility demonstrated capacity in eight areas: removing barriers to accessing services, infection control, workforce, surge capacity, financing, critical infrastructure, risk communications, and medical supplies and equipment. These self-reported capacities were summarized nationally and validated with the ministries of health. The analysis of service volume data determined the outcome: maintenance of essential health services. Of primary health-care facilities, 1,453 were surveyed. Facilities maintained between 84% and 97% of the expected outpatient services, except for Bangladesh, where 69% of the expected outpatient consultations were conducted between March 2020 and December 2021. For Burkina Faso, Chad, Guatemala, Guinea and Nigeria, critical infrastructure was the largest constraint in resilience capabilities (47%, 14%, 51%, 9% and 29% of facilities demonstrated capacity, respectively). Medical supplies and equipment were the largest constraints for Liberia and Malawi (15% and 48% of facilities demonstrating capacity, respectively). In Bangladesh, the largest constraint was workforce and staffing, where 44% of facilities experienced moderate to severe challenges with human resources during the pandemic. The largest constraints in facility resilience during COVID-19 were related to health systems building blocks. These challenges likely existed before the pandemic, suggesting the need for strategic investments and reforms in core capacities of comprehensive primary health-care systems to improve resilience to future shocks.