Health systems challenges, mitigation strategies and adaptations to maintain essential health services during the COVID-19 pandemic: learnings from the six geopolitical regions in Nigeria

BACKGROUND

The COVID-19 pandemic control strategies disrupted the smooth delivery of essential health services (EHS) globally. Limited evidence exists on the health systems lens approach to analyzing the challenges encountered in maintaining EHS during the COVID-19 pandemic. This study aimed to identify the health system challenges encountered and document the mitigation strategies and adaptations made across geopolitical zones (GPZs) in Nigeria.

METHODS

The national qualitative survey of key actors across the six GPZs in Nigeria involved ten states and the Federal Capital Territory (FCT) which were selected based on resilience, COVID-19 burden and security considerations. A pre-tested key informant guide was used to collect data on service utilization, changes in service utilization, reasons for changes in primary health centres' (PHCs) service volumes, challenges experienced by health facilities in maintaining EHS, mitigation strategies implemented and adaptations to service delivery. Emerging sub-themes were categorized under the appropriate pillars of the health system.

RESULTS

A total of 22 respondents were interviewed. The challenges experienced in maintaining EHS cut across the pillars of the health systems including: Human resources shortage, shortages in the supply of personal protective equipments, fear of contracting COVID-19 among health workers misconception, ignorance, socio-cultural issues, lockdown/transportation and lack of equipment/waiting area (. The mitigation strategies included improved political will to fund health service projects, leading to improved accessibility, affordability, and supply of consumables. The health workforce was motivated by employing, redeploying, training, and incentivizing. Service delivery was reorganized by rescheduling appointments and prioritizing some EHS such as maternal and childcare. Sustainable systems adaptations included IPC and telehealth infrastructure, training and capacity building, virtual meetings and community groups set up for sensitization and engagement.

CONCLUSION

The mitigation strategies and adaptations implemented were important contributors to EHS recovery especially in the high resilience LGAs and have implications for future epidemic preparedness plans.

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.

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.

Disruptions in maternal and child health service utilization during COVID-19: analysis from eight sub-Saharan African countries

The coronavirus-19 pandemic and its secondary effects threaten the continuity of essential health services delivery, which may lead to worsened population health and a protracted public health crisis. We quantify such disruptions, focusing on maternal and child health, in eight sub-Saharan countries. Service volumes are extracted from administrative systems for 63 954 facilities in eight countries: Cameroon, Democratic Republic of Congo, Liberia, Malawi, Mali, Nigeria, Sierra Leone and Somalia. Using an interrupted time series design and an ordinary least squares regression model with facility-level fixed effects, we analyze data from January 2018 to February 2020 to predict what service utilization levels would have been in March-July 2020 in the absence of the pandemic, accounting for both secular trends and seasonality. Estimates of disruption are derived by comparing the predicted and observed service utilization levels during the pandemic period. All countries experienced service disruptions for at least 1 month, but the magnitude and duration of the disruptions vary. Outpatient consultations and child vaccinations were the most commonly affected services and fell by the largest margins. We estimate a cumulative shortfall of 5 149 491 outpatient consultations and 328 961 third-dose pentavalent vaccinations during the 5 months in these eight countries. Decreases in maternal health service utilization are less generalized, although significant declines in institutional deliveries, antenatal care and postnatal care were detected in some countries. There is a need to better understand the factors determining the magnitude and duration of such disruptions in order to design interventions that would respond to the shortfall in care. Service delivery modifications need to be both highly contextualized and integrated as a core component of future epidemic response and planning.

Changes in sexual risk behavior among adolescents: is the HIV prevention programme in Nigeria yielding results?

This study conducted an analysis of the 2007 and 2012 National HIV and AIDS Reproductive Health Survey data with the aim of identifying the changes in high risk sexual behaviour among adolescents aged 15-19 years. It focused on changes in the history of use of condom with boyfriends/girlfriends, engagement in transactional sex, sex with multiple partners and age of sexual debut. Bivariate analysis was conducted to ascertain differences in the number of adolescents who engaged in these high sexual risk behaviours over the five-year study period. Data was also analysed for association between risk behaviour and possible predisposing factors. Over the five year period, HIV prevalence in the population increased significantly (p = 0.02) especially in female (p = 0.008). The number of female adolescents who became sexually active decreased significantly (p = 0.02), and use of condom at last sexual act with non-marital sexual partners significantly increased (p = 0.01). There was an insignificant increase in the proportion of males and females who engaged in transactional sex and who had multiple sex partners over the study period. More females who engaged in transactional sex were HIV positive (p = 0.01), and more males who were sexually active in the last 12 months were HIV positive (p = 0.01). There may be a need to redress the current HIV prevention intervention strategies. Attention needs to be paid to the national programme for the prevention of mother to child transmission of HIV programme as well as HIV prevention needs of female adolescents.

Standard of care for HIV prevention technology research: a consensus document from Nigeria

AIM

A framework of care includes the notion that care is that received from outside an individual and nurtures its body and soul. Defining care and the context of providing it is difficult especially with the ever changing and evolving field like that found operational in the HIV and AIDS research field. The standard of care for HIV and AIDS prevention trials continues to evolve and countries/communities are encouraged to define locally relevant standard of care guidelines. The paper reports on the consensus reached by stakeholders in Nigeria on the standard of care to be provided during HIV prevention research. It is an attempt by the community of stakeholders involved with New HIV Prevention Technology trials in Nigeria to define the standard of care for HIV prevention research in Nigeria.

METHOD

Four consultative meetings involving policy makers, the national government and government agencies, representatives of donor communities, regulatory agencies in the country, community advocates, people living with HIV/AIDS, sex workers, people who engage in sae sex practices, researchers, women, youths, journalists and organizations that serve these various communities, were held. This is a report of the consensus reached on the standard of care for HIV prenvention in Nigeria.

RESULTS

Such obligations include the provision of counselling and testing for trial participants throughout the trial and during the post trial period using the most sensitive and specific test kits for the most prevalent HIV strains in the country. ART provision should also be provided for trial participants who seroconvert during the trial by the sponsors after which the trial participants are rolled unto the national governments' ART programme. Researchers and sponsors also have defined obligatory responsibilities to volunteers who screen out of the trial and to trial participants' spouse. The report also defines good research practice with respect to access to health care services as well as moral obligatory responsibilities of researchers and sponsors to trial participants.

CONCLUSION

The consensus on standard of care for HIV prevention research in Nigeria is a step forward with respect to mapping the path for future HIV prevention research in Nigeria is a step forward with respect to mapping the path for future HIV preventive research in the country. As emerging issues emerge, there will be a need to review and define these standards again.