Dr Emeka Kanebi (Lead writer)
‘Not all deviance is negative; without it, we would never change the world’ — Stacy Pershall
Primary health care (PHC) is a non-negotiable cog in the healthcare delivery system but somewhat remains the holy grail in most healthcare systems, especially in low- and middle-income countries like Nigeria.
With 2030 in view and the world desperate to make more significant progress to the attainment of the United Nations Sustainable Development Goals (SDGs), a barrage of varying investments are being launched to scale proven PHC interventions innovatively and sustainably, with the hope of the seeming elusive ‘Health for All’.
The Nigeria Health Sector Renewal Investment Initiative (NHSRII) continues to serve as a blueprint towards the achievement of universal health coverage (UHC) in the country. Strategies are being deployed using the Sector-Wide Approach (SWAp) to achieve critical milestones.
In operationalising this, there is a recurring tilt, where health development partners seem to begin by focusing more on amplifying what is not working across PHC interventions in communities. Significant funding is then piped into understanding why specific population groups do not access healthcare services or adhere to positive health behaviors, the foundation on which solutions are crafted and deployed.
Although, this seems like a logical approach to problem solving, should it be the dominant lens through which we navigate PHC challenges in Nigeria?
As the Alma Ata Declaration (1978) continues to echo into the 21st Century, governments, development partners, communities are being nudged to think “outside” the box, looking away from the usual solutions that have led to a plateau, and sometimes, a regression of Nigeria’s achievements in health to seeking the “silver bullet” from other environments which are likely dissimilar but demonstrate seemingly more sustainable results that our health system so desperately craves.
For example, incentive programmes, including cash transfers (conditional or unconditional) and non-financial incentives, have shown evidence of increasing vaccination uptake among zero and under-immunised children. However, these interventions have also led to unintended consequences with coverage declining when the incentives are removed.
Also, at the vanguard of solutions launched during the COVID-19 pandemic, telemedicine was deployed through various digital health platforms and seemed a viable and scalable option in Nigeria to reduce the strain on the healthcare system and curb health misinformation.
Patients were able to seek information, consultations, and treatment from healthcare providers remotely, without immediately visiting a physical clinic. However, as the pandemic subsided, utilisation of these services declined, with patients reverting to their previous, more traditional methods of seeking healthcare. It also became apparent that factors such as the significant digital divide had the potential to further widen the health access gap, with varied patterns of digital health utilisation observed across the country.
Can we explore more sustainable options in curating and deploying solutions? one that redirects us to start looking more within, not for problems as we so quickly do but for our own solutions, borne out of the power of our resilience, from our very own experts? Yes, we can! through the ‘Positive Deviance’ lens.
This lens peers through communities and reveals the existence of clusters of individuals and groups, the Positive Deviants, whose uncommon, yet successful strategies lead them to birth better solutions to their problems than their peers, despite all odds.
The positive deviance lens
Authors, Richard Pascale, Jerry Sternin, and Monique Sternin, in their book, The Power of Positive Deviance: How Unlikely Innovators Solve the World’s Toughest Problems, developed the ‘Positive Deviance’ approach which involves identifying and amplifying solutions already existing in communities, especially among those who are marginalised or poor, by encouraging them to adopt exceptional practices that have led to success in their own locally generated solutions.
Nigeria and other low and middle income countries must begin to resist the predilection to drown the air waves and potential investors in health with grim narratives of low Bacillus Calmette-Guerin (BCG) vaccination coverage of 14.1% among children or the poor percentage of pregnant women receiving antenatal care from a skilled healthcare provider of 26.4% in Sokoto State as documented in the Nigeria Demographic and Health Survey 2023–24: Key Indicators Report, to broadcasting that we might indeed have a glass that is half full.
All key stakeholders can pivot to this proposed Positive Deviance approach, increasing deep dives into these communities with low coverage rates, realising that these 14.1% represent 177 caregivers of children and 26.4% represent 408 pregnant women are a critical number , the ‘Positive Deviants’, that we should be learning from and amplifying their stories.
These outliers, regardless of sharing similar limitations, experiences, cultures, and hesitancies with their non-complying peers, continue to defy the odds, finding unusual ways to navigate their challenges, locally and ingeniously curating differentiated health solutions and deploying strategies to achieve desired results for better health outcomes.
As foreign assistance dwindles and low- and middle-income countries strive to break cycles of dependency, we can commit and build capacities across all levels on the foundation that communities and its people can lead their own development towards self-reliance.
Together we can focus on understanding and amplifying what is working, using these local insights towards sustainably deploying primary health care interventions with the hope of achieving universal health coverage.
“The important thing about a problem is not its solution, but the strength we gain in finding the solution.” — Seneca the Younger.