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Table 2 How community health committees limit informal health care providers in Nigeria

From: Information, regulation and coordination: realist analysis of the efforts of community health committees to limit informal health care providers in Nigeria

Outcome
(Outcome Strategies)
Mechanism
(Modes of Functioning)
Context
(Enablers and Constraints)
Information
Formal – Encouraging the use of formal services at the health facility through personal contact and campaigns
Informal – Discouraging the use of informal health care providers community through personal contact
Mode I: Village Square
Mode II: Community Connectors
Mode III: Government Botherers
Mode IV: Back-up Government
Mode V: General Overseers
* Triggered by need to reduce the transaction costs of accessing health care
■ Having the autonomy to modify membership to have committee members with rich personal network and wide reach in the community.
■ Significant health events like disease outbreaks and vaccine refusal and support to conduct information campaigns from governments, NGOs and traditional leaders.
■ High cost of participation in meetings and information campaigns in large communities and where members cannot afford the cost of transportation.
■ The extent of competition from informal providers in the local health care market – low levels of competition removes necessity for information campaigns.
Regulation
Formal – Monitoring formal health service delivery to ensure responsiveness, quality and credibility
Informal – Monitoring informal health care providers to keep their activities within safe limits
Mode I: Village Square
Mode II: Community Connectors
Mode III: Government Botherers
Mode IV: Back-up Government
Mode V: General Overseers
* Triggered by need to reduce the transaction costs of accessing health care
■ Having responsive government PHC managers who discipline health workers or transfer them elsewhere at the behest of committee members.
■ Traditional leaders who admonish health workers or facilitate the link of committees to government PHC managers to effect behaviour change among health workers.
■ More challenging to monitor and regulate informal providers out of the market when they are many and control a large share of the local health care market.
■ Mentoring by NGOs to facilitate monitoring of traditional birth attendants and inviting them provide services in the health facility to enhance monitoring.
Coordination
Formal—Mobilising resources to improve the quality and accessibility of formal services at the health facility
Informal—Facilitating referral from informal to formal health care providers in the community
Mode I: Village Square
Mode II: Community Connectors
Mode III: Government Botherers
Mode IV: Back-up Government
Mode V: General Overseers
* Triggered by need to reduce the transaction costs of accessing health care
■ Having high income people on the committee and in the community who rely on the health facility, else committees need traditional leaders to help raise funds from them.
■ Highly networked communities where committee members belong to other community groups helps fund-raising from religious, women’s, youth and cultural groups.
■ Mentoring on fund raising by and donations from NGOs and traditional leaders; and mentoring on fund raising from government PHC managers.
■ Having traditional leaders, women’s groups and NGOs that help committees to broker agreements between informal providers and the health facility.
  1. Context–mechanism–outcome (CMO) configurations explaining how community health committees limit informal health care providers in Nigeria
  2. Source: findings of this study