One or more contextual factors were identified within the program intervention which may or may not interact to trigger mechanisms, which causes service providers and users to behave in ways that lead to various outcomes. Below, we present different C-M-O configurations which explore the presence or absence of security components during the program and community efforts to maintain facility security after the program. We present three revised CMO configurations (after testing our initial program theory) related to the presence of security in the healthcare facility:
CMO1: Provision of security fence, security guard, adequate lighting and staff accommodation within the health facility supports health workers and service users to feel safe and confident to provide and use 24- hour services.
In facilities where these security components were in place or had been instituted at the beginning of the program, health workers and service users perceived the facilities as guarded and secure, hence felt safe to provide and use services. This was reported by program managers, users and staff and exemplified with the following quote by a program manager:
“[Security] It was a big problem. That was why they could not run 24-hours services. So, we had to fence some of the health centers and put [i.e. recruit] security men, just to make sure that they are secured… So, if they [health workers] get there, number one, security is utmost to them. It is very important that at least you ensure that their own lives are safe so that they can save other women’s lives.” (IDI, program manager, male)
Availability of staff accommodation within the health facility resulted in more health workers living within the facility, thus making workers feel safe at night, being were aware that other co-workers (and their families) living in the facility. This increased the provision of 24- hour services, and utilization especially at nights, which explained how security personnel and healthcare staff were available during nocturnal obstetric emergencies:
“There was a woman around my house who my husband called when I was in labor, she ran out to get a taxi. We got here by 2am and the gateman went to get a nurse and they immediately attended to me, they took very good care of me !” (FGD-, female, farmer/petty trader)
During the program, health facilities had adequate numbers of staff that made it possible for there to be more than one health worker running a shift. The fact that they worked in pairs made the health workers feel safer, in addition to the feeling that they had help at hand from other staff living within the facility accommodation, if there was any threat.
“In a shift, we may have up to two or three [staff], so being that you have a colleague, it will still stimulate you, despite the fact that there is no gate or fence, but having someone you are working with, that will scare away the fear. So, it really helped us and increased the health care services that we gave to them.” (IDI, health worker)
In opposition to this, the absence of security in healthcare facilities was identified as having a different impact which was phrased as:
CMO2: Absence of security (fence, security guard and adequate lighting) and no staff accommodation within facility made health workers feel unsafe within the facility, especially at night, with a resultant reduction in 24 hours access and utilization of facility services by service users.
Before the program, some facilities were not fenced and did not have gates and security men to safeguard health workers and patients. This created a feeling of fear and insecurity among the health workers and service users, which resulted in challenges highlighted by the participants. In some facilities where night-time security was not assured, health workers resorted to locking the facility doors at night and would not respond when potential service users knocked as they were not certain they were free from threats. Pregnant women and their family members experienced being turned back at unguarded facility doors from within because the night duty staff were unable to ascertain the identity of the potential service users and did not feel safe to open the doors.
“….. many centers don’t have security men. We have about 40 health facilities here, both full-fledged primary health care and health posts, but we have only one security man. Because most deliveries are usually in the night, when these women come shouting, crying…….and there is no security man to help assure that the person that has come is actually a pregnant woman and not a robber, the nurse will not come out…” (IDI, Local Govt. Policymaker-male)
Within the context of these pre-existing conditions, when SURE-P/MCH resources were phased out some communities collaborated to preserve security in the health centres ensuring the sustainability of this outcome. This was phrased as:
CMO 3: In facilities where the community ensured sustained presence of security guard after SURE-P/MCH, health workers continued to feel safe and confident to provide 24 hours services, and hence sustained, improved service delivery and utilization.
Participants highlighted the collaborative efforts made by their communities to safeguard the PHCs and how these efforts produced positive effects including some communities employing and paying security guards to help secure the facilities and medicines that were brought therein. Fences, gates and security personnel encouraged the health workers to feel safe in their places of work and had confidence in their host communities, which also encouraged community members to utilize PHC facilities.
“There was a time when people’s children were stolen [abducted]. The community decided to stop this through employing a security man who will safeguard the facility. The security guard was paid by the Ward Development Committee (WDC)” (FGD, male WDC member)
Conversely, in communities that were unable to sustain the program inputs or take initiatives to provide security, service provision and utilization became constrained once the program ended. An example is illustrated with the quote below:
“A friend of mine who was pregnant came to the health center with her husband in the middle of the night without knowing that the program had ended. We stood long at the gate and knocked for almost an hour but there was no response. I went to the second gate and it was empty,...I got tired and picked a stone and threw it on the roof. Someone eventually came out…” (FGD-, female, petty trader)
Even when women had available emergency transportation, after arrival at the premises, delayed or denied facility access were reported by users and confirmed by staff who feared for their own safety. Once a decision to seek medical care has been made, other obstacles had to be overcome when the medical facility was reached. These included: delay in receiving prompt care after reaching the hospital, and if access was denied due to the fear of crime, women had to seek care at another medical facility.
CMO 4: Presence of a male security guard in the facility made the female health workers feel safer and more secure and confident to deliver 24 hours services leading to improved service delivery, access and utilization.
In Nigeria, the responsibility of performing security roles such as opening gates for and screening visitors at night usually relies on male security guards. Where there were no security guards employed, and the health workers had to carry out this function at nights, it made them feel vulnerable and sometimes they completely refused to take on these roles. Staff believed that having a male security guard in their midst was a source of strength for them.
“A woman is not supposed to open this gate for a visitor in the night, a woman, a nurse. It is the watch night [security guard] that will open it, come to the quarters [accommodation] and call the nurse whether there is a fence or not. It is the watch night that will call us before we come out. At least we have hope that we have a man in our midst. Nurses are women but all the time we will be the watch night, we will be the nurse, we will be everything and one person on duty. … Security matters a lot …” (IDI, facility manager/health worker, female).
Staff also pointed out that service users also felt safer once they arrive at the facility. Although the gender of the security guard and staff was identified by respondents as important, there is a more nuanced understanding of the security guards in this context, not only in terms of gender but also on their knowledge of the community and ability to identify strangers who may be perceived as a threat, conflict management skills experience, crime deterrence equipment and symbolic authority (i.e. uniform).
In summary, these CMO configurations show that a well-resourced MCH program (what) will be beneficial (work) to MCH service providers and users (Whom), in circumstances where there are adequate resources and the health facility is secure enough (especially at night) to make them feel safe to offer and use services (how). This could be because, anecdotally, a large proportion of deliveries occur at night (why). We further refined our program theory as follows, “In the context where programs, or communities ensure sustained employment of security guards, erect perimeter fences and there is availability of accommodation and adequate lighting in the health facility premises, female health workers and service users (pregnant women) are likely to feel safer (especially at night) and therefore willing to provide and/or use MCH services respectively, thus ensuring the provision of round the clock MCH services, and improved access and utilization of MCH services .” We further acknowledge that this theory can and will be refined by future studies.