1. Immunization – Penta 3 Coverage (U1)

2. Nutrition – Vitamin A Supplementation (U5) 3. HIV/AIDS – Prevention of Mother to Child Transmission (PMTCT) of HIV 4. Family Planning – Contraceptive Prevalence Rate (CPR): Modern Contraceptives 5. Maternal Health – Skilled Birth Attendance (SBA) 6. Malaria – Utilization of Insecticidal Treated Nets (ITN) This definition of success formed the boundaries in which ADG, the TA firm, was expected to then undertake a process of locally‐driven problem‐solving within the states. ADG was required to work with states to identify, analyze and ‘fix’ the wide range of problems that cumulatively contribute to low coverage in the above areas, and therefore low health outcomes among the Nigerian population. Since low coverage in the six different indicators is unsurprisingly caused by a wide range of factors, often very specific to the peculiar context and personalities present in the state, ADG was inevitably engaging with a wide range of very diverse problems and causes.<sup>9</sup> In documenting the approach undertaken, we find that the TA provided by ADG exhibited aspects of all three of the “key ingredients” stipulated in the firm’s Terms of Reference: “[1] working in problem‐driven and politically informed ways; [2] being adaptive and entrepreneurial; and [3] supporting change that reflects local realities and is locally led”.

The problem construction and deconstruction process facilitated by ADG appears to have been locally‐anchored and sincerely appreciated by state officials. This is despite the fact that, in our view, the scope of problems ADG was tasked with fixing were large and diverse to the point of being unmanageable. Officers from the three State SOML Program Management Units (PMUs) that ADG were assisting narrate how the firm constantly pressed them to justify their proposed interventions on the basis of how it would affect the six outcomes, thus inculcating a far greater attention to data than usual. While it is apparent that the process ADG facilitated for identifying the causes of low coverage in the indicators was more thorough and nuanced than the traditional solution‐focused approach, the identified causes and problems themselves were not actively captured on paper or routinely revisited in the states. Nevertheless, with the help of their data capture platform, PIGEON, officers from the PMU and within local government were being alerted on a week‐to‐week basis of low reporting levels or unexpected results, and immediately following up on them directly with local government counterparts and with health facilities (often with advice from ADG as well<sup>10</sup> ). In this way, problem‐solving was made an active feature of ongoing implementation efforts.

9 A small snapshot of the sort of problems that have been identified as requiring “fixing” is reflected in the following list: People use the bed nets we distribute for fishing so that they can catch fish to eat and sell; Health workers have not been paid for the past six months so they do not come to the facilities for work; The roof of the health facility has fallen in so no‐one wants to go there; Basic equipment and drugs are unavailable in the health facilities, so people do not see the value in going there; Women do not use contraceptives or use them and do not report it; Religious leaders are opposed to the use of contraceptives by their members; Some health facilities are inaccessible in the rainy months; Health workers charge people for services that should be free, thus dissuading them from using them; Some people in the community do not trust immunizations, believing there is a plot by another identity group to infect the local people with a virus; Traditional birth attendants are more accessible, particularly for rural communities than skilled birth attendants in the health facilities and they offer more services (they will cook you pepper soup); There is no transport available for taking pregnant women to secondary health facilities; Health workers do not come to work because of security issues and doctors having been kidnapped in the past; It is culturally problematic for health workers to come into a person’s home, particularly if they are of a different gender, thus limiting the ability to monitor or advise on mosquito bednet utilization; People get upset if we test them for HIV but then we do not have drugs available for treatment so some health workers avoid testing.

10 Like the DHIS data, which are collected at the facility rather than household level, the PIGEON data are known to have a poor correlation with state level household survey data; as such, their use by ADG (as providing an 6