Table 2.

Illustrative quotations from Liberia and Merseyside related to each FCDO Principle

Principle	Comparison	Quotations
Principle 1: Develop flexible pathways for medical supplies	Supply chains disturbed across settings due to global shortages and price inflation. Lack of buffer stock in both settings. Restructuring of supply chains in Liberia led to disturbance for routine supplies.	‘Supply chain are affected greatly because their concentration is on how to provide the COVID response activities meaning the …medicines and medical supplies that are needed [for] NTDs (Neglected Tropical Diseases), lack of attention will now be paid to that.’ (LIB national decision maker 029) ‘With regards to PPE, there was national guidance about what we should do and there was a huge amount of fear amongst nurses and medics and everyone else understandably. Everyone was scared. I was scared. If someone said they weren’t scared, then they’re lying or they’re a fool. The national guidance was confused, and availability of PPE fluctuated. Procurement here [NHS hospital] did a very good job, but sometimes it just wasn’t delivered nationally. And we went through other supply chains…’ (LIV hospital decision maker, Merseyside UK 014)
Principle 2: Prioritise a list of essential health services (and continued provision of quality and equitable routine services)	Discontinuation of elective non-urgent care in UK, contrasts with early emphasis on continued routine care in Liberia.	‘So we just have to be robust and do the necessary investment into routine health services, preventive in terms of creating awareness and education among health workers about COVID and how we can continue to care for our patients, with fighting the infection at the same time.’ (LIB national decision maker 001) ‘There’s the whole big risk around the screening program…the screening program was stopped, restarting that it’s gonna be really challenging. And I suppose that’s another risk in terms of people with delayed diagnosis and the right treatment, as a result of not having had that screening mammograms.’ (LIV hospital decision maker Merseyside UK 051)
Principle 3: Build trust with local communities	Both settings experiences reduced service utilisation due to loss in community trust. Introduction of innovative follow-up visits to patients led to increased service use in Liberia.	‘Some of the useful things that we have been using from Ebola time is, as I said before, to involve the communities …The community aspect is very important because it will help us for the COVID where communities, family members, all of those at the community level are influential group they will be able to comply like we did in the Ebola.’ (LIB national decision maker 005) ‘The elderly population have been shielding because of comorbidities and all that. I think they probably not being as vocal about things that they're concerned about because they're worried about that they will be asked to come in. They fear that that they will catch COVID when they come here.’ (LIV hospital health worker Merseyside UK 048)
Principle 4: Foster good communication at all system levels	Expansion of virtual communication in both settings. In Merseyside frequently changing guidance from multiple sources created confusion.	‘One of the things that quickly used to come to me is to able to adapt to working with social media technology and all of that, because that’s the first thing if you have to communicate with people in this manner you need to understand zooming, skyping, how to take notes…’ (LIB national decision maker 029) ‘And there’s so many different sources of information that say different things from what people hear within the hospital talking to friends on the corridor, that you've got to come out with a consistent message. And I think it took longer than was ideal to get a central source of information…But people need to be told what the situation is rather than try to be falsely reassured sometimes as well.’ (LIV hospital decision maker, Merseyside UK 004)
Principle 5: Support, recognise and encourage staff	Health worker redeployment was common across settings. Health worker training varied in UK according to cadre.	‘Like take for example, when COVID came some of our workers from the (name) Hospital was recruited to go at the front line and (hospital name) is for routine services so taking employees from there to go at the front line that tells you it kind of understaff… So routine services kind of slow down and every attention was placed on COVID but going forward, with the system in place, routine services have gotten back on its feet.’ (LIB national decision maker 010) ‘And it felt like there was unequal share of knowledge and also an unequal kind of confidence in protective clothing. … And I think the people that spent the most time with the patient, the patient areas, for instance, the healthcare assistants and the cleaning staff didn't have all of the information [at the] beginning or any PPE training.’ (LIV hospital health worker Merseyside UK 017)
Principle 6: Facilitate rapid resource flow and greater flexibility in it’s use	Prior under-investment in health was common across settings. In Merseyside there was increased funding available and removal of bottlenecks, which enabled swifter action.	‘The first thing is, we need ownership by government, ownership is not depending on other countries to provide us the resources, to provide the technical capacity. So that is the best recommendation I would say. The ownership has to be there, resources have to be available and the infrastructure has to be available in terms of being resilient.’ (LIB national decision maker 029) ‘To be honest, it was a fairly novel experience because it was a situation where if we asked we more or less got [funding).’ (LIV hospital decision maker, Merseyside UK 004)
Principle 7: Ensure agile tracking of health information	Data quality reduced in Liberia. In Merseyside increased data was collected, but inadequate data analysis measures were put in place.	‘Another recommendation is that we could include COVID to our regular disease surveillance. Like we have the measles, the Lassa, and thing. I think we should include COVID because COVID maybe all around. Like we included Ebola, there should be a document on COVID that will form part of our regular surveillance.’ (LIB county decision maker 024) ‘‘…there’s some value in looking at the things that we were looking at before COVID, because at least we have some longitudinal data on that so that we can see what the effect of COVID is.’ (LIV hospital health worker, Merseyside UK 020)
Principle 8: Cultivate effective partnerships and networks	Liberia was able to call on prior decision-making structures (established during Ebola response) to enable swift decisions. Need for stronger engagement between primary and secondary care in Merseyside.	‘Involvement of multi-sectorial stakeholders in the response; that was one major thing that we learned from Ebola. And that has been brought to be on this response, so there has been a spark from the level of the presidency where they have key ministries and agency heads heading pillars on the COVID response, involving the community people.’ (LIB national decision maker 028) ‘I think one thing, it’s really highlighted is the divide between hospital and primary care. We didn't work together very well before the epidemic, and we are still not working together very well. And I think if things were to get better, the whole health system needs to work better.’ (LIV community-level health worker, Merseyside UK 033)
Principle 9: Structures and mechanisms for advanced preparedness	Learning from Ebola prompted rapid preparedness in Liberia, in contrast to Merseyside.	‘If you don’t prepare well and you are caught unaware you will have a lot of issues, so we didn’t wait for COVID to enter Liberia before we prepositioned basic PPE and those are all part of the preparedness phase.’ (LIB county decision maker 026) ‘‘It was blatantly obvious that anything we've ever planned for in relation to a pandemic or anything along those lines was not the plans that we needed… So I think going forward there needs to be almost a better planning system in place…it’s not just a matter of just saying any pandemic it’s about what kind of pandemic.’ (LIV hospital decision maker, Merseyside UK 069)
Principle 10: Adapt governance and leadership structures to facilitate timely decision making and effective coordination of response	Need for rapid guidance from national level to enable subnational decision making was common in both settings.	‘So, at this point in time we think if you give the resources, put the money in the hands of the county health team to buy what they need, that will be more effective … So, we want decision should be given back to the people on the frontline so that they make the decision rather than a centralized point in Monrovia where people sit and decide for people in the lower level and the people choices made the right kind of thing they might need at that level.’ (LIB national decision maker 028) ‘… we were having to work, to a large extent, in the dark. The amount of guidance that came through nationally and even regionally, was actually relatively limited at that stage and we were having to do what felt like quite a lot of planning in isolation.’ (LIV decision maker Merseyside UK 008)

FCDO, Foreign, Commonwealth and Development Office.