Health service resilience in Yobe state, Nigeria in the context of the Boko Haram insurgency: a systems dynamics analysis using group model building

Abstract

BackgroundYobe State has faced severe disruption of its health service as a result of the Boko Haram insurgency. A systems dynamics analysis was conducted to identify key pathways of threat to provision and emerging pathways of response and adaptation.MethodsStructured interviews were conducted with 39 stakeholders from three local government areas selected to represent the diversity of conflict experience across the state: Damaturu, Fune and Nguru, and with four officers of the PRRINN-MNCH program providing technical assistance for primary care development in the state. A group model building session was convened with 11 senior stakeholders, which used participatory scripts to review thematic analysis of interviews and develop a preliminary systems model linking identified variables.ResultsPopulation migration and transport restrictions have substantially impacted access to health provision. The human resource for health capability of the state has been severely diminished through the outward migration of (especially non-indigenous) health workers and the suspension of programmes providing external technical assistance. The political will of the Yobe State government to strengthen health provision — through lifting a moratorium on recruitment and providing incentives for retention and support of staff — has supported a recovery of health systems functioning. Policies of free-drug provision and decentralized drug supply appear to have been protective of the operation of the health system. Community resources and cohesion have been significant assets in combatting the impacts of the insurgency on service utilization and quality. Staff commitment and motivation — particularly amongst staff indigenous to the state — has protected health care quality and enabled flexibility of human resource deployment.ConclusionsA systems analysis using participatory group model building provided a mechanism to identify key pathways of threat and adaptation with regard to health service functioning. Generalizable systems characteristics supportive of resilience are suggested, and linked to wider discussion of the role of factors such as diversity, self-regulation and integration.

The spillover effect of midwife attrition from the Nigerian midwives service scheme

“…[24–27] Midwives’ attrition reduced MSS clinics’ capacity to provide after-hours delivery care, and explains the level trend in use of delivery services in rural public sector clinics. [6] Midwives’ attrition also increased the availability of midwives in urban areas, which may have increased the capacity of urban (public sector) clinics to provide after-hours delivery care. This may explain why we observed a level trend in use of antenatal service, a 5-percentage point increase in use of delivery services in urban public sector clinics, and a 4 percentage point reduction in deliveries occurring away from clinics (see Table 5).…”

“…[1–4] This mobilization and deployment may have increased the pre-existing national and rural midwives’ workforce by about 3% and 9% respectively (see Table 1), and each clinic was supposed to receive four midwives who would work in shifts to provide 24-h coverage. [2, 6] Despite its large scope, the scheme had a limited impact on use of obstetric services. [1–3] For instance, Okeke et al (2016) showed that in its first year, the scheme increased use of antenatal services at rural public-sector clinics by 5-percentage points, but had no effect on the use of delivery services at these clinics.…”

Conflicts and insurgency: Barriers to global quality health service for internally displaced persons in the North Eastern Part of Nigeria

“…Some health infrastructure and facilities have been attacked, with insurgents carting away valuable drugs, hospital equipment, ambulances and vehicles. This has undermine quality health services as some of these facilities meant to be used for in-house facilities for keeping materials and addressing emergency cases becomes unavailable (Ager et al, 2015). In Borno for example in was observed in a survey that about 593 health facilities, including 2 tertiary hospitals, 16 secondary hospitals, 113 primary health care centres, 239 primary health care clinics, 219 health posts and 4 IDP camp clinics exists in Borno.…”

“…Movement for health workers and patients to access health infrastructures and facilities has been a principal problem due to delays and limitations imposed by the security services (the Joint Task Force, JTF). (Ager et al, 2015)…”

“…That said, the lack of coordination and poor environmental conditions has also resulted in poor health standards and their implication for the quality of health services for IDPs. Despite the increasing numbers of studies and institutional reports on IDPs and the various specific health challenges such as sexually transmitted disease, sexually and gender-based violence, post-traumatic stress disorder and depression among others (Ager et al, 2015, Owoaje et al, 2016, there is a dearth of studies on the effect of global quality health service on internally displaced persons in the North Eastern part of Nigeria. Apart from the fact that many of the previous studies focus on mental health, they also failed to provide a general picture of the health problems of the IDPs and their lack of access to global quality health service due largely to the consequence of insurgency.…”