By Olive Aniunoh & Ndu Nwokolo
Healthcare delivery and the system remain one sector in development that is often significantly impacted during violent conflicts such as wars and armed conflicts. In many instances, during violent conflicts or prolonged wars, health facilities are often targeted, either burnt down or looted. Also, healthcare personnel and even patients are threatened, physically assaulted or even prevented from either giving or receiving care. North East Nigeria, with more than fourteen years of active violent conflict arising from Boko Haram terrorist activities, is not exempted from such threats. Healthcare provisioning in the region has been impacted directly or indirectly by the violent situation, thereby redefining and distorting the healthcare system and delivery. For instance, in 2022, Nigeria recorded 43 incidents in which 37 health workers were kidnapped,11 health supplies were looted, and seven health workers were killed. A further breakdown of this data shows that 17 of these incidents happened in the Northeast states of Borno and Yobe.
Aniunoh Nwokolo
However, the consequences of the conflict in the region extendbeyond the immediate destruction of health infrastructure such as public and private hospitals, community health centres, ambulances, supply trucks, kidnapping or killing of health workers to the broader fabric of healthcare delivery, accessibility, and quality. This was in addition to an existing problem of neglect and underfunding (Howell et al., 2020). Often, the knowledge, scope scale and impact of attacks on humanitarian health actors are quantified and assessed from physical attacks such as destruction of buildings, supplies, killings and kidnappings and less on issues such as quality of healthcare, prevention of access to vulnerable people, mental health and well-being of care and health givers. This omission and oversight have, in many shapes and forms, continued to impact support recovery processes, which healthcare provides for the entire post-conflict reconstruction. As shown in the 2022 International Rescue Committee survey on the protection of health care in North East Nigeria, the psychological well-being of health workers and assessing healthcare needs rank among the primary threats. Thus, this week’s edition of the Nextier SPD Weekly Policy examines how conflict shapes health outcomes, resource allocation, and system resilience in Nigeria’s North East. It looks at the long—and short-term impacts of violent conflicts on Nigeria’s healthcare system and suggestsmeasures to combat this escalating threat.
- The Short-term Impact of Violent Conflicts on the Health System
In the immediate aftermath of violent conflicts, health systems are often overwhelmed by several acute challenges. These include a surge in trauma cases, reduced access to healthcare services, the collapse of health infrastructure, and a rise in communicable diseases. Violent conflicts often lead to the destruction or closure of health facilities, forcing healthcare providers to flee or reducing their ability to perform their duties. In the North East, attacks on hospitals by insurgents such as Boko Haram have made it difficult for residents to access healthcare. Clinics and hospitals in areas like Borno, Adamawa, and Yobe states have been damaged or abandoned due to fear of further violence.Conflict zones also typically see a sharp rise in patients with trauma injuries such as gunshot wounds, fractures, and burns. A typical example is the case of Médecins Sans Frontières (MSF),suspending all its work, such as anti-malaria treatment and obstetrical care in Gwoza and Pulka towns in Borno in August 2021 due to the worsening security situation. At that period, other non-governmental organisations (NGOs) ceased operations in the area, leaving thousands without access to needed health care.
The North East has seen an influx of internally displaced persons (IDPs) into makeshift camps, further straining already limited medical resources. This increases the burden on healthcare systems that are often ill-equipped to handle such crises, leaving many without timely care. Conflicts frequently displace large populations, forcing them into overcrowded living conditions with inadequate sanitation. As Bertone et al. (2018) argued, armed conflicts affect healthcare provisioning by worsening pre-existing weaknesses in the system. The North East has seen outbreaks of cholera, measles, and malaria in IDP camps, exacerbating the humanitarian crisis. The destruction of water and sanitation infrastructure and limited access to clean drinking water contribute to these outbreaks. In addition, the health system’s capacity to respond is severely constrained by the ongoing conflict. Routine immunisation campaigns are disrupted, particularly for polio, measles, and tuberculosis. The suspension of these programmes leaves children vulnerable to preventable diseases. The North East, previously a hotspot for polio, has struggled to maintain immunisation rates in conflict zones, increasing the risk of disease resurgence.
- Violent Conflicts and the Health System: The Long-term Impact
The impacts of violent conflict on the health system extend beyond infrastructure damage and the immediate loss of life. The cumulative effect of years of instability erodes the health sector’s capacity to provide consistent, quality care and weakens the broader health ecosystem. Violent conflicts have led to the migration of health professionals out of conflict-ridden areas. Many doctors, nurses, and other healthcare workers have relocated to safer regions within Nigeria or emigrated entirely. This has left the North East with a severe shortage of skilled personnel, which hinders the delivery of critical services even after the conflict subsides. Prolonged exposure to violence and trauma has created a mental health crisis that the Nigerian health system is ill-prepared to handle. Many people in the Northeastsuffer from post-traumatic stress disorder (PTSD), depression, and anxiety, yet mental health services are scarce. The stigma surrounding mental health, coupled with the lack of specialised professionals, exacerbates this issue.
The destruction of health facilities and equipment and the loss of personnel require significant rebuilding investment. However, the economic damage caused by the conflict has reduced the resources available for such investments. The North East, one of Nigeria’s poorest regions, struggles to secure adequate funding for health system recovery, perpetuating a cycle of underdevelopment and poor health outcomes. Long-term conflict has disrupted the management of chronic diseases such as diabetes, hypertension, and HIV/AIDS. This disruption may have significantly exacerbated the spread of HIV/AIDS due to the disruption of healthcare services, displacement of populations, and increased vulnerability to sexual violence. As observed byAbdullahi et al. (2020), in the IDP camps in North East Nigeria, “a burden of TB in IDP populations of Northeast Nigeria is many times higher than national rates and HIV rates higher than state-level estimates”. Conflict-driven displacement forces people into overcrowded camps where access to antiretroviral treatments (ARTs) and healthcare services is severely limited. This not only leads to higher HIV transmission rates but also disrupts the treatment of those already living with the virus, increasing the risk of drug resistance. Additionally, the breakdown of social structures and heightened incidences of sexual violence, including rape, further contribute to the rise of HIV infections in conflict zones. The cumulative effects of untreated chronic diseases not only reduce life expectancy but also place an additional burden on the health system.
The ongoing conflict has also eroded health governance in the North East. The decentralisation of healthcare management has been complicated by insurgent control of certain areas, leading to fragmented service delivery and a lack of coordination between federal and state health authorities. Weak governance makes implementing national health policies, managing resources efficiently, or responding to health emergencies harder.
- Conflict-Driven Humanitarian and Health Crises
Nigeria has become a humanitarian crisis hotspot. Conflict-induced displacement has contributed to food insecurity and malnutrition, which further strains the health system. Malnutrition, especially among children, has long-term implications for the region’s health indicators, contributing to high rates of stunted growth and under-five mortality. Moreover, women and girls are disproportionately affected, with higher rates of sexual violence, leading to reproductive health issues and increased maternal mortality.
- Strategies for Strengthening Health Systems in Conflict Zones
Addressing the long-term impacts of violent conflicts on the health system requires a multifaceted approach. Key strategies include investing in the reconstruction of health facilities and providing modern equipment, which is essential to reviving the health system in the North East.
- Strengthening Health Workforce: Implementing incentives to attract and retain health workers in conflict-affected areas is crucial. These could include hazard pay, mental health support for health workers, and educational opportunities.
- Integrated Health and Humanitarian Services:Humanitarian aid must be integrated with health services to effectively address the health needs of displaced populations. This includes enhancing coordination between government agencies, international organisations, and local NGOs to ensure adequate service delivery.
- Mental Health and Psychosocial Support (MHPSS):Expanding mental health services and reducing the stigma surrounding mental illness is vital for the long-term well-being of conflict-affected populations.
- Strengthening Governance: Effective health governance and policy implementation, including efficient resource useand transparency, are necessary to restore trust in the health system.
- Improving Research and Documentation: A better understanding of attacks on the healthcare system and delivery in Northeast Nigeria can help prevent further attacks and mitigate their effects. Documenting and researching the patterns of attacks can also help avoid attacks by identifying vulnerabilities, shaming perpetrators, and developing security strategies to nip such attacks.
- Policy Recommendations
- There is a need to implement incentives to attract and retain health workers in conflict-affected areas.
- Humanitarian aid must be integrated with health services to effectively address the health needs of displaced populations.
- It is crucial to expand mental health services and reduce the stigma surrounding mental illness for the long-term well-being of conflict-affected populations.
- Effective health governance and policy implementation, including efficient resource use and transparency, are necessary to restore trust in the health system.
- There is a need to improve research and documentation on the healthcare system and delivery in North East Nigeria.
- Conclusion
The short-term and long-term impacts of violent conflicts on the health system in Nigeria’s North East are severe, with lasting effects on healthcare delivery, health outcomes, and the region’s overall development. Building resilience within the health system and addressing the underlying causes of conflict will be essential to mitigate these impacts and create a pathway to sustainable recovery. While the Nigerian government, in collaboration with international partners, has made efforts to address these challenges, more comprehensive solutions are needed to restore the region’s health system and ensure that it can meet the needs of its population.
(Olive Aniunoh is a Legal and Policy Research Analyst at Nextier and a graduate of Law from the University of Birmingham, England; while Dr. Ndu Nwokolo is a Managing Partner at Nextier, Honorary Fellow at the School of Government at the University of Birmingham, UK)
