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.
Highlights
Yobe State has faced severe disruption of its health service as a result of the Boko Haram insurgency
Fifteen variables were confirmed by Group model building (GMB) participants as key in accounting for health systems functioning during the crisis
Conclusions quantitative data was not available to pursue simulation and sensitivity analyses, systems dynamics analysis using participatory group model building provided a mechanism to identify key pathways of threat and response regarding health service functioning. These pathways are to some degree unique to the specific circumstances of Yobe state within the context of the ongoing insurgency, certain broader systems principles supportive of resilience are suggested
Summary
Yobe State has faced severe disruption of its health service as a result of the Boko Haram insurgency. Health systems resilience in contexts of adversity Resilience has emerged as the dominant concept underpinning development assistance and humanitarian support in nations vulnerable—through conflict or natural disaster — to crisis [1,2,3]. Fostering a complex adaptive systems approach, it is recognized that ‘the ability of the system or process to deal with the shock or stress is based on the levels of exposure, the levels of sensitivity and adaptive capacities’ [4]. More recently resilience has come to the fore as a construct relevant to understanding the basis for health services continuing in contexts of major adversity, most notably in the context of health systems in West Africa and management of the Ebola virus outbreak [7, 8]
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