Several towns in the north-eastern region of Nigeria have been overrun by Boko Haram militants, who are engaged in violent clashes with authorities. Millions have been displaced and in May 2013, Nigeria declared a state of emergency in Borno, Yobe and Adamawa. Health services in the region have been severely affected. Felix Obi and Ejemai Eboreime shed light on the situation.

Which areas are being affected by Boko Haram and how many people are at the centre of it?

The Boko Haram insurgency, which began in 2009, has mostly affected people living in Nigeria’s north-eastern states. One of them Borno state has been at the epicentre of the insurgency.

To date more than 20,000 people have been killed and over 2 million people have fled their homes. There are over 7 million people in need of humanitarian assistance in Borno, Yobe and Adamawa states – and more than half are children.

What effect is this having on health services?

Even before the insurgency, North-East Nigeria had some of the worst health and socioeconomic indices in the country. This is against the backdrop of a weak health system marked by inadequate health facilities and a dearth of skilled health workers. There’s also little donor support compared with other regions of Nigeria.

The insurgency has compounded these problems and also disrupted what health services there were.

Insurgents have destroyed about 788 health facilities in the region. In Borno 48 health workers have been killed and over 250 injured. The state has lost up to 40% of its facilities and only a third of those left in Borno state remain functional.

Attrition rates of health workers have also played a role. Over the past two years Borno state has lost 35% of its doctors to other states.

Insecurity in the areas occupied by the insurgents also make planning and delivering essential health interventions difficult. Resources in camps for internally displaced people have been overstretched, with humanitarian agencies providing most of the health services.

What impact has this had on people?

There are several health consequences. Over 2 million people have been displaced due to the conflict and live in camps for internally displaced people scattered across the North-East Nigeria. Some have gone as far as Abuja and beyond to southern states like Edo.

Overcrowding and poor hygiene in the camps have made them potential spots for recurrent outbreaks of diseases like cholera. There are also many cases of acute malnutrition. Deaths from malnutrition occur frequently.

And two years after Nigeria celebrated its last case of polio in 2014, new cases of the diseasehad resurfaced in the region. This is due to the fact that insurgents occupying villages and towns prevented the polio vaccine being brought into the area.

There has been an outbreak of the Cerebrospinal Meningitis epidemic in north west Nigeria in the states of Zamfara, Sokoto, Kebbi, Katsina and Niger. There are fears that the epidemic could spread to the North-East Nigeria because the health system is so fragile.

What are the long-term consequences?

One direct health consequence will be an increase in infant and maternal mortality cases. But there will also be a range of other socio-economic consequences that will affect people’s health. These include:

• the disruption in agricultural activities means that food insecurity has worsened which obviously has consequences on peoples’ health

• a plunge in access to education, particularly for girls. Research has shown that there’s a link between women’s education levels and infant and maternal mortality.

• worsening poverty and inequality in what is already one of Nigeria’s most impoverished regions

• financial implications. The massive destruction of homes and social amenities means that the government will be faced with rebuilding infrastructure, while individual households grapple with rebuilding communities.

What is the Nigerian government doing to rebuild the north-east’s health system?

The government has flagged several initiatives to rebuild the health systems of the affected states in the North-East Nigeria. This includes the Presidential Initiative for the North East, an economic redevelopment plan for affected states.

Nigerian President Muhammadu Buhari has been eager to reconstruct the area and launched a plan that includes resuscitating health services. The plan estimates that the cost of damaged health facilities is about US$ 147 million. The reconstruction process will require huge investments over the short and long-term.

The government also plans to use US$ 20 million from the Global Financing Facility to support essential services in the north east. The Global Financing Facility partnership is a World Bank and United Nations initiative that finances interventions to improve the health of women, children, and adolescents in a country.

There are also efforts to expand the Nigeria State Health Investment Project – another World Bank supported initiative which encourages the delivery and use of maternal and child health interventions and improve the quality of care at health facilities – to the remaining north-east states.

It remains to be seen how these initiatives will significantly change the health landscape and reverse North-East Nigeria’s poor health indices.

Author:  Felix Abrahams Obi:  Research Fellow/Research Uptake Officer of the Health Policy Research Group, University of Nigeria and  Ejemai Eboreime:  PhD fellow in Implementation Science, University of the Witwatersrand

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