Why Conflict Doesn’t Need to Mean Cut-Off

In the northeastern corner of Nigeria, bordering Cameroon to the east and Niger to the north lies Borno state. Home to over 4 million people, the area is infamous for the war that has been raging for over a decade. Since 2009, Borno state has been the epicenter of the Boko Haram insurgency. Since the rise of the conflict, Borno’s inhabitants have lived with the ever-present danger of violence, kidnapping and loss of life, as witnessed globally by the kidnapping of 276 Chibok schoolgirls in 2014. Over half of the state’s inhabitants have lost their homes and primary livelihoods and remain displaced people in a land that once offered stability and opportunity. Yet despite the difficulty of existence in a conflict zone, life with all its attendant expectations must somehow carry on. Food must be planted and harvested, livelihoods must be managed, people must marry and as children are born, they must still be vaccinated.

Within Borno, the State Primary Health Care Development Agency (Borno SPHCDA) remains responsible for delivering health services to its population.

However, large pockets of people live beyond the government safe zones in insurgent-held territories rendering them extremely vulnerable. Dishearteningly, the states’ health center infrastructure had been decimated over the years, making service delivery in some areas difficult and almost impossible in other areas. With the escalation of conflict, immunization coverage had fallen sharply to 12% by 2013, compelling the Borno SPHCDA to creatively address the question of how to reach vulnerable children, cognizant of the continued insecurity wrought by the conflict. Lessons from an ongoing strategy to expand access to polio vaccines known as Reaching Inaccesible Children (RIC) offered a valuable starting point.

SPHCDA was clear that while provision of health services was its mandate, delivery in a situation defined by constantly changing variables posed a conundrum that was beyond its scope. Incorporating new allies in the quest to achieve routine immunization goals was necessary if they were to turn around the fast-declining vaccination coverage. As a result, SPHCDA worked with three core implementation initiatives that each brought in specific expertise to tackle low vaccination coverage. In addition, SPHCDA received vaccine and related supplies from National Primary Health Care Development Agency (NPHCDA), commodities from UNICEF while WHO provided supervisory support.

Together, this unusual collective proceeded to break down the challenges facing vaccination delivery, the most critical being the lack of physical structure through which they could deliver their work. Many health facilities were bullet ridden shells, offering no protection for service delivery.

The teams strategized and developed two options for service – the first was a strategy for delivery in insurgent held areas. Known as the “hit and run” approach, the teams would venture into a community in rebel-held areas, assemble all children under five, quickly identify their immunization needs and provide the requisite vaccinations within the shortest time possible. The deftly executed services would be complete within a few hours. A second option was designed for more stable areas where a security detail from the cJTF would provide key information for safe zones for the health team to set up a temporary health post known as a “fixed post” within a two-kilometer radius from several villages or settlements. At these fixed posts, basic health services including immunization would be provided over a 4-6 hour period before the post was disassembled and the team deployed back to a safe zone. The GIS team’s information would be critical for this effort, ensuring that communal sites could serve as many people as possible. This two-pronged approach enabled the team to turn around the dwindling coverage numbers in several settlements from 2017.

Despite these supply solutions, the team still faced serious challenges including: fear amongst health workers to deploy into rebel-held territory; a compromised immunization information chain resulting from the reluctance of mothers to hold onto immunization cards for fear of them being found by Boko Haram; difficulty in maintaining the vaccination schedule due to timings on account of shifting concerns; and rumors and myths about vaccination cropping up in selected areas that dampened demand.

Yet, since the development of this approach, marked improvements have been seen in the locations. Since 2018, a continued rise in the number of children that have received the complete immunization regimen has been recorded. Meanwhile despite the potential risk of being seen as a government supporter by insurgents, more and more community members have taken up the government- provided health services that ride on the fixed post strategy.

Like many hotspots across the globe, Borno state has been in the unenviable position of having to craft solutions for increasing access to and use of care under the most difficult of circumstances. Yet the team at SPHCDA and their partners are bringing hope to those who need it most, through a partnership that leverages new technology and age-old systems of community resilience. Approaches like theirs remind us that there is still hope for the vulnerable when health becomes the responsibility of a wider community.