How community engagement prevents and protects health care from attacks in north-east Nigeria – World Health Organization (WHO)
As countries face increasingly complex health challenges, Community Engagement has become a powerful global public health tool to support behavioral change. In north-east Nigeria’s Borno state, the Ministry of Health, WHO and partners currently leverage CE to prevent attacks on health care and protect the delivery of essential health services.
Since 2009, the north-eastern states of Borno, Adamawa and Yobe (BAY) in north-east Nigeria have been facing one of the most severe humanitarian crises in the world. An estimated 5.6 million people1 are in need of health interventions in BAY states, where insecurity issues, movement restrictions and funding gaps have severely crippled the health system.
The ongoing conflict has also led to an escalation of attacks on health care and heavily restricted humanitarian access altogether. Health facilities are regularly attacked, vandalized, looted or burnt down and over 30 000 health workers across the region face constant risk of being assaulted, abducted or criminalized for providing care to opposing parties.
Since January 2020, 23 attacks on health care have been reported in north-east Nigeria via WHO Surveillance System for Attacks on Health Care (SSA)2. Impacting health facilities, transport, supplies as well as the safety of health workers and patients, these have not only reduced the ability of health systems to deliver services to those most in need, but have also created important barriers to health access.
A destroyed health facility in Borno, north-east Nigeria, 2016. © WHO / S. Zimble 2016
In complex emergency contexts, every attack has a dramatic impact on communities. “In Borno state more than 40% of health facilities are non-functioning or too damaged to provide health services to the population, so when a health facility is damaged or burnt down up to 50 000 people are at risk of losing access to all essential services.” said Dr Kazadi Mulombo, WHO representative to Nigeria. “Communities living in remote areas where no health facilities are functional may also lose access to mobile health teams, forced to interrupt services due to security concerns. These attacks not only compromise the health of thousands but also cause significant losses of government, humanitarian agencies and donors’ resources.”
Under such security-compromised conditions – and mindful of local counter-terrorism laws – introducing protective measures against attacks became essential to the delivery of health services. Since 2018, the Ministry of Health, WHO and partners have adopted community engagement (CE) approaches in Borno state to secure protection for their own teams as well as grassroots health workers.
Mobile teams set-up make a makeshift clinic under the shade of threes. © WHO / A. Clements-Hunt 2017
Communities are key actors in the prevention of attacks and protection of health care. Lessons learned in the Democratic Republic of the Congo showed that inviting communities to take ownership of the health services delivered in their area is paramount in preventing attacks on health care. By nurturing ties with different communities, health care providers not only improve safe access to services but also establish long-lasting trust in the health response.
The Ministry of Health, WHO and partners apply three good practices across their CE activities:
As a result, communities in Borno state are playing a critical role in protecting the health services that operate for their benefit. Community members have been seen acting as sentinels in front of health facilities, alerting health workers of pending attacks, and even creating human shields in front of health facilities. “Health facilities are for us, for treatment of our children” said a community elder “We will protect them from bad people who want to attack them, who want to damage them”. In addition, communities have also started providing disease-related data for surveillance databases and alerting health workers to potential outbreaks of infectious diseases, including malaria, cholera and hepatitis.
However, securing ‘community engagement’ is an ongoing investment, rather than a one-off event. Consensus exists on the need to maintain regular engagement with members of the community, including weapon-bearers, as opposed to reaching out to them solely during crisis. Health care providers need regular engagement to grasp how group dynamics differ in each context, and how to formulate their messages with impact. This calls for regular, consistent efforts being made to reach out to communities, in moments of stability as well as instability.
Engaging communities in Borno state could not have been achieved without significant efforts from health workers, local leaders and donors working to end attacks on health care. Moving forward, the WHO Country Office in Nigeria aims to strengthen its engagement with youth to further promote the dissemination of information and volunteerism in community services.
Continuing its work for the prevention of attacks and protection of health care, WHO encourages further investments in capacity building and sensitization of communities to the impact of attacks on health services that operate for their benefit.
2 Dashboard – Surveillance System for Attacks on Health Care. Accessed 9 December 2020.
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