An investigation of the essential health services available to Internally Displaced Populations (IDPs) in Northern Nigeria

Background Since 2011, Nigeria has experienced major conflicts from the Boko Haram terrorist group in the north-east region. Over 20 million people have been affected and about two million were forced out of their homes to other countries as refugees or remained in the country as Internally Displaced Persons (IDPs). As of December 2015, the majority of IDPs had settled across 13 of the 37 states in the country, and about 19% (~418,000) lived in camps or camp-like settings. Prior to this conflict, the northern regions had very poor health indices including poor immunisation coverage of 14.2% compared to the national average of 51%. Among the IDPs, the most common health conditions and causes of deaths were related to infectious diseases and severe acute malnutrition. Limited evidence existed on the availability of health-related resources and the IDP health management processes. Also little was known on the perceptions of IDPs in respect to their health. This thesis aimed to review the accessibility and provision of essential health services available to IDPs living in camp-like settings in Northern Nigeria, from both user and provider perspectives. Observed practices were assessed in relation to the IDP health issues and internationally recommended standards. Methods A systematic review was conducted to appraise the essential health interventions implemented among conflict-induced IDP locations in low and middle-income countries from year 2000 to 2017. Primary data were collected in Nigeria, using a cross-sectional mixed-methods study approach, from nine camps across seven states between September and October 2016. Camp audits were performed through direct observations and interviews with camp managers (CMs) and the findings were assessed against 15 of the 40 Sphere minimum standards. A survey was conducted with 2,253 IDPs using an interviewer-administered questionnaire, which included questions on displacement history, living conditions, personal health history, and involvement in management. Focus group discussions (FGDs) exploring the internal IDP management structures were conducted with IDPs in eight camps. While semi-structured face-to-face interviews aimed to explore different perceptions around camp, health and external management processes were conducted with nine CMs, seven health service providers (HSPs) and eight administrative policy makers (APMs). Results From the systematic review, 28 publications met the inclusion criteria suggesting not many peer-reviewed papers had been published in this study area since the year 2000. Most studies were cross-sectional and all were from Sub-Saharan African and South Asian regions. The studies focused more on disease prevention interventions which included water treatment and disease treatment interventions, for example, malaria. Only one study reported on food distribution and two studies on vaccination. A key recommendation from the included studies was the need for more intervention evaluation assessments to be carried out. The primary data collection showed only three of the nine camps visited had external administrative support and two camps were planned sites. Assessment of the audit findings showed only five of the 15 standards reviewed, including availability of water and shelter, were “partially met” and the others were “unmet”. These “unmet” standards included those related to sanitation, vaccination, planning, and community involvement. The majority of IDP disease burden were attributed to common diseases including malaria (57%), fever (23%), typhoid (8%), diarrhoea (5%) and cough (3%). Factors significantly associated with increased likelihood of falling sick were age, overcrowding, long term-illness, type of toilets used, the distance from households to toilets, and the presence of disease-causing vectors. The self-reported proportion of IDPs ever vaccinated was 62.4%, but only 15.5% was received while in the study camps. The FGDs and interviews showed a general lack of knowledge on recommended IDP management guidelines. Also observed was the implementation of non-standard management approaches, poor prioritization of IDP needs, weak government involvement especially in informal camp locations, and high reliance on non-governmental and international organisations. Conclusions Several gaps existed between the IDP needs, health-related resources provided and recommended international standards. Disparities were also observed in resource availability across the different camp types and locations. IDPs residing in formal camps had more support and resources compared to those in informal camps. These inequalities suggested IDP management was mostly unstructured and this contributed to further deprivation and poorer quality of life for the IDPs. Ensuring standardised management, provision and even distribution of resources across IDP locations, would improve IDP management and health outcomes. To accomplish this, the level of government engagement in IDP management needs to be amplified. Achieving this would require the review and adoption of the Nigerian national IDP policy. This would increase accountability from all relevant government organisations and improve resource prioritization. In addition, empowering and engaging the IDPs in management processes would equip them to better manage their affairs, and this would in turn reduce the burden on supporting organisations