title: Health service resilience in Yobe state, Nigeria in the context of the Boko Haram insurgency: a systems dynamics analysis using group model building.
abstract: BACKGROUND
  Yobe 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.
  
  
  METHODS
  Structured 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.
  
  
  RESULTS
  Population 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.
  
  
  CONCLUSIONS
  A 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.
authors.affiliation: Mailman School of Public Health, Columbia University, New York, NY USA ; Institute for International Health and Development, Queen Margaret University, Edinburgh, UK.
authors.forename: Alastair K
authors.initials: AK
authors.lastname: Ager
authors.affiliation: School of Public Health, University of the Western Cape, Cape Town, South Africa.
authors.forename: Martina
authors.initials: M
authors.lastname: Lembani
authors.affiliation: PRRINN-MNCH, Kano, Nigeria.
authors.forename: Abdulaziz
authors.initials: A
authors.lastname: Mohammed
authors.affiliation: PRRINN-MNCH, Kano, Nigeria.
authors.forename: Garba
authors.initials: G
authors.lastname: Mohammed Ashir
authors.affiliation: PRRINN-MNCH, Kano, Nigeria.
authors.forename: Ahmad
authors.initials: A
authors.lastname: Abdulwahab
authors.affiliation: Institute for International Health and Development, Queen Margaret University, Edinburgh, UK.
authors.forename: Helen
authors.initials: H
authors.lastname: de Pinho
authors.affiliation: School of Public Health, University of the Western Cape, Cape Town, South Africa.
authors.forename: Peter
authors.initials: P
authors.lastname: Delobelle
authors.affiliation: School of Public Health, University of the Western Cape, Cape Town, South Africa ; University of Montreal Hospital Research Centre, School of Public Health, University of Montreal, Montreal, QC Canada.
authors.forename: Christina
authors.initials: C
authors.lastname: Zarowsky
keywords: Causal loop diagrams; Community cohesion; Conflict; Group model building; Health systems; Insecurity; Insurgency; Political will; Quality; Service provision; Staff commitment; Staff motivation; Systems dynamics