Effects of banditry on primary health care delivery in north-western Nigeria

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Introduction
The North West of Nigeria comprises the states of Katsina, Jigawa, Kaduna, Kano, Kebbi, Sokoto and Zamfara.The region has a population of about 49 million people, around 23% of the country's total population.Kano is the most populous city in the North West, as well as the second most populous city in Nigeria, and the fifteenth most populous city in Africa [1].The predominant religion in this region is Islam, and majority of the people are farmers.
Banditry is a type of armed violence motivated primarily by the criminal intent to steal and plunder for economic gain [2].Banditry is a problem that often arises due to existing crises between people who compete for common economic interests, and it is linked to the conflict between pastoralists and crop producers [3].The insecurity continues to be a major security challenge, causing instability, destabilising governance, and exposing the environment to numerous threats, impeding socioeconomic development [4].The current insecurity in the region has a significant impact on the price of cash crops because transportation of such crops to markets is frequently disrupted, causing farmers to abandon commercial harvests and leading to food insecurity [5].
Oyinloye identified five types of banditry: rural banditry, resources-induced banditry, ethno-religiousinduced banditry, political-induced banditry, and nomadic free-range grazing-induced banditry [6].Rural banditry, political-induced banditry and nomadic freerange grazing-induced banditry are the most common types of banditry in the North West of Nigeria.Banditry can result in financial losses, physical injury or death, social intimidation, restrictions on freedom of movement, and even psychological fear of political intimidation [7].Banditry, despite its pervasiveness, has a number of negative consequences, including, but not limited to, impact on socioeconomic activities, exacerbating the breakdown of law and order, and having negative effects on health care facilities, personnel and health indices [8].
The menace of banditry has led to the closure and damage of health facilities in affected regions, jeopardizing access to medical services, creating a dire situation for patients who depend on these facilities for primary healthcare, maternal care, immunization, and emergency medical attention [5].It has also caused the disruption of supply chains, resulting in shortages of essential drugs, medical equipment, and vaccines.This, in turn, hampers the ability to provide healthcare effectively and respond to public health emergencies.Vulnerable populations, such as women, children, and the elderly, are disproportionately affected by the effects of banditry on healthcare delivery.The limited access to healthcare services exacerbates maternal and child health issues, malnutrition, and high mortality rates in these groups.
Population displacement due to insecurity caused by banditry further compounds public health challenges by inflicting psychological trauma on both healthcare providers and the community at large.This breakdown of social cohesion, stoking of fear, and stress causes profound psychosocial impacts on the population of this region, which is detrimental to their overall well-being [9].Healthcare workers, including doctors, nurses, and support staff, are increasingly displaced from their positions due to the insecurity caused by banditry.The exodus of skilled healthcare personnel leaves a critical void in healthcare delivery services, particularly in areas that are most affected by insecurity.
Insecurity, population displacement, and reduced access to healthcare further compound public health challenges [10].While efforts have been made to address the situation, the effectiveness of government and humanitarian responses is often hindered by the volatile security situation.The ability to provide assistance and support to affected regions is limited, further exacerbating the problem.Therefore, the complex interplay between banditry and primary healthcare delivery in north-western Nigeria necessitates comprehensive strategies and interventions to mitigate the adverse effects of banditry and promote a more resilient and effective healthcare system.It is against this background that the study aims to investigate the effects of banditry on primary health care delivery in northwestern Nigeria.

Significance
Healthcare delivery is crucial in providing muchneeded assistance to less-privileged people, especially in rural areas.Unfortunately, banditry has affected the provision of basic healthcare services to the local communities in north-western Nigeria.This paper can contribute to humanitarian efforts to address the healthcare needs of those living in insecure, banditryaffected areas by creating awareness for developing strategies to prevent and manage health crises in the region.It can also encourage the development of healthcare policies tailored to the unique challenges posed by banditry.These policies should focus on healthcare infrastructure, security measures, and support for healthcare workers to retain and protect this critical workforce.Governments and organizations can allocate resources more effectively based on the study's findings.This can ensure that healthcare facilities in the region receive the necessary support to function optimally and ultimately contributing to a safer and more stable region.

Literature Review Effects of Banditry on Primary Healthcare Delivery
The surge of banditry in the northwestern region of Nigeria, accompanied by a tide of cattle rustling, maiming, kidnappings, killings, displacements of persons, and disruption of socioeconomic activities, has complicated every aspect of life in affected areas, in the region directly and indirectly, as well as in distant settlements in the whole country [5].It is reported that most of the affected healthcare facilities are used by the bandits as hideouts, as well as using remote areas in the bush and forests for their activities [11].Primary healthcare (PHC), which has been a valuable tool for achieving essential care for all in Nigeria, is under threat in this region, as most of these PHCs are located in rural areas.
The effects of banditry on PHC delivery in Northwestern Nigeria have significant consequences on the region's healthcare system, as PHC is crucial to universal health coverage due to its geographical spread and affordability.Banditry has led to the displacement of healthcare professionals, including doctors, nurses and support staff.Many have been forced to leave their positions due to security concerns, resulting in a shortage of skilled healthcare workers, and leading to the closure of some healthcare facilities.Closure of PHC facilities disrupts access to essential healthcare services, such as maternal care, immunization, and emergency medical treatment [8].Banditry contributes to public health challenges, with an increased risk of disease outbreaks and higher morbidity and mortality rates in the affected regions [12].Insecurity, population displacement, and limited healthcare access compound these challenges.
The ability of the government and humanitarian agencies to provide assistance and support to affected areas has been largely affected, making it difficult to address the healthcare needs of the population effectively.These challenges collectively undermine the PHC systems in north-western Nigeria, making it imperative to develop comprehensive strategies and interventions to mitigate these adverse consequences and restore a more resilient and effective healthcare infrastructure [13].
Okojie et al. in their study, identified that the increasing activities of armed banditry in Anka local government area of Zamfara State has caused the abandonment of about 23 out of 41 health care centres, due to fear of incursion, which has deterred those needing urgent medical care from seeking healthcare [7].Armed bandits are said to frequently kidnap and sexually abuse healthcare workers, damage medical facilities and plunder essential drugs from these facilities [7].Healthcare workers have become targets for abduction by armed bandits and terrorist organizations.On the 22 nd April 2021, two young female nurses who were on duty were kidnapped by armed bandits who invaded the rural hospital in Idon, Kajuru local government area of Kaduna State [14].This occurrence prompted a protest by the National Association of Nigeria Nurses and Midwives (NANNM) through its state affiliate in Kaduna State, demanding the immediate and unconditional release of the young nurses [14].The Ministry of Health was given a 48-hour deadline to respond by the union.This event prompted the union to advise members to stop wearing their uniforms when returning to work so as to protect their identity in the face of attacks, and they also stressed that a lack of security at their workplaces will force them to ask their members to refrain from reporting to duty [14].
In a similar attack, several unidentified gunmen attacked the staff quarters of the National Tuberculosis and Leprosy Training Centre, Zaria, Kaduna State, kidnapping about seven health centre staff, including five males and two nursing mothers after a heavy shootout with the police on 4 th July 2021 [15].On 25 th June, 2022, gunmen kidnapped three health workers, along with the Medical Director of the General Hospital Dansadau, Dr Mansur Muhammad, in Zamfara State along the Gusau-Dansadau highway in the Maru Local Government Area.The bandits later released them after 5 million naira ransom was paid for the health workers in order to save their lives [16].It is reported that some of the healthcare personnel have left those healthcare facilities that were affected by banditry, due to fear of being kidnapped for ransom or being forced to care for sick bandits and their abductees.
In Katsina State, it was reported that two PHC facilities in Batsari Local Government Area were burnt down by bandits and about 69 primary health care centres across the State were temporarily shut down as most of the health centres were threatened or taken over by bandits, or had some installations in these facilities, like solar-powered refrigerators, converted to use by the bandits [17].The continuous invasion of previously peaceful satellite towns in the region has led to drastic reduction in health service delivery, in terms of reduced working hours, as facilities open in the morning and close well before twilight, and there are no night shifts due to fear of attack in the facility or on the way home to or from night shifts.Even newborn babies have been abducted in these areas for ransom because they believe that parents will be willing to pay higher sums and pay more quickly.
The on-going and increasing banditry is causing forced migration from rural areas to more secure areas within larger cities.This forced migration has placed a higher demand on the resources in these larger cities and increased the burden of diseases caused by poor hygiene, lack of potable water supply and malnutrition [18].The disease burden of malaria is very high as these refugees inhabit uncompleted buildings and also reside in makeshift temporary structures made of rusted, leaking zinc sheets in slums where mosquito populations are large and even bite during the day, rendering the use of mosquito nets less effective.
According to Médecins Sans Frontières (MSF), the malnutrition crisis is increasing in northwestern Nigeria, as between January to May 2023, 10,200 severely malnourished children with medical complications were given inpatient care and about 51,000 children were admitted to their outpatient feeding programs [19].According to their report, the case numbers are incredibly high and are 26% more than in the same period in 2022 [19].Violence and banditry in northwest Nigeria have contributed to this alarming malnutrition crisis.There is widespread poverty and unemployment, as a large proportion of the population in this region are peasant farmers who are unable to farm, without sufficient money to buy enough food, resulting in malnutrition, weakening of the immune system, and poor growth in children [19].It can be concluded that the effects of banditry have led to the reduction of agricultural productivity as well as low food supply, hunger, and malnutrition.

Conclusion
The effects of banditry on primary healthcare delivery in north-western Nigeria have been deeply troubling, multifaceted, and far-reaching, with implications for both the providers and recipients of healthcare services.The menace of banditry has led to profound psychological stress and tension amongst rural dwellers, socio-economic impacts, shortages of skilled healthcare professionals (due to fear of kidnapping and other unpleasant conditions), as well as damage and closure of PHC facilities, and emergence of disease outbreaks and rising malnutrition rates (due to higher demand on facilities in cities caused by forced migration from rural areas).
The triple challenge of malnutrition, increased burden of diseases and migration of healthcare workers due to insecurity is a huge source of concern.These attacks on health facilities and healthcare workers are unusual given that health workers should not be considered as targets in conflict situations as they attempt to deliver health services in communities, especially during pandemics or disease outbreaks.

Recommendations
The study recommends the following measures as solutions for addressing the effects of banditry on the provision of healthcare services by primary healthcare workers: 1. Implement robust security measures to safeguard healthcare facilities and workers.This should include increased police presence, local community engagement, and collaboration with relevant security agencies to create safe zones for healthcare operations.
2. Launch community outreach programs to educate local populations about the importance of primary healthcare services and their right to access them.3. Implement telemedicine services and mobile clinics to provide healthcare services in areas with limited access due to security concerns.4. Train healthcare workers in conflict-prone areas in emergency response and conflict resolution to deal with security threats effectively while providing care. 5. Establish a comprehensive database to track the impact of banditry on primary healthcare services.6. Collaborate with local non-governmental organisations (NGOs), community leaders, and traditional healers to bridge gaps in healthcare delivery and increase community trust in healthcare providers.7. Rebuild and reinforce healthcare infrastructure that has been damaged due to banditry.8. Mobilize humanitarian organizations and international aid to support healthcare services in affected regions.9. Work on broader conflict resolution initiatives to address the root causes of banditry and insecurity, creating a more stable environment for healthcare delivery.10.Launch campaigns to raise awareness about the detrimental impact of banditry on healthcare.