Access is already one of Africa's biggest health care provision challenges, and the militant insurgency in the north of Nigeria is adding a layer of difficulty and hampering potential progress. In Nigeria, which is West Africa's economic powerhouse, astonishingly, only 38 percent of births are assisted by a skilled birth attendant, and 13 percent are completely unassisted. The effects of insecurity on education, population displacement and governance, means that access to health care becomes much harder in places like Borno State, that are already very restricted due to the predominantly rural nature of the landscape.
The effects of the insurgency on education is crucial when much of health care is about access to information -- 'what sort of medical care do I need?' 'What sort of medical care am I entitled to?' The attack on educational systems undermines the ability for accurate information to be disseminated and for women to take ownership over their own bodies. For the mainly rural states, that already have only limited resources, this is hugely problematic, and results in a large-scale loss of lives.
Let us not forget that Boko Haram translates as 'Western education is forbidden'. This explicit disdain for education -- most notoriously seen in the kidnapping of the Chibok schoolgirls -- has also seen Bayero University in northern Kano State and the University of Maiduguri in Borno State become targets for terrorism. These threats not only jeopardise current educational programmes such as the compulsory one-year service undertaken by university graduates, the National Youth Service Corps (NYSC), which was suspended in the some parts of the north recently, but they also deter prospective students from applying to further their education.
This translates to fewer operating health workers in places that need them the most. In Jigawa State, in 2011, there were fewer than 30 trained midwives in the whole state for a population of nearly 5 million people. This is devastating for health service delivery, given that the UNFPA says increasing the number of midwives could prevent as many as two-thirds of all maternal and newborn deaths. Taking into consideration that in Maiduguri, in Borno State, the likelihood of a woman dying is 1 in 23 compared with 1 in 4,700 in the UK, this is a very big problem.
The internal displacement of people has a hugely detrimental effect on maternal health care provision. Health care services have collapsed in Borno State as doctors, nurses and pharmacists flee for their lives from the brutal violence unleashed by the Boko Haram militants.
The whole health care system in these parts of Nigeria, that have hardly any access, have become a "growing health crisis." The sick are forced to trek vast distances to receive medical attention, and vaccination programmes for children are compromised. People are forced to cross into neighbouring Cameroon in search of treatment, with pregnant women and the sick using donkeys and auto-rickshaws to negotiate the difficult terrain. This gruelling trek takes its toll, as by the time the sick reach hospitals across the border they are in a worse state, and many die.
Nigeria's National Commission for Refugees recently made data available showing that as many as 3.3 million people have been internally displaced in the country by violence, including at least 250,000 people who have fled armed conflict perpetrated by Boko Haram. According to the Internal Displacement Monitoring Centre, at least 37 percent of primary health facilities in areas under the state of emergency have been shut as a result of the violence, and in the worst-affected areas, none at all are thought to be open.
How can people access health if they do not know where they will be tomorrow? How can people access health care if they do not know where the nearest facility is? How can health care be effective in northern Nigeria if there are no health care workers?
And, finally, the issue of governance is key, as the loss of control over territory makes it difficult for state governments and civil society organisations to identify functional facilities and deliver high-quality maternal, child and adolescent health care. Additionally, state governments' attention and resources gets redirected towards tackling terrorism, rather than prioritising maternal and child health care.
The insurgency is having massively detrimental effects on the lives of families in the northern states of Nigeria. There is no simple solution, but in order to deliver necessary health care, there needs to be a commitment to security for health professionals. Ensuring governance, rebuilding education systems, and resettling internally displaced peoples will take time. However, in the short term, we need to heighten security to get health care workers to the people that need access to health care. Earlier this year, we saw the north of Borno State empty of health professionals. As we continue to increase access to health care across Nigeria, our leaders must work harder to ensure security in order to allow access in northern states too.