What works and who knows? The importance of community and health worker perspectives in defining solutions to attacks on healthcare

Abstract

Attacks against healthcare are increasingly a strategy of modern warfare, with devastating short and long-term impacts on health staff, patients, and the health system as a whole. What is the solution? Communities play a significant role in protecting healthcare in war zones, as do health workers and civil society networks. We argue existing methods can help identify operationally-relevant solutions in a timely way, facilitating response strategies co-designed with those most affected and in support of existing capacities. This commentary draws on three studies in Nigeria, South Sudan, and Democratic Republic of Congo (2022–2024) that examined health worker and community perspectives on attacks on healthcare and about response priorities in order to inform strategies to prevent attacks and reduce their impact. Here we identify two additional contributions of this research approach. First, these studies document contextually-relevant responses of community- and health worker-defined actions and priorities. Second, they provide new insights on how health worker and community perspectives can be gathered in a timely way, considering the many competing priorities of health workers and people exposed to conflict. They elicited what affected people prioritise, when asked. As such, the approaches are relevant for operational actors working in all areas where people face systematic violence against healthcare.

Background

Health facilities, transport, staff and patients are regularly attacked in more than 27 countries in conflict, with 2024 recording the most ever incidents of violence against or obstructions to healthcare [1]. The use of heavy weaponry, for example during airstrikes in Myanmar [2], Ukraine [3], Syria [4], and Gaza [5], have destroyed entire health facilities, leaving the nearby population with limited alternatives for seeking care. Violence against healthcare, however, is not always so visible. The kidnapping and arrest of doctors, affecting at least 613 health workers in 2024 [1], threats against patients, and curfews and checkpoints that limit movement are more difficult to document. Nevertheless, they have detrimental impacts on the health system and the right to health.

The characteristics of this violence, and the consequences for the people affected by it, vary significantly across crises. This commentary draws on three studies from Democratic Republic of Congo (DRC), Nigeria, and South Sudan. The studies aimed to capture the perspectives and experiences of frontline health staff and communities exposed to the violence in order to better understand these contextual differences and what they mean for response strategies [6–8]. In the DRC (especially in the east), violence against the health system is often linked to clashes between rebel groups and the Congolese army, reflecting the destabilisation of a political regime and the intended takeover of mineral-rich territories. Additionally, violence against healthcare can result from tensions between ethnic groups related to land and cattle. As part of these dynamics, the health system and the local population are often collateral victims [8]. In Nigeria, attacks on health commonly include violence against hospitals and ambulances by unknown perpetrators. While the violence is traditionally concentrated in the northeast of the country, where the Boko Haram conflict has raged for over 10 years, attacks have been recorded throughout the country. Kidnapping of health workers is common, and often directly linked to a lack of services in inaccessible areas. In these places, armed groups demand a ransom or forcefully capture staff and health resources to service non-state armed group members and communities in areas with limited health services [7]. South Sudan continues to be one of the most violent countries worldwide, with the highest recorded attacks against aid workers in 2022 [9]. While the 2018 peace agreement has led to a fragile truce, localised violence remains common. Violence against the health system is often committed by armed community members, related to tensions over land and resources, cattle raiding, and reprisal attacks [6].

In the same way that the characteristics and consequences of attacks differ, so do the solutions to this violence. Research on attacks, and their impact on those in need of healthcare, has greatly improved in scope and quality [11, 15–22]. Only more recently have the perspectives and experiences of frontline staff been highlighted, including their vision for how best to address the attacks and their impact. These three studies demonstrate that frontline workers and communities are an underutilised source of information to inform strategies and responses in support of solutions to protect healthcare in conflict. They provide new insights on how these perspectives can best be gathered in a timely and operationally-relevant way, considering the competing priorities of health workers and people exposed to conflict, and they detail what affected people prioritise, when asked. As such, they articulate practical solutions that address the priorities of those most affected.

Priorities and perspectives of affected people are an essential, but underexplored, source of solutions

Health staff, authorities, and communities prioritised a range of measures required to reduce the violence and its impact. Across the three contexts, their responses share common threads that transcended context: affected areas require security interventions for facilities, staff, and patients; rapid interventions can reduce the impact of an attack on patients, specifically marginalised groups (e.g. temporary relocation of health services during repair; cash grants to facilitate transport to other health facilities); and hold perpetrators accountable. Improved data collection and use was frequently mentioned in the three studies reviewed, to enable actors to implement evidence-based security and response strategies [10]. Respondents also requested that global actors increase their support, by providing financial resources and by facilitating stronger accountability measures in the absence of pathways for national prosecution. In general, the findings underlined the role of community members as part of the response. In all three contexts, respondents recommended setting up early warning systems at the community level to alert health actors to possible attacks. Relatedly, respondents perceived the promotion of local ownership of health infrastructure as a key violence prevention measure.

Respondents identified measures to protect and motivate affected healthcare workers as a priority in all studies. They recommended improving working conditions by ensuring enough staff, medicine, and equipment. They also suggested offering financial incentives, especially in high-risk areas, to help attract and retain staff. For example, almost 80% of the respondents in Nigeria who experienced an attack reported reduced psychological wellbeing, including one or more symptoms of heightened distress. These findings mirror other studies of the impact on health workers [11, 15, 17–19, 22]. Worryingly, however, support is limited: almost half the respondents who witnessed an incident did not receive any type of formal support after this attack. A majority of respondents in Nigeria therefore prioritised post-incident psychological support services to staff and their families. This support could take the form of peer support. For instance, in the aftermath of one incident, health staff from a nearby centre who had similar experiences spent time with their affected colleagues. This measure proved an effective and contextually-relevant psychological support measure to boost morale [8].

The studies shine a light on response interventions that do not typically appear among the priorities of response actors. Almost all respondents highlighted the role of safe transport, both for health staff traveling to and from work and for community members forced to access more distant health services following the suspension of services at their usual provider. For instance, providing transport via qualified drivers can reduce preventable traffic accidents and mitigate the risk of harassment that respondents encountered in public or private transport. Such transport, which does not require ambulance services, is not part of traditional humanitarian health service delivery. In fact, none of the humanitarian response plans for the three countries specifically mention physical access to health services. Moreover, in South Sudan and Nigeria, survey respondents were asked to report incidents they witnessed or directly experienced in 2022, using a predefined list. Their responses were more likely to highlight less violent incidents (e.g. more cases of harassment and threats), a finding that mirrors other studies, particularly self-reports by health workers [11, 21, 22].

Aside from proposed solutions that transcended context, others were highly context specific. These often took the form of recommended security risk management approaches. For instance, in South Sudan, community violence against the health system is common, partly due to high levels of private firearm possession [13]. To reduce the occurrence and impact of violence, respondents highlighted the need to engage community members in protecting health staff. In a crisis marked by tribal violence, respondents recommended fostering community acceptance around recruitment of staff from other tribes or areas of the country. In addition, awareness raising on sensitive topics, such as family planning, was offered as an approach to reduce patient and staff violence. In Nigeria, the violence is characterized by kidnapping of health staff, with over 120 staff kidnapped in the last five years, many of whom were working in the Borno, Adamawa and Yobe (BAY) states [12]. Respondents recommended that health staff reduce their visibility when traveling to and from work, as wearing their uniform could increase their vulnerability. In DRC, the community is seen as instrumental to keeping staff safe, especially in hard-to-reach areas with limited government or humanitarian presence. Respondents proposed to establish forums for dialogue between communities, local authorities, and armed groups to negotiate non-aggression agreements around health infrastructure and teams. These mechanisms are similar to acceptance-based security risk management approaches for aid workers [20], but these have not necessarily been applied systematically in relation to local health provision or contexts.

Tried and tested methods can be used to elicit local priorities and responses in a timely and operationally-relevant way

Each of the three studies was designed and implemented by operational organisations using existing data collection methods, with support from local and international researchers. Three authors (SLM, OO, LT) were directly involved in the design and implementation of three operational studies in South Sudan, Nigeria, and DRC. In South Sudan and the BAY states of Nigeria, the self-administered, online surveys were shared by email and WhatsApp with key health networks. The DRC study took a different approach, by identifying three recent attacks on health centres in North and South Kivu in order to develop case studies, complemented with a review of health facility-level patient data. The use of these tried and tested methods is crucial in identifying community and health worker perspectives. Moreover, they can be implemented by operational actors and subsequently incorporated into programmes and operational responses (see also [23]).

The method chosen in each case reflected its particular circumstances, such as the level of access to the intended respondents, time available for the study, and the sensitivity of the data collected. The approach in South Sudan and Nigeria, with data gathered through self-administered online surveys, was chosen to facilitate data collection and staff response, due to their high and volatile workload. A short, self-administered survey allowed staff to submit responses at their convenience. The survey contained questions that staff might be hesitant to directly report, such as their perspectives on priority interventions that could highlight gaps in their employers’ safety practices. Other studies [14] indicate that anonymous, self-administered surveys have the potential to collect more comprehensive information on sensitive topics as compared to enumerator-administered surveys. The South Sudan and Nigeria studies confirmed this finding [6, 7].

Despite their limitations (e.g. the use of convenience sampling that introduces biases related to recall or digital access), the studies in South Sudan and Nigeria show that mobile-phone surveys can be an effective approach to collect context-specific, relevant perspectives on priorities for prevention and response. For instance, 98 percent of respondents provided at least one practical solution to reduce the violence or its impact. An important factor for this success was access to a diverse profile of respondents through pre-existing health networks. As such, the methodology represented a rapid, cost-efficient method to consult a large number of health workers in difficult-to-reach areas, in a short period of time (only two months from start to finish). Operational actors in both countries subsequently used the survey results to support funding applications inclusive of security measures, expand security strategies to involve national partners, and inform staff of the main risks within their specific contexts.

The case study approach used in DRC [8] proved to be an appropriate methodology for exploring in detail the impact of attacks on healthcare on the surrounding population. The use of both qualitative and quantitative methods allowed for the triangulation of sources and types of data to provide a broad yet nuanced picture. This approach allowed for a review of the differences and similarities between attacks, and their effect on identified response strategies. For example, in one case, the attack resulted in the displacement of a large part of the population. Response priorities in that context focused on measures enabling return to (destroyed) homes and livelihoods. In the two other cases, the population continued to reside in the areas affected by violence. There, respondents prioritised measures in support of affected health staff.

Despite the DRC study limitations (e.g. recall bias, case studies chosen based on security concerns, and missing data), this study illustrates the possibilities when the context allows for in-person data collection as part of a mixed method approach [8]. Qualitative findings from focus group discussions and interviews with key informants were verified by data on outpatient visits, providing a more comprehensive picture of the impact of violence on health workers and the local population.

Conclusion: Global action is key but must be linked to locally-sourced solutions and insights

International political efforts and humanitarian action remain fundamental to prevent violence against healthcare and ensure accountability. From a global perspective, recommendations to prevent and protect appear alike: better security risk management, community engagement, emergency health responses, and measures to ensure accountability for attacks. Although similar in nature, their implementation differs significantly across contexts. This necessitates a local, regularly updated analysis based on the perspectives of those most affected in order to ensure contextually-relevant global and local responses.

The studies summarised in this commentary illustrate how timely and context-specific data collection techniques implemented by operational actors can gather practical and locally-sourced insights to inform response strategies. Such assessments can facilitate frequent updates, including monitoring of operationally-relevant changes in needs and priorities. This monitoring approach is beneficial in contexts affected by severe violence. These more rapid approaches are arguably preferable over long-term in-depth studies, considering the highly volatile conflict contexts and their detrimental consequences.

As those exposed to armed conflict and the resulting everyday challenges, health staff and communities are best placed to understand the actions that could help reduce this violence and its impact. Additional efforts are required to capture and use these insights for global and local action. Such analysis remains absolutely critical, both now and into the future.

Abbreviations

BAY states

Borno, Adamawa and Yobe

DHIS2

District Health Information System

DRC

Democratic Republic of Congo

ERSP-UCB

Ecole Régionale de Santé Publique de l'Université Catholique de Bukavu

IRC

International Rescue Committee

RIAH

Researching the Impact of Attacks on Healthcare Project

IHO

Impact Health Organization

TRI-SS

The rescue initiative South Sudan

UNHSS

United Networks for Health South Sudan

Author contributions

SLM, LT and OK wrote the first draft of the commentary, which LF revised with LT. All authors reviewed and approved the final manuscript.

Funding

Foreign, Commonwealth and Development Office, United Kingdom, 300484-101, 300484-101, European Civil Protection and Humanitarian Aid Operations, EC520, EC520.

Availability of data and materials

No datasets were generated or analysed during the current study.

Declarations

Ethics approval and consent to participate

Not applicable.

Consent for publication

All authors reviewed and approved the final manuscript.

Competing interests

The authors declare no competing interests.