TY - JOUR
AU - Pritchard,, Catherine
AB - Abstract Background Armed conflict in Nigeria resulted in more than 2 million internally displaced persons (IDPs). IDPs live in poor conditions lacking basic resources with variable provision across different locations. This audit aimed to determine the health-related resources available to IDPs in camp-like settings in Nigeria and whether these met international standards. Methods Using a cross-sectional study approach, information was collected in nine camps across seven states from camp managers, and direct observation in September–October 2016. The Sphere minimum standards in humanitarian crises were used as the audit standards. Findings The 5 of 15 assessed standards were met to some extent, including the availability of water and shelter. Sanitation and vaccination were unmet in five camps, with severe overcrowding in five camps, and inadequate waste disposal in all camps. Health programme implementation was uneven, and especially poor in self-settled and dispersed settlements. Conclusion Inequality in distribution of humanitarian support was observed across different settings, which could lead to a higher likelihood of water, food and air-related diseases and thereby, a poorer quality of life for IDPs. Ensuring standardized health assessments could promote a more even distribution of resources across IDP locations. displacement camps, healthcare, internally displaced persons, Nigeria, public health Introduction As of 2016, ~40.3 million people had been internally displaced due to conflict and violence, and globally there were twice as many internally displaced persons (IDPs) as refugees.1 IDPs are those who remain within the affected country’s borders whereas refugees and asylum seekers are those who move into other countries.2 Unlike refugees, IDPs are not directly managed by international organizations but are the responsibility of the affected nation’s government.2 Available services and evidence of health interventions for IDPs are less established compared to refugees.3 One major consequence of displacement is limited access to amenities such as food, water, shelter and healthcare and the resulting dependence on humanitarian assistance.4,5 Vulnerability from displacement is also compounded by settlement locations.6,7 Most locations where displaced people settle lack the capacity to effectively manage the migratory crisis and this is more problematic among IDPs.8,9 Location vulnerability impacts the physical, emotional and mental health of those affected.10–12 In addition, infrastructural damage and insecurity, which are major consequences of conflict, significantly affect healthcare,12–14 thus leading to poorer health outcomes including the spread of infectious diseases, high morbidity and mortality, as well as limited availability of basic health services.9,14–18 Ensuring targeted provision of standard public health measures can minimize these impacts.16,19 Nigeria as a country has experienced armed conflict from the Boko Haram Islamic terrorists since 2011 in three North-Eastern states: Borno, Yobe and Adamawa states. Since 2014 there has been mass human displacement affecting ~15 million people and resulting in over 2 million IDPs.20 The International Organization on Migration (IOM) Displacement Tracking Matrix (DTM) Round VII report in December 2015,21 showed IDPs had settled in 13 of 37 states in the country, all within the northern region (Fig. 1). Fig. 1 Open in new tabDownload slide Nigeria IDP settlement locations (December 2015). Fig. 1 Open in new tabDownload slide Nigeria IDP settlement locations (December 2015). In Nigeria, the IDPs settled in a range of settings with host communities, families or in camp-like locations.22 Camp-like settings are categorized as planned, transit, dispersed and self-settled camps.21 Planned camps are officially authorized by the national authorities. Transit camps are created to serve as temporary shelters for displaced persons before they are moved to more stable locations. Dispersed settlements are residential areas under one camp management but scattered across wide distances. Self-settled locations are where IDPs settle of their own accord without official approval. Generally, most organized humanitarian support are provided for IDPs living in camp-like settlements.23 Hence, IDPs in self-settlements are a concern as they have no official status, which influences the support they receive and consequently their health status.24 Although some research on the health and well-being of IDPs from the Boko Haram crisis have been conducted,24–29 there is limited knowledge on how camps are organized, managed, and the availability of basic resources and access to health services. In addition, little is known about the distribution of resources across the different camp types and sites. Such evidence is required to effectively deliver coordinated and integrated life-saving assistance to IDPs. The objectives of this study, which is part of a doctoral thesis, was to assess camp conditions in IDP camp-like settings in Nigeria; and to evaluate if their management and organization met international standards, with a specific focus on health impact. The study aims to contribute to the growing evidence base on IDP management in Nigeria. Methodology Study design A cross-sectional study design using an audit survey approach was conducted between September and October 2016 in seven states in Nigeria where IDPs had settled. Nine camp-like locations where IDPs displaced by the Boko Haram crisis were visited. The questionnaire and standards for the audit were developed and adapted from the Sphere Handbook.30 The handbook is the most commonly used guideline for assessing attainment of international minimum standards during humanitarian aid responses. In total, 15 of the Sphere minimum standards from three sectors: Water, Sanitation and Hygiene (WASH), Shelter and Health, were considered for inclusion in this study (Table 1). Table 1 List of audit standards Sector Audit standards Sphere minimum standard Water supply, sanitation and hygiene (WASH) 1 Access and water quantity Water Supply Standard 1: Access and water quantity All people have safe and equitable access to a sufficient quantity of water for drinking, cooking and personal and domestic hygiene. Public water points are sufficiently close to households to enable use of the minimum water requirement. 2 Environment free from human faeces WASH-Excreta disposal Standard 1: Environment free from human faeces The living environment in general and specifically the habitat, food production areas, public centres and surroundings of drinking water sources are free from human faecal contamination. 3 Appropriate and adequate toilet facilities Excreta disposal Standard 2: Appropriate and adequate toilet facilities People have adequate, appropriate and acceptable toilet facilities, sufficiently close to their dwellings, to allow rapid, safe and secure access at all times, day and night. 4 Waste collection and disposal Solid waste management Standard 1: Collection and disposal The affected population has an environment not littered by solid waste, including medical waste, and has the means to dispose of their domestic waste conveniently and effectively. 5 Physical, environmental and chemical protection measures Vector control Standard 2: Physical, environmental and chemical protection measures The environment where the disaster-affected people are placed does not expose them to disease-causing and nuisance vectors, and those vectors are kept to a reduced level where possible. 6 Hygiene promotion implementation Hygiene Promotion Standard 1: Hygiene promotion implementation Affected men, women and children of all ages are aware of key public health risks and are mobilized to adopt measures to prevent the deterioration in hygienic conditions and to use and maintain the facilities provided. Shelter, Settlement and Non-Food Items (NFI) 7 Strategic planning Shelter and Settlement Standard 1: Strategic planning Shelter and settlement strategies contribute to the security, safety, health and well-being of both displaced and non-displaced affected populations and promote recovery and reconstruction where possible. 8 Covered living space Shelter and Settlement Standard 3: Covered living space People have sufficient covered living space providing thermal comfort, fresh air and protection from the climate ensuring their privacy, safety and health and enabling essential household and livelihood activities to be undertaken. 9 Individual, general household and shelter support items Non-food Items Standard 1: Individual, general household and shelter support items The affected population has sufficient individual, general household and shelter support items to ensure their health, dignity, safety and well-being. Health action 10 Health service delivery Health System Standard 1: Health service delivery People have equal access to effective, safe and quality health services that are standardized and follow accepted protocols and guidelines. 11 Prioritizing health services Essential Health Services Standard 1: Prioritizing health services People have access to health services that are prioritized to address the main causes of excess mortality and morbidity. 12 Human resources Health System Standard 2: Human resources Health services are provided by trained and competent health work- forces who have an adequate mix of knowledge and skills to meet the health needs of the population. 13 Drugs and medical supplies Health System Standard 3: Drugs and medical supplies People have access to a consistent supply of essential medicines and consumables. 14 Communicable disease prevention Essential Health Services Standard 1: Communicable disease prevention People have access to information and services that are designed to prevent the communicable diseases that contribute most significantly to excess morbidity and mortality. 15 Prevention of vaccine- preventable diseases Essential Health Services Child health Standard 1: Prevention of vaccine-preventable diseases Children aged 6 months to 15 years have immunity against measles and access to routine Expanded Programme on Immunization (EPI) services once the situation is stabilized. Sector Audit standards Sphere minimum standard Water supply, sanitation and hygiene (WASH) 1 Access and water quantity Water Supply Standard 1: Access and water quantity All people have safe and equitable access to a sufficient quantity of water for drinking, cooking and personal and domestic hygiene. Public water points are sufficiently close to households to enable use of the minimum water requirement. 2 Environment free from human faeces WASH-Excreta disposal Standard 1: Environment free from human faeces The living environment in general and specifically the habitat, food production areas, public centres and surroundings of drinking water sources are free from human faecal contamination. 3 Appropriate and adequate toilet facilities Excreta disposal Standard 2: Appropriate and adequate toilet facilities People have adequate, appropriate and acceptable toilet facilities, sufficiently close to their dwellings, to allow rapid, safe and secure access at all times, day and night. 4 Waste collection and disposal Solid waste management Standard 1: Collection and disposal The affected population has an environment not littered by solid waste, including medical waste, and has the means to dispose of their domestic waste conveniently and effectively. 5 Physical, environmental and chemical protection measures Vector control Standard 2: Physical, environmental and chemical protection measures The environment where the disaster-affected people are placed does not expose them to disease-causing and nuisance vectors, and those vectors are kept to a reduced level where possible. 6 Hygiene promotion implementation Hygiene Promotion Standard 1: Hygiene promotion implementation Affected men, women and children of all ages are aware of key public health risks and are mobilized to adopt measures to prevent the deterioration in hygienic conditions and to use and maintain the facilities provided. Shelter, Settlement and Non-Food Items (NFI) 7 Strategic planning Shelter and Settlement Standard 1: Strategic planning Shelter and settlement strategies contribute to the security, safety, health and well-being of both displaced and non-displaced affected populations and promote recovery and reconstruction where possible. 8 Covered living space Shelter and Settlement Standard 3: Covered living space People have sufficient covered living space providing thermal comfort, fresh air and protection from the climate ensuring their privacy, safety and health and enabling essential household and livelihood activities to be undertaken. 9 Individual, general household and shelter support items Non-food Items Standard 1: Individual, general household and shelter support items The affected population has sufficient individual, general household and shelter support items to ensure their health, dignity, safety and well-being. Health action 10 Health service delivery Health System Standard 1: Health service delivery People have equal access to effective, safe and quality health services that are standardized and follow accepted protocols and guidelines. 11 Prioritizing health services Essential Health Services Standard 1: Prioritizing health services People have access to health services that are prioritized to address the main causes of excess mortality and morbidity. 12 Human resources Health System Standard 2: Human resources Health services are provided by trained and competent health work- forces who have an adequate mix of knowledge and skills to meet the health needs of the population. 13 Drugs and medical supplies Health System Standard 3: Drugs and medical supplies People have access to a consistent supply of essential medicines and consumables. 14 Communicable disease prevention Essential Health Services Standard 1: Communicable disease prevention People have access to information and services that are designed to prevent the communicable diseases that contribute most significantly to excess morbidity and mortality. 15 Prevention of vaccine- preventable diseases Essential Health Services Child health Standard 1: Prevention of vaccine-preventable diseases Children aged 6 months to 15 years have immunity against measles and access to routine Expanded Programme on Immunization (EPI) services once the situation is stabilized. Open in new tab Table 1 List of audit standards Sector Audit standards Sphere minimum standard Water supply, sanitation and hygiene (WASH) 1 Access and water quantity Water Supply Standard 1: Access and water quantity All people have safe and equitable access to a sufficient quantity of water for drinking, cooking and personal and domestic hygiene. Public water points are sufficiently close to households to enable use of the minimum water requirement. 2 Environment free from human faeces WASH-Excreta disposal Standard 1: Environment free from human faeces The living environment in general and specifically the habitat, food production areas, public centres and surroundings of drinking water sources are free from human faecal contamination. 3 Appropriate and adequate toilet facilities Excreta disposal Standard 2: Appropriate and adequate toilet facilities People have adequate, appropriate and acceptable toilet facilities, sufficiently close to their dwellings, to allow rapid, safe and secure access at all times, day and night. 4 Waste collection and disposal Solid waste management Standard 1: Collection and disposal The affected population has an environment not littered by solid waste, including medical waste, and has the means to dispose of their domestic waste conveniently and effectively. 5 Physical, environmental and chemical protection measures Vector control Standard 2: Physical, environmental and chemical protection measures The environment where the disaster-affected people are placed does not expose them to disease-causing and nuisance vectors, and those vectors are kept to a reduced level where possible. 6 Hygiene promotion implementation Hygiene Promotion Standard 1: Hygiene promotion implementation Affected men, women and children of all ages are aware of key public health risks and are mobilized to adopt measures to prevent the deterioration in hygienic conditions and to use and maintain the facilities provided. Shelter, Settlement and Non-Food Items (NFI) 7 Strategic planning Shelter and Settlement Standard 1: Strategic planning Shelter and settlement strategies contribute to the security, safety, health and well-being of both displaced and non-displaced affected populations and promote recovery and reconstruction where possible. 8 Covered living space Shelter and Settlement Standard 3: Covered living space People have sufficient covered living space providing thermal comfort, fresh air and protection from the climate ensuring their privacy, safety and health and enabling essential household and livelihood activities to be undertaken. 9 Individual, general household and shelter support items Non-food Items Standard 1: Individual, general household and shelter support items The affected population has sufficient individual, general household and shelter support items to ensure their health, dignity, safety and well-being. Health action 10 Health service delivery Health System Standard 1: Health service delivery People have equal access to effective, safe and quality health services that are standardized and follow accepted protocols and guidelines. 11 Prioritizing health services Essential Health Services Standard 1: Prioritizing health services People have access to health services that are prioritized to address the main causes of excess mortality and morbidity. 12 Human resources Health System Standard 2: Human resources Health services are provided by trained and competent health work- forces who have an adequate mix of knowledge and skills to meet the health needs of the population. 13 Drugs and medical supplies Health System Standard 3: Drugs and medical supplies People have access to a consistent supply of essential medicines and consumables. 14 Communicable disease prevention Essential Health Services Standard 1: Communicable disease prevention People have access to information and services that are designed to prevent the communicable diseases that contribute most significantly to excess morbidity and mortality. 15 Prevention of vaccine- preventable diseases Essential Health Services Child health Standard 1: Prevention of vaccine-preventable diseases Children aged 6 months to 15 years have immunity against measles and access to routine Expanded Programme on Immunization (EPI) services once the situation is stabilized. Sector Audit standards Sphere minimum standard Water supply, sanitation and hygiene (WASH) 1 Access and water quantity Water Supply Standard 1: Access and water quantity All people have safe and equitable access to a sufficient quantity of water for drinking, cooking and personal and domestic hygiene. Public water points are sufficiently close to households to enable use of the minimum water requirement. 2 Environment free from human faeces WASH-Excreta disposal Standard 1: Environment free from human faeces The living environment in general and specifically the habitat, food production areas, public centres and surroundings of drinking water sources are free from human faecal contamination. 3 Appropriate and adequate toilet facilities Excreta disposal Standard 2: Appropriate and adequate toilet facilities People have adequate, appropriate and acceptable toilet facilities, sufficiently close to their dwellings, to allow rapid, safe and secure access at all times, day and night. 4 Waste collection and disposal Solid waste management Standard 1: Collection and disposal The affected population has an environment not littered by solid waste, including medical waste, and has the means to dispose of their domestic waste conveniently and effectively. 5 Physical, environmental and chemical protection measures Vector control Standard 2: Physical, environmental and chemical protection measures The environment where the disaster-affected people are placed does not expose them to disease-causing and nuisance vectors, and those vectors are kept to a reduced level where possible. 6 Hygiene promotion implementation Hygiene Promotion Standard 1: Hygiene promotion implementation Affected men, women and children of all ages are aware of key public health risks and are mobilized to adopt measures to prevent the deterioration in hygienic conditions and to use and maintain the facilities provided. Shelter, Settlement and Non-Food Items (NFI) 7 Strategic planning Shelter and Settlement Standard 1: Strategic planning Shelter and settlement strategies contribute to the security, safety, health and well-being of both displaced and non-displaced affected populations and promote recovery and reconstruction where possible. 8 Covered living space Shelter and Settlement Standard 3: Covered living space People have sufficient covered living space providing thermal comfort, fresh air and protection from the climate ensuring their privacy, safety and health and enabling essential household and livelihood activities to be undertaken. 9 Individual, general household and shelter support items Non-food Items Standard 1: Individual, general household and shelter support items The affected population has sufficient individual, general household and shelter support items to ensure their health, dignity, safety and well-being. Health action 10 Health service delivery Health System Standard 1: Health service delivery People have equal access to effective, safe and quality health services that are standardized and follow accepted protocols and guidelines. 11 Prioritizing health services Essential Health Services Standard 1: Prioritizing health services People have access to health services that are prioritized to address the main causes of excess mortality and morbidity. 12 Human resources Health System Standard 2: Human resources Health services are provided by trained and competent health work- forces who have an adequate mix of knowledge and skills to meet the health needs of the population. 13 Drugs and medical supplies Health System Standard 3: Drugs and medical supplies People have access to a consistent supply of essential medicines and consumables. 14 Communicable disease prevention Essential Health Services Standard 1: Communicable disease prevention People have access to information and services that are designed to prevent the communicable diseases that contribute most significantly to excess morbidity and mortality. 15 Prevention of vaccine- preventable diseases Essential Health Services Child health Standard 1: Prevention of vaccine-preventable diseases Children aged 6 months to 15 years have immunity against measles and access to routine Expanded Programme on Immunization (EPI) services once the situation is stabilized. Open in new tab Audit assessment variables The audit survey questionnaire comprised four main sections with closed questions. These sections were the camp details (location, established date, availability of shelter, water and sanitation); population demography, health resources (health staff and medical commodities) and intervention programmes received (poverty, WASH, protection and health). Key indicators from the Sphere handbook were used as the benchmark.30 However, most of the indicators had no specific outcome measure but used signals which showed when standards were attained. In line with the indicators, a 3-point grading system was developed for this study: ‘Met’, ‘Partially Met’ or ‘Unmet’. Standards were considered ‘met’ if it had been implemented in all nine camps; ‘partially met’ if implemented in six or more camps, and ‘unmet’ if attained in five or less camps. Some indicators were related to more than one standard therefore assessments of each standard took into consideration all findings associated to that standard. In this study, distances identified to be ‘Very Close’ were <200 m, ‘Not too far’ <500 m and ‘Very far’ were over 500 m from the households. Setting The nine camps across the seven states were selected based on population size and security clearance. All camps audited were established between 2012 and 2015 and spread across rural and urban locations (Fig. 1). The camps selected for inclusion in this audit were sites in 7 of the 13 states where IDPs displaced by armed conflict had settled as listed in the DTM December 2015 report.21 State selection was based on zonal spread: Borno and Taraba (North-East), Kaduna and Kano (North-Central) and Nasarawa, Plateau and FCT (North-Central). Data collection Individuals responsible for the daily running and management of each camp were identified and asked to complete the audit questionnaire. In most locations these were camp leaders, who were IDPs themselves. Bakasi and Stefanos Foundation camps had external camp administration personnel (representatives of organizations) who managed general camp affairs and visited the camps daily. In these camps, information was obtained directly from the external camp administrators. Questionnaires were completed by trained field investigators who personally administered the survey to the camp managers on the camp premises. For each question, responses from the camp leaders and direct observations of all relevant information were directly recorded on the audit survey forms. Data collected were verified for accuracy in the field by the field team leaders and checked for consistency by the lead researcher. Ethical clearance Ethical clearance was received from the Nigerian National Health Research Ethics Committee (Ref: NHREC/01/01/2007–08/06/2016) and the University of Nottingham Medical School Research Ethics Committee (Ref: OVSb12072016). Permits to access the camps was given by the Nigerian National Emergency Maintenance Agency (NEMA). Written signed consents were received from all participants. Result Location characteristics Of the nine camps visited, there were four camp types established between 2012 and 2015 with diverse household sizes and available resources (Table 2). Household numbers varied from 47 to 1739 IDP shelters. Camp managers in the FCT and Kano state were unsure of the number of households but provided estimates. Kyuata camp reported 4000 shelters but these included houses of non-IDP local residents living within the IDPs dispersed settlement area. The average household size, which represented the number of people living under the same sheltered structure, ranged from 6 to 21. Shelters used were mainly pre-existing concrete buildings and a few camps had temporary homes made from aluminium roofing sheets, and tents. The primary water sources were boreholes but the main excreta disposal facilities were pit latrines in eight camps. The use of outdoor open spaces for defecation, which is not recommended, was common in two camps. Access to healthcare staff was unavailable in four camps. Table 2 Settlement location characteristics State Camp name Established date Camp type Approximate household number Average household size Shelter Water source Distance to water source Type of toilet Healthcare staff on camp OR visiting Borno Bakasi 2015 Planned 1739 6 Tent Borehole Not too far Pit Yes FCT Durumi 2012 Self-settled 375 19 Aluminium sheet and Polyester Borehole Not too far Pit Yes FCT Kuchingoro 2012 Self-settled 532 10 Aluminium sheet and Polyester Borehole Not too far Pit Yes Kaduna Kyuata 2014 Dispersed 4 000 10 Mud and Tent Borehole Not too far Pit Outdoors No Kano Gaida 2014 Dispersed 100 21 Concrete Building Well Very close Pit Water closet No Nasarawa Gurku 2013 Planned 600 20 Concrete Building Borehole Not too far Pit Yes Plateau Stefanos Foundation 2014 Transit 61 7 Concrete Building Borehole Very close Pit Water closet Yes Taraba Mullum 2014 Dispersed 212 7 Thatch Borehole Very far Outdoors No Taraba Gullum 2014 Transit 47 8 Concrete Building Borehole Not too far Pit No State Camp name Established date Camp type Approximate household number Average household size Shelter Water source Distance to water source Type of toilet Healthcare staff on camp OR visiting Borno Bakasi 2015 Planned 1739 6 Tent Borehole Not too far Pit Yes FCT Durumi 2012 Self-settled 375 19 Aluminium sheet and Polyester Borehole Not too far Pit Yes FCT Kuchingoro 2012 Self-settled 532 10 Aluminium sheet and Polyester Borehole Not too far Pit Yes Kaduna Kyuata 2014 Dispersed 4 000 10 Mud and Tent Borehole Not too far Pit Outdoors No Kano Gaida 2014 Dispersed 100 21 Concrete Building Well Very close Pit Water closet No Nasarawa Gurku 2013 Planned 600 20 Concrete Building Borehole Not too far Pit Yes Plateau Stefanos Foundation 2014 Transit 61 7 Concrete Building Borehole Very close Pit Water closet Yes Taraba Mullum 2014 Dispersed 212 7 Thatch Borehole Very far Outdoors No Taraba Gullum 2014 Transit 47 8 Concrete Building Borehole Not too far Pit No Open in new tab Table 2 Settlement location characteristics State Camp name Established date Camp type Approximate household number Average household size Shelter Water source Distance to water source Type of toilet Healthcare staff on camp OR visiting Borno Bakasi 2015 Planned 1739 6 Tent Borehole Not too far Pit Yes FCT Durumi 2012 Self-settled 375 19 Aluminium sheet and Polyester Borehole Not too far Pit Yes FCT Kuchingoro 2012 Self-settled 532 10 Aluminium sheet and Polyester Borehole Not too far Pit Yes Kaduna Kyuata 2014 Dispersed 4 000 10 Mud and Tent Borehole Not too far Pit Outdoors No Kano Gaida 2014 Dispersed 100 21 Concrete Building Well Very close Pit Water closet No Nasarawa Gurku 2013 Planned 600 20 Concrete Building Borehole Not too far Pit Yes Plateau Stefanos Foundation 2014 Transit 61 7 Concrete Building Borehole Very close Pit Water closet Yes Taraba Mullum 2014 Dispersed 212 7 Thatch Borehole Very far Outdoors No Taraba Gullum 2014 Transit 47 8 Concrete Building Borehole Not too far Pit No State Camp name Established date Camp type Approximate household number Average household size Shelter Water source Distance to water source Type of toilet Healthcare staff on camp OR visiting Borno Bakasi 2015 Planned 1739 6 Tent Borehole Not too far Pit Yes FCT Durumi 2012 Self-settled 375 19 Aluminium sheet and Polyester Borehole Not too far Pit Yes FCT Kuchingoro 2012 Self-settled 532 10 Aluminium sheet and Polyester Borehole Not too far Pit Yes Kaduna Kyuata 2014 Dispersed 4 000 10 Mud and Tent Borehole Not too far Pit Outdoors No Kano Gaida 2014 Dispersed 100 21 Concrete Building Well Very close Pit Water closet No Nasarawa Gurku 2013 Planned 600 20 Concrete Building Borehole Not too far Pit Yes Plateau Stefanos Foundation 2014 Transit 61 7 Concrete Building Borehole Very close Pit Water closet Yes Taraba Mullum 2014 Dispersed 212 7 Thatch Borehole Very far Outdoors No Taraba Gullum 2014 Transit 47 8 Concrete Building Borehole Not too far Pit No Open in new tab Audit findings Table 3 outlines the available resources identified on each camp and how they scored against each standard under the WASH, shelter and health headings. Findings across all camps showed 5 of 15 standards assessed were met to some extent, including availability of water and shelter. Sanitation, vaccination, planning and community involvement standards were unmet in over half of the sites. Table 3 Summary of standard attainment Sectors Audit standards No. of camps per resource Standards attainment WASH sector 1 Access and water quantity Eight borehole, one well Partially met Two very close, six not too far, one very far 2 Environment free from human faeces Eight pits, two water closet, two outdoor Unmet 3 Appropriate and adequate toilet facilities Partially met 4 Waste collection and disposal One drainage Unmet Five throwing on ground, four burning, two burying 5 Physical, environmental and chemical protection measures Unmet 6 Hygiene promotion implementation Four WASH, five health education Unmet Shelter, settlement and non-food items 7 Strategic planning Two planned, two self-settled, three dispersed, two transit Unmet Two tent, one thatched, one mud, four concrete, two aluminium and polyester 8 Covered living space Two tent, one thatched, one mud, four concrete, two aluminium and polyester Partially met 9 Individual, general household and shelter support items Seven food distribution, seven NFI distribution, five medical aid Partially met Health action 10 Health service delivery Six camps with accessible health services (on camp, visiting or emergency options) Partially met 11 Prioritizing health services Unmet 12 Human resources Four health staff resident, four health staff visiting Unmet 13 Drugs and medical supplies Three camps Unmet 14 Communicable disease prevention Four WASH, five health education, five immunization Unmet 15 Prevention of vaccine-preventable diseases Five camps Unmet Sectors Audit standards No. of camps per resource Standards attainment WASH sector 1 Access and water quantity Eight borehole, one well Partially met Two very close, six not too far, one very far 2 Environment free from human faeces Eight pits, two water closet, two outdoor Unmet 3 Appropriate and adequate toilet facilities Partially met 4 Waste collection and disposal One drainage Unmet Five throwing on ground, four burning, two burying 5 Physical, environmental and chemical protection measures Unmet 6 Hygiene promotion implementation Four WASH, five health education Unmet Shelter, settlement and non-food items 7 Strategic planning Two planned, two self-settled, three dispersed, two transit Unmet Two tent, one thatched, one mud, four concrete, two aluminium and polyester 8 Covered living space Two tent, one thatched, one mud, four concrete, two aluminium and polyester Partially met 9 Individual, general household and shelter support items Seven food distribution, seven NFI distribution, five medical aid Partially met Health action 10 Health service delivery Six camps with accessible health services (on camp, visiting or emergency options) Partially met 11 Prioritizing health services Unmet 12 Human resources Four health staff resident, four health staff visiting Unmet 13 Drugs and medical supplies Three camps Unmet 14 Communicable disease prevention Four WASH, five health education, five immunization Unmet 15 Prevention of vaccine-preventable diseases Five camps Unmet Open in new tab Table 3 Summary of standard attainment Sectors Audit standards No. of camps per resource Standards attainment WASH sector 1 Access and water quantity Eight borehole, one well Partially met Two very close, six not too far, one very far 2 Environment free from human faeces Eight pits, two water closet, two outdoor Unmet 3 Appropriate and adequate toilet facilities Partially met 4 Waste collection and disposal One drainage Unmet Five throwing on ground, four burning, two burying 5 Physical, environmental and chemical protection measures Unmet 6 Hygiene promotion implementation Four WASH, five health education Unmet Shelter, settlement and non-food items 7 Strategic planning Two planned, two self-settled, three dispersed, two transit Unmet Two tent, one thatched, one mud, four concrete, two aluminium and polyester 8 Covered living space Two tent, one thatched, one mud, four concrete, two aluminium and polyester Partially met 9 Individual, general household and shelter support items Seven food distribution, seven NFI distribution, five medical aid Partially met Health action 10 Health service delivery Six camps with accessible health services (on camp, visiting or emergency options) Partially met 11 Prioritizing health services Unmet 12 Human resources Four health staff resident, four health staff visiting Unmet 13 Drugs and medical supplies Three camps Unmet 14 Communicable disease prevention Four WASH, five health education, five immunization Unmet 15 Prevention of vaccine-preventable diseases Five camps Unmet Sectors Audit standards No. of camps per resource Standards attainment WASH sector 1 Access and water quantity Eight borehole, one well Partially met Two very close, six not too far, one very far 2 Environment free from human faeces Eight pits, two water closet, two outdoor Unmet 3 Appropriate and adequate toilet facilities Partially met 4 Waste collection and disposal One drainage Unmet Five throwing on ground, four burning, two burying 5 Physical, environmental and chemical protection measures Unmet 6 Hygiene promotion implementation Four WASH, five health education Unmet Shelter, settlement and non-food items 7 Strategic planning Two planned, two self-settled, three dispersed, two transit Unmet Two tent, one thatched, one mud, four concrete, two aluminium and polyester 8 Covered living space Two tent, one thatched, one mud, four concrete, two aluminium and polyester Partially met 9 Individual, general household and shelter support items Seven food distribution, seven NFI distribution, five medical aid Partially met Health action 10 Health service delivery Six camps with accessible health services (on camp, visiting or emergency options) Partially met 11 Prioritizing health services Unmet 12 Human resources Four health staff resident, four health staff visiting Unmet 13 Drugs and medical supplies Three camps Unmet 14 Communicable disease prevention Four WASH, five health education, five immunization Unmet 15 Prevention of vaccine-preventable diseases Five camps Unmet Open in new tab Achievement of minimum standards The proportion of standards met were mostly shelter-related and was followed by those WASH-related as illustrated in Table 3. Inadequate provision of waste disposal facilities for solid waste excreta and drainage was observed in all nine camps and severe overcrowding in five camps. Most of the IDP leaders responsible for managing camp affairs had no recollection of any needs assessments ever having been conducted. The findings showed health-related standards attainment was the lowest and this was of major concern. It was observed that only three of four camps with health services facilities had basic medical amenities like weighing scales, beds, stethoscopes and essential drugs. In addition, two camps which reported having healthcare on-site, referred to services provided by traditional birth attendants. Overall, health programme implementation was uneven with formally recognized camps having more access to health services, in contrast to dispersed settlements who reported having no direct access to health staff. Findings distribution by location Attainment by camp locations shown in Table 4 showed two camps were planned, in contrast to five camps which were either self-settled or dispersed camp types. Camps nearer to the crisis locations were more planned whereas those further away were mostly self-settled. Also, the camps further away from the crisis state had less access to resources. The camp in the main crisis location, Borno state, had the highest number of standards met when compared to camps in Kaduna and the FCT which were the most distant locations. Review of each camp by sectors showed attainments were mostly ‘Partially met’ or ‘Unmet’ in over 70% of camps, as reflective in the overall minimum standards findings (Table 3). Table 4 Attainment by location and sector Zone State Camp name Camp type Location sector overall score (15) Met Partially met Unmet North-West Kano Gaida Dispersed 5 3 7 North-West Kaduna Kyuata Dispersed 0 4 11 North-East Taraba Mullum Dispersed 0 4 11 North-East Borno Bakasi Planned 11 3 1 North-Central Nasarawa Gurku Planned 4 10 1 North-Central FCT Durumi Self-settled 3 3 9 North-Central FCT Kuchingoro Self-settled 3 3 9 North-East Taraba Gullum Transit 2 7 6 North-Central Plateau Stefanos Foundation Transit 8 6 1 Sector attained scores (135) 37 42 56 Total score attainable by Sector Wash (54), Shelter (27), Health (54) WASH Shelter Health WASH Shelter Health WASH Shelter Health 10 (20.4%) 9(33.3%) 17(31.5%) 23(40.7%) 7(25.9%) 13(24.1%) 21(38.9%) 11(40.7%) 24(44.4%) Zone State Camp name Camp type Location sector overall score (15) Met Partially met Unmet North-West Kano Gaida Dispersed 5 3 7 North-West Kaduna Kyuata Dispersed 0 4 11 North-East Taraba Mullum Dispersed 0 4 11 North-East Borno Bakasi Planned 11 3 1 North-Central Nasarawa Gurku Planned 4 10 1 North-Central FCT Durumi Self-settled 3 3 9 North-Central FCT Kuchingoro Self-settled 3 3 9 North-East Taraba Gullum Transit 2 7 6 North-Central Plateau Stefanos Foundation Transit 8 6 1 Sector attained scores (135) 37 42 56 Total score attainable by Sector Wash (54), Shelter (27), Health (54) WASH Shelter Health WASH Shelter Health WASH Shelter Health 10 (20.4%) 9(33.3%) 17(31.5%) 23(40.7%) 7(25.9%) 13(24.1%) 21(38.9%) 11(40.7%) 24(44.4%) Shading represents attainment of 6 or more standards in each camp location Open in new tab Table 4 Attainment by location and sector Zone State Camp name Camp type Location sector overall score (15) Met Partially met Unmet North-West Kano Gaida Dispersed 5 3 7 North-West Kaduna Kyuata Dispersed 0 4 11 North-East Taraba Mullum Dispersed 0 4 11 North-East Borno Bakasi Planned 11 3 1 North-Central Nasarawa Gurku Planned 4 10 1 North-Central FCT Durumi Self-settled 3 3 9 North-Central FCT Kuchingoro Self-settled 3 3 9 North-East Taraba Gullum Transit 2 7 6 North-Central Plateau Stefanos Foundation Transit 8 6 1 Sector attained scores (135) 37 42 56 Total score attainable by Sector Wash (54), Shelter (27), Health (54) WASH Shelter Health WASH Shelter Health WASH Shelter Health 10 (20.4%) 9(33.3%) 17(31.5%) 23(40.7%) 7(25.9%) 13(24.1%) 21(38.9%) 11(40.7%) 24(44.4%) Zone State Camp name Camp type Location sector overall score (15) Met Partially met Unmet North-West Kano Gaida Dispersed 5 3 7 North-West Kaduna Kyuata Dispersed 0 4 11 North-East Taraba Mullum Dispersed 0 4 11 North-East Borno Bakasi Planned 11 3 1 North-Central Nasarawa Gurku Planned 4 10 1 North-Central FCT Durumi Self-settled 3 3 9 North-Central FCT Kuchingoro Self-settled 3 3 9 North-East Taraba Gullum Transit 2 7 6 North-Central Plateau Stefanos Foundation Transit 8 6 1 Sector attained scores (135) 37 42 56 Total score attainable by Sector Wash (54), Shelter (27), Health (54) WASH Shelter Health WASH Shelter Health WASH Shelter Health 10 (20.4%) 9(33.3%) 17(31.5%) 23(40.7%) 7(25.9%) 13(24.1%) 21(38.9%) 11(40.7%) 24(44.4%) Shading represents attainment of 6 or more standards in each camp location Open in new tab Discussion Main finding of this study Our study represents the first audit to assess IDP conditions and access to resources by settlement types. The results showed significant disparities between IDP living standards in Nigeria and the Sphere minimum standards. None of the 15 standards reviewed was fully ‘met’ (achieved in all nine camps), five standards were ‘partially met’ and the other 10 standards were ‘unmet’. Furthermore, there was an observed difference in resource availability by camp types and locations. This implies a gap exists in the availability of health-related services provided to IDPs across the country, and this could compromise their health and well-being. What is already known on this topic A study by Tunçalp et al. in 2015, focused on health facilities for displaced populations and access to services, showed that levels of conflict and displacement were associated with the availability of critical services, such that areas with high concentrations of IDPs had less service availability.13 The review by Porter and Haslam31 showed that IDPs living in institutional and temporary accommodation, like transit camps, experienced restricted opportunities and had worse health outcomes. Conversely, the study by Kiboneka et al.,32 focussing on HIV treatment for IDPs, did not find worse outcomes for IDPs resident in camps compared to those in urban dwellings. However, the study did not investigate the variance between different camp types.32 The geographical spread of shelters, as observed in this study, is a significant factor to be considered for the protection of IDPs. In addition, the dispersed layout in settlements like Gaida camp has a significant impact on security, cultural activities and use of resources.33 Consequently, the camp type, location, size, residential spread and management are factors that influence living conditions of IDPs in camps and subsequently their health-related outcomes. Limited access to basic resources such as clean water and adequate sanitation, especially in camps not formally recognized, is generally associated with poor health and well-being.34,35 This increases health risks and susceptibility of the IDPs to various health and well-being challenges.11 Poor disposal of waste observed in all the camps increases the risk of surface water, groundwater and environmental pollution.36 Despite availability of toilets, some IDPs preferred defecating in open fields. Since all the camps sourced water directly from the ground, through boreholes and wells, such practices could lead to both water and food contamination. In addition, inadequately disposed solid waste provided breeding sites for disease vectors like flies, cockroaches and rats, further increasing the risk of infectious diseases associated with poor management of water disposal and sanitation is the increase in malaria. Nigeria is a malaria endemic location,37 and several IOM Nigeria DTM reports highlight need to place the control of malaria as high priority. Overcrowding is a known issue in these situations. Studies have shown overcrowding is associated with of high risks of water, food and air-related diseases; especially malaria, diarrhoea and respiratory infections.5,16,38 The audit showed that camps had household sizes ranging from 10 to 21, and the camps mostly overcrowded were categorized as self-settled or dispersed. Considering all the camps audited had been established for at least 1–4 years, such living conditions could have long-term health implications such as tuberculosis.35 Previous studies identified an association between health knowledge and health protection. Camps with no health education had poorer living environments and unsafe hygiene practices during handling of food and water.34,39,40 An IDP situation assessment in Nigeria linked poor WASH practices to the following morbidity figures: diarrhoea (39.6%), skin infections (10.4%), eye infections (0.9%), with diarrhoeal diseases incidence at 19% among children under-5 and malaria consultations at 47% for all age groups.39 The hygiene-related standard unmet in most camps could be linked to the lack of appropriate facilities especially in the camps with no WASH resources or health education interventions. Building health knowledge, attitude and practice capacities among displaced populations is a key contributor to health protection and should not be neglected.41 This was shown in the study by Bile et al.42 where promotion of health education activities, as part of a primary healthcare intervention package in camps for displaced mothers, increased their knowledge on vital health issues like prevention and control of diarrhoea, infant feeding, reproductive health, personal hygiene and immunization. Although over 50% of the health sector standards were either ‘met’ or ‘partially met’, the key factors required for delivering effective services, such as the availability of health staff and medical supplies, were lacking. Evidences have shown gaps in the presence of skilled health staff has been linked to delays in recognition of disease outbreaks.43 Such delayed awareness has further been associated with excess mortality in IDP populations compared to refugees or non-displaced residents.9 Overall disparities displayed a fundamental weakness in healthcare management and monitoring of IDPs living in camps. External humanitarian support is critical in providing sufficient skilled human resources required to effectively manage health issues in emergencies. This relates to evidence from other studies that showed the presence of external support from non-governmental organizations (NGOs) and United Nations organizations were associated with a greater likelihood of health service provision.13,44 Humanitarian support, especially when done in collaboration between organizations,45 could increase overall aid effectiveness and reach more IDP locations. Most of the recent IDP initiatives tend to be focused on the North-East region, the main conflict region.46 IDPs in other regions like the FCT were at a disadvantage because they were practically overlooked.24 The Borno state camp, which is formal, received the most supportive interventions (e.g. resource provision and medical aid) and NGO involvements. Rapid assessments from January 2016 were mainly focused on Borno state. This could be because it was the main conflict point and more people were affected.47 Other factors that have caused high levels of unmet needs in similar settings included low levels of assistance and insecurity.17,43 Consequently, effective deployment of conventional prevention interventions is a major challenge in conflict and post-conflict situations. Furthermore, providing humanitarian assistance was indicated to be easier if the IDPs were not scattered across a region.5,48 What this study adds Evidence on humanitarian interventions for this population has been weak.3 This study contributes by highlighting the disparity and inequality in access to required basic resources by IDPs in Nigeria, with emphasis to settlement types. A major strength of the study is the contribution to evidence on health-related interventions among IDP populations, which could be used in planning, management and development of interventions in any humanitarian response situations. Limitations of this study This audit was based on a cross-sectional study of self-reports, within the context of ongoing population movement and an evolving post-conflict situation, and represents only one point in time. Due to active violence in some states several IDP settlements were inaccessible. However, the nine camps visited represented ~8000 IDPs. The results need to be interpreted within the study context and audit period, and care would be required when generalizing the findings to other settings. The audit questions, although simplified, were not always answered fully as some IDP leaders found a few questions difficult, and gave responses based on personal experiences which may not represent the experiences of the IDP camp residents. It is acknowledged that the audit questionnaire requires further adaptation to make it more culturally acceptable. Direct observation of resources was not possible in some locations due to insecurity and time constraints, so it was not possible to corroborate all answers given with what was provided in the camps. Conclusion Our findings show the poor living conditions and uneven distribution of resources for IDPs in Nigeria. The settlement location also had an influence on access to services. Overall, the limited access to health-related resources increased the risks of water, food and air-related diseases especially malaria, diarrhoea and respiratory infections. This information can be used at an operational level by practitioners and policy makers to design the environmental, infrastructure and monitoring interventions to effectively manage IDP situations and ensure camps are meeting international humanitarian and health standards. Further research is required to show the association between resource availability and specific health outcomes. Supplementary data Supplementary data are available at the Journal of Public Health online. Acknowledgements The study is part of a self-funded PhD research conceptualized and designed by the first author W.E. We acknowledge Dr Sidi Ali-Mohammed, Head Humanitarian Assistance, Resettlement and Rehabilitation on the Presidential Committee on the North-East Initiative (PCNI), for his support in providing country displacement data. 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TI - An audit of healthcare provision in internally displaced population camps in Nigeria
JO - Journal of Public Health
DO - 10.1093/pubmed/fdy141
DA - 2019-09-30
UR - https://www.deepdyve.com/lp/oxford-university-press/an-audit-of-healthcare-provision-in-internally-displaced-population-GEduIIeWbA
SP - 583
VL - 41
IS - 3
DP - DeepDyve
ER -