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, 17,18,19, 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.
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