Structural determinants of STI service delivery for internally displaced persons in Nigeria: A qualitative study of policy and humanitarian perspectives

This qualitative study reveals that STI service delivery for internally displaced persons in Nigeria is critically undermined by HIV-centric vertical financing, weak implementation of policies, and sociocultural barriers, necessitating a strategic rebalancing of funding and strengthened health systems to ensure equitable access.

The Gist

Imagine Nigeria's healthcare system as a massive, bustling hospital, but one that is currently running on a very specific, narrow power grid. This study looks at what happens when people are forced to flee their homes (becoming Internally Displaced Persons, or IDPs) and try to get treatment for sexually transmitted infections (STIs) within this system.

Here is the breakdown of the paper using simple language and everyday analogies:

1. The "VIP" Disease vs. The "Invisible" Diseases

The Analogy: Imagine a hospital where HIV is the "VIP Patient." It has its own dedicated wing, a personal security team, a steady supply of free food, and a special elevator that never stops. Because of this, the hospital staff knows exactly where the VIP is, what they need, and how to treat them.

The Reality: In Nigeria, HIV gets almost all the attention and money from international donors. It is "vertically financed," meaning it has its own separate pipeline of resources.
The Problem: Other STIs (like syphilis, gonorrhea, or chlamydia) are like patients in the waiting room with no tickets. They don't have a dedicated wing. If you have these infections, you often have to pay for your own medicine out of your pocket, or you might not find any medicine at all. The study calls this a "hierarchy of infections" where HIV is seen as the only one that matters, making everything else "invisible."

2. The "Paper Castle" vs. The "Cracked Foundation"

The Analogy: The Nigerian government has built a beautiful, magnificent castle on paper. The blueprints (policies) say, "We will care for everyone, including those in camps, and we will use modern tools like self-testing kits." It looks perfect on the drawing board.

The Reality: When you walk into the actual camp (the foundation), the walls are crumbling. The study found that while the policies exist, the implementation is broken.

• The Supply Chain: The castle has no food. Clinics in IDP camps often run out of basic antibiotics.
• The Staff: Many doctors and nurses have fled the conflict zones, leaving the camps with very few workers.
• The Result: People are told to use "syndromic management." This is like a mechanic saying, "I can't see the engine, but since your car is making a noise, I'll just pour oil in it and hope it works." Doctors treat symptoms without proper lab tests because the labs are empty or broken.

3. The "Toilet" Misunderstanding

The Analogy: Imagine a person has a painful infection. Instead of thinking, "I caught this from a partner," they think, "Oh, I must have sat on a dirty toilet."

The Reality: The study found that many people in these camps believe STIs are caused by "toilet infections" or poor hygiene rather than sexual contact.

• Why it matters: This is a way to avoid the shame of talking about sex. But it's dangerous. If you think it's a dirty toilet, you might just wash more or take random herbs, rather than getting the right medicine or telling your partner. It delays real treatment and leads to serious long-term problems like infertility.

4. The "Gatekeeper" and the "Locked Door"

The Analogy: In some parts of Nigeria, a woman trying to get medical help is like a child trying to leave the house. She can't go unless her father or husband (the gatekeeper) gives her permission.

The Reality: Cultural norms often mean men control women's access to healthcare. If a husband says "no," a woman cannot go to the clinic, even if she is sick. This is made worse in camps where women are economically desperate and might be forced into transactional sex (trading sex for money or safety), putting them at high risk for STIs but giving them zero power to say "no" or demand protection.

5. The "New Tech" Trap

The Analogy: Imagine a hospital trying to solve its problems by handing out smartphones to patients so they can "self-diagnose" via an app. It sounds futuristic and helpful!

The Reality: The study warns that while "self-care" (like testing yourself at home) and digital apps are great ideas, they don't work well in IDP camps.

• The Catch: Many people in the camps don't have smartphones, don't have internet, and can't read well. If the only way to get help is through an app, the most vulnerable people are left behind. It's like trying to give a high-tech map to someone who doesn't have a compass or a road to walk on.

6. The "House of Cards" Moment

The Analogy: The entire system is like a house of cards built on a single, shaky pillar (HIV funding).

The Reality: The paper mentions a recent event (a US funding freeze in 2025) where the main pillar supporting HIV care was suddenly pulled out. The whole structure wobbled.

• The Lesson: Because the system relied so heavily on one specific donor for HIV, when that money stopped, everything else (including the already weak care for other STIs) collapsed further. It proved that you can't build a stable health system on a single, shaky foundation.

The Bottom Line

The study concludes that Nigeria has the blueprints to fix this, but it lacks the bricks and mortar.

To fix STI care for displaced people, they need to:

1. Stop treating HIV as the only VIP: Mix the funding so other infections get support too.
2. Fix the supply chain: Make sure antibiotics and tests actually arrive at the camps.
3. Train the locals: Use community health workers who stay in the camps, rather than relying on doctors who flee.
4. Change the conversation: Talk about STIs in ways that reduce shame and involve men, so women can get help without asking for permission.
5. Build a stronger foundation: Don't rely on one donor. Create a system that can survive even if one source of money dries up.

In short: The system is currently "policy-rich but implementation-poor." It looks good on paper, but for a person living in a displacement camp, the reality is often a locked door, an empty medicine cabinet, and a long walk to nowhere.

Technical Summary

1. Problem Statement

Sexually Transmitted Infections (STIs) remain a critical public health burden in low- and middle-income countries, particularly among Internally Displaced Persons (IDPs) in conflict zones. In Nigeria, which hosts over three million IDPs, the landscape of STI care is characterized by a paradox:

• Policy Rich, Implementation Poor: Nigeria has extensive SRH policies, including self-care guidelines and humanitarian commitments (e.g., Minimum Initial Service Package). However, these rarely translate into effective service delivery for IDPs.
• Structural Marginalization: Non-HIV STIs (e.g., syphilis, gonorrhea, chlamydia) are structurally invisible compared to HIV. HIV programming dominates financing, supply chains, and surveillance, leaving non-HIV STIs underfunded, unsubsidized, and often reliant on out-of-pocket payments.
• Systemic Fragility: The health system for displaced populations is fragmented, relying heavily on informal providers (Patent and Proprietary Medicine Vendors - PPMVs), suffering from chronic commodity shortages, and lacking robust data surveillance.
• Contextual Urgency: The study was conducted prior to the January 2025 suspension of US foreign assistance (PEPFAR), which abruptly disrupted HIV supply chains, highlighting the extreme fragility of a donor-dependent, vertically financed health architecture.

2. Methodology

• Study Design: A qualitative, interpretive study grounded in the Structural Determinants of Health framework (Heller et al.) and Global Health Priority-Setting theories (Gómez et al., Smith et al.).
• Setting: Nigeria, focusing on regions with high IDP concentrations (North-East, North-West, North-Central).
• Participants: 11 semi-structured, in-depth interviews conducted between May and September 2022 with key stakeholders:
  • Federal and State Ministry of Health officials (HIV/STI units, Primary Health Care boards).
  • Representatives from UN agencies (UNFPA, WHO) and international/national NGOs.
  • Senior clinicians (Obstetrician-gynaecologists) and programme managers.
• Data Analysis: Thematic analysis focusing on institutional narratives regarding funding architectures, governance, commodity security, workforce constraints, and sociocultural norms. The analysis prioritized structural explanations over individual behavioral accounts.

3. Key Contributions

• Reframing STI Access: Moves beyond individual behavioral explanations to demonstrate how financing hierarchies and political economy dictate access to STI care. It argues that the "invisibility" of non-HIV STIs is a structural outcome of vertical funding models rather than a lack of policy.
• The "HIV-Centric" Trap: Documents how the success of vertically funded HIV programs (PEPFAR, Global Fund) has inadvertently created a "hierarchy of infections," where non-HIV STIs are deprioritized, lack dedicated budget lines, and are effectively privatized in displacement settings.
• Policy-Implementation Gap: Provides empirical evidence of the disconnect between Nigeria's progressive SRH policies (self-care, task-shifting) and the reality in IDP camps, where insecurity, workforce depletion, and weak supply chains prevent implementation.
• Sociocultural Nuance: Highlights how local narratives (e.g., attributing STIs to "toilet infections" rather than sexual transmission) and gendered power dynamics (male gatekeeping) interact with structural barriers to delay care-seeking.

4. Key Results

The study identified five interrelated structural dynamics shaping STI service delivery:

A. Funding Architecture & HIV Dominance

• HIV is the only infection with a dedicated, subsidized, and monitored supply chain.
• Non-HIV STI care is largely "privatized" within IDP camps; patients must pay for antibiotics and diagnostics out-of-pocket.
• Vertical funding silos prevent integration; HIV programs often operate independently of broader SRH or STI units.

B. Policy Abundance vs. Implementation Constraints

• While national guidelines include IDPs, operational delivery in camps is patchy.
• Humanitarian coordination often prioritizes "life-saving" services (shelter, food, obstetrics) over chronic/stigmatized conditions like STIs.
• Reliance on syndromic management (treating based on symptoms without lab confirmation) is common due to a lack of diagnostics, raising concerns about antimicrobial resistance.

C. Health System Constraints

• Commodities: Chronic stock-outs of STI diagnostics and antibiotics in conflict zones.
• Workforce: Severe "brain drain" and displacement of health workers. Services rely heavily on lower-cadre workers (CHEWs) and unregulated PPMVs, with weak supervision.
• Data: Non-HIV STI data is statistically invisible. Informal providers and humanitarian clinics do not feed data into national systems, preventing accurate burden estimation and resource allocation.

D. Sociocultural & Gender Dynamics

• Stigma & Narratives: Symptoms are often misattributed to poor sanitation ("toilet infection") to avoid sexual stigma, leading to delayed treatment.
• Gendered Power: In Northern Nigeria, women often require male permission to seek care. Economic precarity in camps drives transactional sex, increasing STI risk while limiting women's bargaining power for protection.
• Prevention Gaps: HPV vaccination is largely inaccessible to IDP girls due to cost and school displacement.

E. Emerging Innovations (Self-Care & Digital)

• Self-care interventions (e.g., HIV self-testing) are expanding but are not yet integrated for non-HIV STIs.
• Digital health platforms show promise for urban youth but are ineffective in IDP camps due to low connectivity, device access, and digital literacy.

5. Significance and Implications

• Systemic Risk: The study serves as a warning that reliance on single-donor, vertical financing (specifically HIV) creates systemic fragility. The 2025 PEPFAR disruption confirmed that when the dominant pillar falls, the entire sexual health architecture for displaced populations collapses, leaving non-HIV STIs completely unsupported.
• Policy Recommendations:
  • Rebalance Financing: Integrate non-HIV STI commodities into existing HIV and SRH procurement platforms rather than creating new parallel lines.
  • Strengthen Surveillance: Digitize data systems to include informal providers and humanitarian actors to make non-HIV STIs visible.
  • Regulate Informal Sector: Formalize and supervise PPMVs and task-shifted workers to ensure quality and antimicrobial stewardship.
  • Contextualize Self-Care: Adapt self-care and digital tools to the realities of IDP camps (e.g., low-tech solutions, zero-rated data) rather than assuming urban connectivity.
• Global Relevance: The findings offer a blueprint for understanding how structural determinants shape health outcomes in humanitarian crises globally, emphasizing that policy frameworks alone are insufficient without equitable financing and integrated supply chains.

Conclusion: Improving STI care for IDPs in Nigeria requires moving beyond "policy proliferation" to address the structural asymmetries in financing, governance, and data. Without rebalancing the HIV-dominated architecture and securing domestic financing, non-HIV STIs will remain invisible and untreated in displacement settings.