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In the last decade, countries worldwide have made significant strides in efforts to eliminate neglected tropical diseases (NTDs). Collaborative efforts involving communities, governments, businesses, and NGOs have driven progress in regions endemic to NTDs. However, areas plagued by conflict and insecurity present formidable challenges to access and public health service delivery. Recognizing the urgency of addressing these issues, the USAID Act to End NTDs | East program (Act | East), led by RTI, is utilizing a conflict-sensitive approach to design and implement activities in conflict settings, notably in Ethiopia and Mozambique
Man with white left eye being inspected

NTDs, like trachoma, can be eliminated. However, conflict has prevented some countries from advancing progress toward elimination. Photo credit: RTI International/Damien Schumann.

Conflict-sensitive NTD services in action: Cabo Delgado

Our NTD work in Mozambique demonstrates how we apply conflict-sensitive approaches to deliver NTD services. Cabo Delgado, abundant in natural resources, faces significant disparities among its population. Colonial era tensions between groups in the region persist escalating from skirmishes between youth and local authorities to conflicts with Al-Shabab, a terrorist group. Since the outbreak of the current conflict in 2017, over 755,000 people have been displaced, 183 schools shuttered, and 43 health centers destroyed or vandalized.

Cabo Delgado is one of the last strongholds in Mozambique for trachoma, an NTD that can lead to permanent blindness. Despite the challenges, the government and its partners remain determined to eliminate the disease by 2030, but this is not possible unless areas in Cabo Delgado can be reached with NTD services.

As a key partner in this endeavor, our conflict-sensitive approach began with extensive information gathering. We engaged with the central and local health authorities, local NGOs, regional security managers, and other stakeholders , including United Nations entities active in the area, the World Health Organization (WHO), and Médecins Sans Frontières, among others. Insights from these groups helped us understand the conflict dynamics in Cabo Delgado and tailor NTD interventions accordingly.

In collaboration with Mozambique’s Ministry of Health, we segmented the area into three zones based  on the level of insecurity: green (most accessible), yellow (intermediate), and red (least accessible). Focusing on the green zones for safety, we communicated with the authorities and other partners before conducting activities, learning best practices from those who regularly experience the impact of the conflict.

map of Cabo Delgado

This map of Cabo Delgado from March 2022 demonstrates levels of insecurity within the region, allowing NTD workers to safely operate.

Following the assessment, the Act | East program began implementing activities in Cabo Delgado’s green zones. In September 2023, a mass treatment campaign for trachoma in Mecufi district reached more than 72,000 people. The following month, small teams conducted surveys in Montepuez, Mecufi, Metuge, and Balana districts to assess trachoma prevalence and treatment needs. Despite challenges in reaching the “yellow and red” zones, progress is being made in reducing the population at risk for trachoma in Cabo Delgado and throughout Mozambique.

Understanding conflict dynamics when supporting health services

Through our conflict-sensitive approach, we’ve learned a few lessons about delivering health services in conflict settings.

  • Context matters more than ever. Conflict zones vary greatly, requiring tailored interventions. In Cabo Delgado, understanding varied risk perspectives was essential for safe implementation.
  • Local knowledge is key. News and information can be unreliable and is often slow to emerge from conflict settings. It is critical to forge relationships with local partners and stakeholders that can provide timely and accurate updates.
  • Change is constant. Partners must be ready to adapt to dynamic conflict situations, identifying opportunities during periods of relative peace. Flexibility is crucial, especially when zone classifications shift (from green to yellow, or back, for example).
  • What’s feasible will look different. Progress may be slower in conflict zones, requiring realistic success standards and thorough planning to avoid unintended consequences. For example, we knew we needed to maintain a low profile during NTD activities in Cabo Delgado to avoid unwanted attention and reduce risk to our NTD workers. To do so, we reduced our 10-person team to just two. In Cabo Delgado, a low-profile approach and reduced workforce mitigated risks.

Our experiences in Cabo Delgado underscore the potential of conflict-sensitive approaches in navigating the complexities of NTD elimination. By addressing disparities, security challenges, and conflict dynamics,  we’ve learned invaluable lessons in conducting surveys and distributing treatments, gradually reducing the population at risk for NTDs in Mozambique.

This approach isn’t limited to Cabo Delgado; we actively apply these lessons in other conflict-affected regions, such as Ethiopia. Through collaborative efforts and meticulous planning, we persist in our mission to achieve a future free from the burden of NTDs, ensuring that progress endures even in the face of conflict.

Team dispensing medications

When conducting NTD work, large teams are often deployed, as seen here in Mozambique. A conflict sensitivity approach often requires rethinking this strategy. Photo credit: RTI International/Damien Schumann

Learn more about how RTI supports governments in finding solutions for neglected tropical diseases (NTD).