Systems Thinking Framework for Strengthening Orthopaedic Trauma Care Delivery in Conflict-Affected States of North East Nigeria

The Boko Haram insurgency and its humanitarian consequences have severely disrupted orthopaedic trauma care infrastructure in North East Nigeria, creating a complex health system context characterised by fragmentation, service collapse, and dependence on humanitarian provision. This study applies a systems thinking framework to map and evaluate orthopaedic trauma care delivery in Borno, Adamawa, and Yobe States, identifying leverage points for sustainable health system strengthening. Using a critical realist ontology and embedded mixed-methods design, the research integrates group model building workshops with key health system actors, network analysis of referral and supply chain linkages, interrupted time-series analysis of trauma care outputs before and during the insurgency period, and in-depth interviews with 50 clinicians, patients, health administrators, and humanitarian actors. System dynamics modelling will simulate the impact of targeted interventions including task-shifting, mobile orthopaedic units, and pre-positioned implant caches on trauma care access and outcomes. The study hypothesises that reinforcing community-level care recognition and task-shifted stabilisation has greater system leverage than facility-level specialist expansion in the current security context. This research constitutes an original methodological contribution to health systems science by applying complex adaptive systems theory to orthopaedic trauma in conflict settings. Findings will be submitted to Lancet Global Health and disseminated to the National Emergency Management Agency and the Federal Ministry of Health. Keywords: systems thinking, orthopaedic trauma, conflict, North East Nigeria, health systems strengthening.