Theorising Health System Resilience in Conflict-Affected States: A Longitudinal Ethnographic Study in North East Nigeria

Health system resilience in conflict-affected settings is a theoretically contested and empirically under-investigated construct, with most existing frameworks developed in high-income and stable contexts that do not reflect the structural realities of sub-Saharan Africa. This study theorises health system resilience through a longitudinal ethnographic investigation of health service continuity, adaptive capacity, and community coping mechanisms in Borno and Yobe States across a 36-month study period. The research employs embedded participant observation, life history interviews with 60 health workers, 90 community members, and 20 humanitarian actors, alongside retrospective document analysis of health management information system data from 2019 to 2024. Monthly field visits to five purposively selected local government areas document evolving resilience practices across periods of active conflict, ceasefire, and partial displacement. Constructivist Grounded Theory underpins the methodology, enabling inductive theory generation from empirical data rather than imposing pre-existing frameworks. The study critically engages with the Blanchet et al. and Kruk et al. resilience frameworks, testing their applicability in the Nigerian conflict context and proposing an original Contextualised Resilience Framework that integrates community agency, informal health networks, and institutional adaptation as distinct analytical dimensions. Original theoretical contributions include a grounded model of resilience that accounts for political economy, security constraints, and humanitarian actor interference. Findings provide a robust basis for conflict-sensitive health system strengthening in Nigeria and comparable West African settings. Keywords: health system resilience, conflict, North East Nigeria, ethnography, theory.