A UNMISS peacekeeper checks a woman’s blood pressure at a medical camp in Nakitune village, Juba, South Sudan. Photo by: Isaac Billy / UNMISS / CC BY-NC-ND

JUBA, South Sudan — Rubbing his hand over his left thigh where he was burned during a motorbike accident, Chance Paul Dongudu softly chuckles.

“We couldn’t even reach the hospital, we fell on the road,” Dongudu said.

Last year the hotel waiter was severely sick with typhoid in his hometown in Mvolo in South Sudan’s Western Equatoria state. Driving to the nearest health care facility, 15 miles (24 km) away, he and his brother were thrown from the bike due to the poor quality of the road. It took three hours navigating a potholed dirt path before arriving at the hospital.

While Dongudu recalls the ordeal and laughs with a wry smile, he says the lack of access to health care is plaguing his community.

“People are suffering … we need help,” he said.

Half of the world’s population can’t access essential health services, according to the World Health Organization. The countries most greatly affected aren’t necessarily the poorest, but the ones with the weakest health systems — particularly fragile states in conflict zones, said Dr. Peter Salama, then-WHO deputy director-general for emergency preparedness and response, during a panel on global health and security last year.

The development of health care systems in these countries often isn’t prioritized, yet more than 2 billion people live in nations where development is affected by fragility, armed conflict, and recurring natural disasters, according to a 2017 report by Cordaid, an organization for relief and development aid in fragile states.

Healthy Access

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As part of the Sustainable Development Goals, under SDG 3, all member countries have committed to achieving universal health coverage by 2030. To meet that target, 1 billion people need to benefit from UHC in the next five years, according to a statement by WHO.

Some health experts think there needs to be a change of strategy in conflict-affected nations, such as South Sudan or the Democratic Republic of the Congo, if ailing health systems are going to improve.

“People often think that once the conflict is over then health systems start to rebuild,” said Natalie Page, health advisor with Medair, an NGO working in both South Sudan and DRC. “It takes years of investment to rebuild health systems. You can’t churn out midwives or doctors overnight.”

The system ‘isn’t working well’

The two African countries are both riddled with years of fighting, weak infrastructure, and a lack of human and financial resources. While the Abuja Declaration, signed in 2001 by African Union countries, urged all states to allocate 15% of national budgets towards health, less than 2% of South Sudan’s national budget goes toward the health ministry, according to the ministry. Approximately 6% is put toward health in DRC, although aid workers familiar with the breakdown say that in reality less than half is received — the rest is used by other government institutions and parliament.

Neither country has a nationwide health coverage plan or provides insurance for its citizens. People like Dongudu, who make around $80 a month, could end up spending a whole month’s salary or savings on medical care if they get sick.

“When you feel sick, you first have to save money before going for treatment, otherwise you won’t get help,” he said.

South Sudan’s government hospitals are overcrowded and under resourced, with a severe shortage of trained medical professionals and lack of medicine. And private clinics are expensive — at least 5,000 South Sudanese pounds (approximately $38) for an appointment, he said.

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At least 20% of South Sudan’s medical facilities have closed due to conflict according to a report by Watchlist on Children and Armed Conflict, and approximately 70% of the country’s 12 million people lack access to adequate health care.

DRC’s situation is just as grim: a similar majority of Congolese have little or no access to health care, according to the U.S. Agency for International Development, and political and economic collapse over the past three decades has had a “dramatic impact” on the country’s health system. Hospitals and clinics also lack personnel, equipment and medicine, and shortages are compounded by financial, geographical, and security challenges. While DRC is no longer at war, armed groups remain active in the East where the country is also grappling with the world’s second deadliest Ebola outbreak, which began over a year ago.

The country’s citizens also bear the cost of their care when using both state-run and private clinics. Although a law was passed in 2017 to provide health insurance, it has not yet been implemented.

“The system isn’t working well,” said Fabien Mayani, lobby and advocacy program manager for Cordaid in DRC.

People working for private companies or international organizations have access to insurance, but 80% of people in DRC work in the “informal economy,” Mayani said. This includes jobs in farming, trading, and artisanal mining, which don’t have a formal status. The challenge is getting local governments to be more responsive to these people, he said.

Struggling to find solutions

Since 2016 Cordaid has been working with DRC’s government as part of a Dutch Ministry of Foreign Affairs-funded advocacy program called Dialogue & Dissent. The five-year program focuses on supporting DRC’s government in establishing a framework to set up UHC. In July, with Cordaid’s support, the government launched the development of a strategy aimed at improving quality health care, expanding coverage, and providing financial protection for people.

The importance of building trust in fragile states

Advocacy advisor for Cordaid, Albert van Hal, said the challenge with remote communities isn’t limited to access. Building trust is crucial, but hard to do. “Decades of conflict brought distrust and distress among communities like the Congo and takes years of presence, dialogue, and good health care provision to gain their trust,” he said.

Distrust can be addressed through educating and recruiting staff from the communities, as well as through village health committees and dialogue between project leaders and local authorities. In general, Cordaid is advocating for a different approach when it comes to providing health care to fragile states to ensure that countries aren’t left behind.

Additionally, in 2018 Cordaid and local partners lobbied and succeeded in adopting a law for North Kivu province to support community insurance programs, where people self-organize and then ask the government for funds. Some community insurance programs already existed. However only one, run by teachers, is successful. Mayani said this is due to a lack of clear policies and the fact that these programs take time to set up. The organization is now trying to implement more community insurance programs, working with police and taxi drivers.

Like DRC, South Sudan is setting up its UHC roadmap. The ministry of gender, child, and social welfare has been working on its national insurance health fund policy since before the civil war erupted in 2013, a policy that would help establish the health insurance fund and provide people who have jobs with coverage. This would extend to six family members, but the policy wouldn’t cover everything — for example noncommunicable diseases such as diabetes where the medicine is expensive. While the policy was approved by the cabinet in 2013, the bill has yet to be submitted to parliament.

Undersecretary for the ministry, Esther Ikere Eluzai, worries that people in rural areas might have a hard time accessing and benefiting from the plan.

“One of the things we’re advocating to see, once the fund is established, is that it can also establish branches in the countryside, at least in all the states … that will make it easier to get health services for the people,” she said.

Long-term approach

Part of the change being pushed by the NGO, donors, and health experts is establishing a long term-approach.

“It’s not just about having available financing for a health coverage scheme, it’s about committing to an overhaul and rationalization of the health system, so that it can be sustainable long-term,” said Miriam Bassi, a global health expert. However, long-term investments in fragile contexts is “rarely a priority and a behemoth task in a place focused on daily survival,” she said.

For systems to change, significant resources and commitment from national government are needed — including investing in human resources and strengthening the use of analytical data for decision making. Health coverage needs to be looked at as a critical building block for development, Bassi said.

A different approach

 The European Union is taking this kind of approach to supporting South Sudan’s health system. Lessons are being learned from the 2013-2016 Ebola crisis in West Africa where donors were focused too much on funding “vertical programs for individual diseases or groups within the population, and not enough on horizontally funding the whole health system,” said Dr. Sinead Walsh, EU Ambassador to South Sudan.

The bulk of the €19 million ($21 million) that the EU committed in 2019 to support health care in South Sudan will support the health system as a whole, she said. This includes funding by the European Commission's humanitarian aid office for nationwide health surveillance and emergency response systems.

One of the challenges in establishing health policies in fragile contexts is the disconnect between strategies defined in headquarters — such as New York or Geneva — and how effective they are once implemented on the ground.

Initiatives developed at the international level that target individual health problems can indeed mobilize resources and boost momentum. However, they won’t be sustainable unless emphasis is put on building entire health systems and tackling the difficult issues in areas such as human resources, medicine supply systems, and health governance, Walsh said.

Sometimes such policies don’t take into account the realities of the situation and have to be better adapted to local problems, said Mayani, adding that there is a disconnect in understanding the context of very poor people in rural areas. For example, many people in rural DRC don’t understand the importance of health insurance; some expect to be able to get coverage without having to pay. Cordaid is working with local partners to try to sensitize and support people in these areas on the value of community insurance, and supports local authorities on local health planning.

Health professionals say that flexible funding from donors will allow them to be innovative in addressing the needs and gaps of vulnerable people. They also urge donors to commit to fragile states, especially once the fighting has ended, so that countries with the greatest need don’t continue to lag behind.

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About the author

  • Sam Mednick

    Sam Mednick is a Devex Contributing Reporter based in Burkina Faso. Over the past 15 years she has reported on conflict, post-conflict, and development stories from the Middle East, Africa, Asia, South America, and Europe. She recently spent almost three years reporting on the conflict in South Sudan as the Associated Press correspondent. Her work has also appeared in The New Humanitarian, VICE, The Guardian, Foreign Policy, and Al Jazeera, among others.