Opinion: South Sudan's children need community health workers to survive

A health worker marks a child's finger to indicate that she has been vaccinated at a vaccination campaign in Juba, South Sudan. Photo by: JC McIlwaine / U.N. / CC BY-NC-ND

Inadequate access to health care and malnutrition in war-stricken countries kills 20 times more children compared to violence from the conflict itself. This is one of the findings of the latest research conducted by Save the Children, highlighting poor health and nutrition as the main killer of children in conflict.

When the world’s youngest nation, South Sudan, gained independence in 2011 after more than 30 years of civil war, there was optimism that a new government and influx of donor support could turn around the nation’s nearly non-existent health sector. At independence, only 25 percent of the nation’s 10.5 million people had access to healthcare.

To gain access in South Sudan, humanitarians walk a political tightrope

Aid actors providing services to the most vulnerable in Southern South Sudan say the key to their success is being able to strategically gain favor with both the government and the opposition.

Unfortunately, not much has improved since then, and South Sudan still has one of the highest child mortality rates in the world. It hasn’t been for lack of trying or a lack of good intentions; but rather a failure to rapidly adapt solutions to our current reality. As donors and implementing agencies meet over the next few months to discuss the next phase of how to fund health in our country, we finally have the chance to get it right.

Soon after independence, various large donor emergency health programs were rolled out focusing mainly on returnees and refugees. Then, in 2012, two large multidonor health funds were established to build the country’s health system, focusing on renovating and stocking rural health facilities.

However, as continued conflict kept people on the move, the high costs of these permanent health facilities made it prohibitive, if not impossible, to achieve coverage throughout the country. While these multidonor pooled funds have strived to keep over 1,000 rural health facilities functional, the sheer magnitude of South Sudan’s health challenges and the ongoing displacement caused by continued fighting make it impossible to increase coverage.

Following the outbreak of civil war in 2013, many of these health facilities in remote rural areas have been looted and closed. Some are now caught up on the frontlines of the ongoing conflict.

At least 50 medical facilities were attacked in 2016 and 2017, according to a report by New York-based organization, Watchlist on Children and Armed Conflict. Other rural health facilities are understaffed and barely functional, going months without drugs or supplies and having only one or two staff members running the facility — instead of the nationally recommended five.

The result is that nearly half the population — and around four million children — cannot get to a health facility to get the treatment they need if they are sick.

“Although expensive to roll-out ... the BOMA Health Initiative is a more viable and realistic solution to reduce child mortality than constructing and staffing rural health facilities.”

About 850 young children die each week in South Sudan, mostly of treatable diseases. If we’re going to save children’s lives, we must move to a different healthcare model — and fast.

Thankfully, South Sudanese government and donors alike have expressed interest in a model centered on community health care, whereby community members are trained to diagnose and treat diseases like malaria, pneumonia, and diarrhea — the top three child killers in the country.

They have even proposed the ambitious BOMA Health Initiative — an enhanced version of the Integrated Community Case Management childhood illnesses program. The initiative aims to have three community health workers at each lowest administrative level — known as a “Boma” — conducting a wide array of services, such as antenatal care, vaccine, treatment of malnutrition, and treatment of most communicable diseases. Although expensive to roll-out, under current circumstances the BOMA Health Initiative is a more viable and realistic solution to reduce child mortality than constructing and staffing rural health facilities.

Despite buy-in from government and donors alike for a community health model, nearly 90 percent of the country’s health funding — which comes from donors — is still programmed around the traditional basic package of health services delivered in permanent rural health facilities. While this approach made sense in 2011, when South Sudan was going through a period of reasonable peace and stability, it does not make sense today.

Across most of South Sudan, children continue to die of treatable illnesses due to the long distance they must travel to access functional health facilities. It is not an uncommon sight to see families wading knee-high in swampy marshes — for a full day — just to reach a health facility to treat their sick child who has malaria, diarrhea, or pneumonia.

On top of the distance, sick children and their parents must contend with insecurity and rough terrain — something that would be hard to navigate at the best of times. In short, the journey is often simply not an option — even when the alternative could mean death.

Donor countries, implementing NGOs, and the South Sudanese government need to shift more of their resources to low-cost community health delivery, focusing on treating the biggest killer diseases for children: Malaria, pneumonia, and diarrhea.

These do not require a qualified health practitioner to diagnose and uncomplicated cases are all treatable at community level.

Although constructing or setting up rural health facilities might be a strategy we return to one day, we urgently need solutions that are in line with our current realities.

First, the South Sudanese government should increase its national health budget and expenditure to the health sector. This will not only make the ambitious BOMA Health Initiative possible, but will also go a long way towards restoring confidence from donors on the government’s commitment to health.

Second, the key donors who are now developing the health-pool fund for South Sudan should prioritize community management of childhood illnesses and invest in it as the most feasible approach to reducing child mortality in South Sudan today.

A successful outcome of these meetings among donors and implementing agencies, would be a decision to allocate more resources to community health initiatives such as ICCM and the BOMA Health initiative.

Only when the provision of health care is fully rolled out at community level in South Sudan will we see preventable child deaths averted, and only then will the world fulfill its promise to its newest fragile country.

The views in this opinion piece do not necessarily reflect Devex's editorial views.

About the author

  • Bester Mulauzi

    Bester Mulauzi is the director of program development and quality in South Sudan at Save the Children. At Save the Children, Mulauzi manages a team of 11 senior expatriate staff in one of the most challenging contexts in the world. He is a member of the South Sudan leadership team charged with designing and leading child health and nutrition programs in an extremely challenging environment. As a spokesperson for the organization, he has given voice to the need for increased donor investments in South Sudan. He is also featured in a prominent global development blog and podcast highlighting the maternal and child health crisis in the country.