Feasibility of health systems strengthening in South Sudan: a qualitative study of international practitioner perspectives

Assessment of prices, availability and affordability of essential medicines in Juba County, South Sudan

BACKGROUND

Access to safe, effective, affordable, and high-quality medications has been included in the Sustainable Development Goals (SDGs) of the United Nations as a crucial step towards attaining universal health coverage. Access to medicines is a fundamental human right. If medicines are accessible and affordable, they save lives by reducing mortality and morbidity associated with acute and chronic diseases. WHO recommends that all countries voluntarily reach the minimum target of 80% availability of medicines by 2025. The primary purpose of this research is to assess access to essential medicines in Juba County, South Sudan.

METHODS

This study was undertaken using the standard World Health Organization/Health Action International Organization (WHO/HAI) approach for surveying the prices, availability, and affordability of medicines. A survey was conducted in six payams of Juba County, South Sudan, and 55 health facilities were assessed.

RESULTS

Prices for generic medicines were better in faith-based health facilities with a median price ratio of 1.95. Private pharmacies and private clinics had MPRs of 4.64 and 4.32, respectively. Local prices were high compared to International referent prices. Availability of medicines was highest in the faith-based health facilities (65.5%) and slightly lower in private pharmacies (55.4%), private clinics (57.7%) and public (50.4%) sectors. Most of the surveyed medicines were unaffordable. The medicines needed to treat non-communicable diseases cost up to 33.7-day wages for one full course of treatment.

CONCLUSIONS

In South Sudan, medicines are poorly available in all sectors. Medicines are affordable in the public sector but Most medicines are unaffordable in private pharmacies, private clinics and faith-based health facilities. Poor medicines availability in the public sector contributes to the overall unaffordability of medicines in all the other sectors.

Bridging the humanitarian-development divide in a protracted crisis: a case study of the use of a central plant to supply oxygen for COVID-19 case management in South Sudan

The rising demand for medicinal oxygen due to the COVID-19 pandemic exacerbated an underlying chronic shortage of the commodity in Africa. This situation is particularly dire in protracted crises where insecurity, dysfunctional health facilities, poor infrastructure and prohibitive costs hinder equitable access to the commodity. Against this backdrop, the Ministry of Health of South Sudan, with the guidance of its partners, procured and installed a pressure swing adsorption central oxygen supply plant to address the shortfall. The plant aimed to ensure a more sustainable and technologically appropriate medicinal oxygen supply system for the country and to bridge the humanitarian and development divide, which had always been challenging. This article discusses the key issues, challenges and lessons associated with the procurement and installation of this plant. The major challenges encountered during the procurement and installation of the plant were the time it took to procure and install in the face of urgent needs for medicinal oxygen and its short and long-term sustainability. Lessons learnt include the need for exhaustive and evidence-based considerations in deciding on which source of medicinal oxygen to deploy in protracted crisis settings. The successful installation and operationalization of the plant demonstrated that it is possible to bridge the humanitarian-development divide amidst the complexities of a protracted crisis and an ongoing pandemic. The Ministries of Health, with the support of its partners, should assess and document the impact of this and other similar central oxygen production plants in protracted crisis settings regarding their sustainability, cost, and effectiveness on medicinal oxygen supply. The Ministry of Health of South Sudan should expedite the finalization and operationalization of the longer-term public-private partnership and continue to monitor the quality of oxygen produced by this plant.

"Midwives are heroes of the country": qualitative evaluation of a midwifery education program in South Sudan

Background

Countries affected by armed conflict have higher maternal mortality than stable settings. South Sudan has one of the highest maternal mortality ratios in the world, with an estimated 789 maternal deaths per 100,000 live births. Long-term socio-political instability has contributed to significant challenges in its health system. To reduce maternal and newborn morbidity and mortality, South Sudan must increase the number of skilled midwives.

Methods

A cross-sectional mixed methods study was conducted in 2022 to assess the midwifery education program at three schools receiving support from International Medical Corps in South Sudan, including in-depth interviews with 15 midwifery school graduates currently working as midwives, their supervisors, 16 school faculty (in dyads), and two Ministry of Health officials; and nine focus group discussions with women clients of graduate midwives.

Results

Participants identified strengths of the schools, including being well equipped with trained and competent teaching staff, competency-based curriculum, including practical training which prepared graduate midwives to apply their skills in practice. Weaknesses of the program included its dependence on donor funding, inadequate mentorship and number of tutors, and insufficient practice for some services due to low client load at clinical sites. Additionally, participants identified challenges affecting midwives' ability to provide good quality care, including lack of equipment and supplies, low client load, low salaries, and insecurity due to conflict. Nevertheless, women in the community appreciated the immense work that midwives do. Midwives were respected by the community at large, and graduates expressed pride and satisfaction in their job, as well as the positive impact they have had in providing critical services to communities.

Discussion

Overall, the quality of the midwifery education program appears to be strong, however gaps in the program and the provision of quality care remain. The findings highlight the need to ensure sustained funding for midwifery education, as well as health system strengthening to ensure midwives can practice their skills. Continued investment in midwifery education and training is critical to reduce high maternal mortality and morbidity in South Sudan.

Health system evaluation in conflict-affected countries: a scoping review of approaches and methods

INTRODUCTION

Strengthening health systems in conflict-affected settings has become increasingly professionalised. However, evaluation remains challenging and often insufficiently documented in the literature. Many, particularly small-scale health system evaluations, are conducted by government bodies or non-governmental organisations (NGO) with limited capacity to publish their experiences. It is essential to identify the existing literature and main findings as a baseline for future efforts to evaluate the capacity and resilience of conflict-affected health systems. We thus aimed to synthesise the scope of methodological approaches and methods used in the peer-reviewed literature on health system evaluation in conflict-affected settings.

METHODS

We conducted a scoping review using Arksey and O'Malley's method and synthesised findings using the WHO health system 'building blocks' framework.

RESULTS

We included 58 eligible sources of 2,355 screened, which included examination of health systems or components in 26 conflict-affected countries, primarily South Sudan and Afghanistan (7 sources each), Democratic Republic of the Congo (6), and Palestine (5). Most sources (86%) were led by foreign academic institutes and international donors and focused on health services delivery (78%), with qualitative designs predominating (53%). Theoretical or conceptual grounding was extremely limited and study designs were not generally complex, as many sources (43%) were NGO project evaluations for international donors and relied on simple and lower-cost methods. Sources were also limited in terms of geography (e.g., limited coverage of the Americas region), by component (e.g., preferences for specific components such as service delivery), gendered (e.g., limited participation of women), and colonised (e.g., limited authorship and research leadership from affected countries).

CONCLUSION

The evaluation literature in conflict-affected settings remains limited in scope and content, favouring simplified study designs and methods, and including those components and projects implemented or funded internationally. Many identified challenges and limitations (e.g., limited innovation/contextualisation, poor engagement with local actors, gender and language biases) could be mitigated with more rigorous and systematic evaluation approaches.

Health services supervision in a protracted crisis: a qualitative study into supportive supervision practices in South Sudan

Background

The health system in South Sudan faces extreme domestic resource constraints, low capacity, and protracted humanitarian crises. Supportive supervision is believed to improve the quality of health care and service delivery by compensating for flaws in health workforce management. This study aimed to explore the current supervision practices in South Sudan and identify areas for quality improvement.

Methods

The study employed qualitative approaches to collect and analyse data from six purposefully selected counties. Data were collected from 194 participants using semi-structured interviews (43 health managers) and focus group discussions (151 health workers). Thematic content analysis was used to yield an in-depth understanding of the supervision practices in the health sector.

Results

The study found that integrated supportive supervision and monitoring visits were the main approaches used for health services supervision in South Sudan. Supportive supervision focused more on health system administration and less on clinical matters. Although fragmented, supportive supervision was carried out quarterly, while monitoring visits were either conducted monthly or ad hoc. Prioritization for supportive supervision was mainly data driven. Paper-based checklists were the most commonly used supervision tools. Many supervisors had no formal training on supportive supervision and only learned on the job. The health workers received on-site verbal feedback and, most times, on-the-job training sessions through coaching and mentorship. Action plans developed during supervision were inadequately followed up due to insufficient funding. Insecurity, poor road networks, lack of competent health managers, poor coordination, and lack of adequate means of transport were some of the challenges experienced during supervision. The presumed outcomes of supportive supervision were improvements in human resource management, drug management, health data reporting, teamwork, and staff respect for one another.

Conclusion

Supportive supervision remains a daunting task in the South Sudan health sector due to a combination of external and health system factors. Our study findings suggest that strengthening the processes and providing inputs for supervision should be prioritized if quality improvement is to be attained. This necessitates stronger stewardship from the Ministry of Health, integration of different supervision practices, investment in the capacity of the health workforce, and health infrastructure development.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08637-4.

How can humanitarian services provision during mass displacement better support health systems? An exploratory qualitative study of humanitarian service provider perspectives in Cox's Bazar, Bangladesh

Health services provision in mass displacement settings is a humanitarian imperative and essential to promoting international and regional security. Internationally displaced populations experience a range of issues pre-, peri-, post-displacement and residing in host countries that affect their health and well-being. This study examined links between humanitarian and government health services provision for forcibly displaced Myanmar nationals (FDMN) in Cox's Bazar to consider how improved knowledge sharing and collaboration might better support health systems during mass displacement. We conducted a qualitative descriptive study, interviewing 25 humanitarian service providers in-person in Bangladesh in early 2021 and analysing data thematically. We found that government restricted what essential services humanitarian health actors could provide and FDMN had to undergo stringent screening and referral to receive tertiary healthcare. Concurrently, the government health system was challenged by accessibility, affordability and availability of medicines, equipment, and trained staff. Humanitarian health service providers augmented government responses by working with community groups, recruiting and training Rohingya volunteers, and involving religious leaders. Findings suggest that easing barriers to a fuller range of health services, allowing access to digital devices, and hiring FDMN to support their communities would improve health system responsiveness to the legitimate needs of FDMN displaced around Cox's Bazar. It is imperative to amplify and listen to the voices of FDMN and collaborate in addressing structural and social barriers constraining their access to effective health services, both to increase trust in and responsiveness of the health system.

Factors influencing severity of recurrent malaria in a conflict-affected state of South Sudan: an unmatched case-control study

BACKGROUND

The burden of malaria remains the highest in sub-Saharan Africa and South Sudan is not an exception. The country has borne the brunt of years of chronic warfare and remains endemic of malaria, with increasing mortality and morbidity. Limited data still exists on factors influencing the recurrence of severe malaria, especially in emergency contexts such as South Sudan, affected by various conflicts and humanitarian situations. This study therefore aimed to investigate factors influencing severity of occurrence malaria in selected primary healthcare centres in South Sudan. This would assist and guide in malaria prevention, treatment, and eradication efforts.

METHODS

We conducted an unmatched case-control study using routinely collected clinic data for individuals aged 1 year and above who received a diagnosis of severe malaria at 3 primary healthcare centres (PHCC); Malual Bab PHCC, Matangai PHCC and Malek PHCC between September 15, 2019 to December 15, 2019 in South Sudan. Patient characteristics were analyzed using simple descriptive statistics. Inferential statistics were also conducted to identify the associated factors influencing recurrence of severe malaria. All analyses were conducted using R Version 3.6.2.

RESULTS

A total of 289 recurrent malaria cases were included in this study. More than half of the participants were female. Overall, the prevalence of severe recurrent malaria was 66.1% (191) while 74.4% (215) did not complete malaria treatment. Among those who did not complete malaria treatment, 76.7% (165) had severe recurrent malaria, while among those who completed malaria treatment 35.1% (26) had severe recurrent malaria (p < 0.001). There is a significant association between marital status (OR 0.33, 95% CI 0.19-0.56, p < 0.001), employment status (OR 0.35, 95% CI 0.14-0.87, p = 0.024), the use of preventive measures (OR 3.82, 95% CI 1.81-8.43, p < 0.001) and nutrition status (OR 0.22, 95% CI 0.13-0.37, p < 0.001). When adjusted for employment, marital status, nutritional and prevention measures in turns using Mantel-Haenszel test of association, this effect remained statistically significant.

CONCLUSIONS

Our study showed that there is a high prevalence of severe recurrent malaria in South Sudan and that a significant relationship exists between severe recurrent malaria and antimalarial treatment dosage completion influenced by certain personal and social factors such as marital status, employment status, the use of preventive measures and nutrition status. Findings from our study would be useful for effective response to control and prevent malaria in endemic areas of South Sudan.

Use of mobile medical teams to fill critical gaps in health service delivery in complex humanitarian settings, 2017-2020: a case study of South Sudan

The vulnerable populations in the protracted humanitarian crisis in South Sudan are faced with constrained access to health services and frequent disease outbreaks. Here, we describe the experiences of emergency mobile medical teams (eMMT) assembled by the World Health Organization (WHO) South Sudan to respond to public health emergencies. Interventions: the eMMTs, multidisciplinary teams based at national, state and county levels, are rapidly deployed to conduct rapid assessments, outbreak investigations, and initiate public health response during acute emergencies. The eMMTs were deployed to locations affected by flooding, conflicts, famine, and disease outbreaks. We reviewed records of deployment reports, outreach and campaign registers, and analyzed the key achievements of the eMMTs for 2017 through 2020. Achievements: the eMMTs investigated disease outbreaks including cholera, measles, Rift Valley fever and coronavirus disease (COVID-19) in 13 counties, conducted mobile outreaches in emergency locations in 38 counties (320,988 consultations conducted), trained 550 healthcare workers including rapid response teams, and supported reactive measles vaccination campaigns in seven counties [148,726, (72-125%) under-5-year-old children vaccinated] and reactive oral cholera vaccination campaigns in four counties (355,790 vaccinated). The eMMT is relevant in humanitarian settings and can reduce excess morbidity and mortality and fill gaps that routine health facilities and health partners could not bridge. However, the scope of the services offered needs to be broadened to include mental and psychosocial care and a strategy for ensuring continuity of vaccination services and management of chronic conditions after the mobile outreach is instituted.

South Sudan's road to universal health coverage: a slow but steady journey

Amidst the myriad of challenges that constrain good quality health care services delivery in the World's youngest nation, South Sudan, there is a beacon of hope. The country's revitalized peace agreement offers a new impetus for rebuilding the country, including its health system. Key achievements in the health care sector of the country such as development and implementation of a health sector strategic and health sector stabilization and recovery plans and implementation of a Boma Health Initiative programme which aims to scale up health services delivery at the community level provide a foundation on which acceleration of universal health coverage could rest. Other key achievements include polio-free certification of the country, significant reductions in the prevalence of Guinea Worm and other neglected tropical diseases and timely detection and response to the ongoing COVID-19 outbreak. Moving forward, attainment of universal health coverage in the country requires a strong and people-centred primary healthcare approach which will ensure that services reach the last mile. Bridging the humanitarian-development nexus is required to ensure accelerated recovery of the country's health system. Furthermore, scaling up of community-based health initiatives such as the Boma Health Initiative as platforms for taking good quality health services to the hard-to-reach areas is imperative. This Journal Supplement highlights the key achievements and challenges on the road to universal health coverage in South Sudan and provides evidence-based information for rapidly scaling up health services provision.

Exploring female frontline health workers' role and capacities in COVID-19 response in India

BACKGROUND

Sendai Framework for Disaster Risk Reduction emphasises building local capacities for disaster risk management. This article asks: What role did female frontline health workers (FFHWs) play in preparing, responding and managing health emergencies in India and how did information and communications technology (ICT) platforms hinder or facilitate their capacities?

METHODS

FFHWs' experiences in providing subnational and local health response to the COVID-19 pandemic in six states in India - Odisha, Bihar, Madhya Pradesh, Uttarakhand, Kerala and Maharashtra - was collected using semi-structured interviews. Data were thematically analysed, and studied within the government policies and guidelines to tackle the emerging concerns in COVID-19.

RESULTS

FFHWs were involved in planning, responding and managing COVID-19 cases, providing awareness and undertaking surveillance within their regions. Moreover they were also responsible to continue with essential health and nutrition service delivery to pregnant women and young infants. They relied on various information and communications technology (ICT) platforms in managing their tasks despite facing several challenges. Besides receiving training from hospitals and health officials, FFHWs received information on COVID-19 and prevention through different channels and modes: majority of them reported TV channels, news coverage, and videos sent on Whatsapp groups.

CONCLUSIONS

There are underlying gender inequalities within the health system whereby limited resources and opportunities are available for the FFHWs, which extends to their use of ICT platforms in health emergencies. Using ICT in an equitable and just manner provides an opportunity to support local action for health resilience swiftly and promptly by building capacities and increasing representation of the frontline workers. This understanding can be further grounded around issues of equity, participation, representation in a gender-responsive health system.

Providing Quality of Care in Fragile and Vulnerable Settings: Lessons from South Sudan

BACKGROUND

In 2020, the World Health Organization (WHO) released a report concerning planning and actions to provide quality of care in fragile, conflict-affected, and vulnerable areas. South Sudan, the world's newest country, has encountered both natural and man-made disasters in recent years that have posed marked challenges to delivery of care. The Southern Sudan Healthcare Organization (SSHCO) operates as a non-governmental organization (NGO) in this setting, delivering and improving healthcare through war, flooding, and infectious outbreaks.

OBJECTIVE

The goal of this paper is to highlight the challenges faced in providing care in South Sudan from an NGO perspective and apply the recent WHO guidelines on quality of care to optimize practical implementation.

METHOD

Each of the WHO's eight elements for quality of care in South Sudan were examined in relation to the experience of SSHCO from 2013-2021. Analysis included: 1. summary of the WHO element; 2. examples of successful implementation; 3. barriers to implementation; and 4. recommendations to improve implementation.

FINDINGS

The team found that communication and coordination were the most important aspects of improving quality of care in South Sudan. These should be prioritized and include intergovernmental partners, the local and national Ministry of Health (MOH), NGOs, and community stakeholders. Communication and coordination should foster community engagement, improved data collecting and reporting, and sharing of publicly accessible information. Better clinical staff training and governance are also required to ensure the most effective use of limited resources.

CONCLUSION

South Sudan faces many barriers to quality of care with communication and coordination identified among the foremost issues. Practical application of the WHO elements of quality of care can assist NGOs in effectively identifying areas for improvement to deliver better quality essential health services.

The introduction of advanced practice physiotherapy within Dutch primary care is a quest for possibilities, added value, and mutual trust: a qualitative study amongst advanced practice physiotherapists and general practitioners

Background

Despite the increased deployment and added value of Advanced Practitioner Physiotherapy (APP) in musculoskeletal care internationally, APP is not yet widely accepted within Dutch primary care. This may be due to specific constraints in the implementation of APP within the Dutch healthcare system. This study aimed to explore the experiences and perceptions of Advanced Practitioner Physiotherapists (APPs) and General Practitioners (GPs) with respect to implementing APP within Dutch primary care.

Methods

This explorative and interpretive qualitative study included 12 APPs and 3 GPs who were in various stages of implementing an APP care model. Semi-structured interviews were conducted between January and March 2021. The topic list was based on existing literature, the personal input of researchers, and the Constellation Approach framework. Data were analysed using a thematic inductive approach.

Results

Four main themes emerged from the data; 1) Both GPs’ trust in APP and a clear added value of APP are critical for starting implementation, 2) APPs need continuous support from GPs, 3) APPs believe that their position needs strengthening, and 4) Implementation of the APP model creates tension over ownership. These four themes highlight the perceived difficulties in gaining trust, lack of clarity over the added value of APP, ambiguity over APPs’ professional profile and positioning, a need on behalf of GPs to maintain authority, lack of reimbursement structure, and the struggle APPs face to strike a balance with current care.

Conclusion

This study demonstrates that implementing an APP model of care is challenging, in part, because the deployment of APP does not sufficiently align with the core values of GPs, while GPs appear reluctant to hand over control of elements of patient care to APPs. APPs do not appear to have ownership over the implementation, given their strong dependence on the practice, values and needs of GPs.

Trial registration

Ethical approval was obtained from the Medical Ethics Committee of VU University Medical Centre in Amsterdam; reference number 2020.17 . All participants were asked to provide written informed consent prior to participating in the study.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-07906-6.

Health System Governance in Settings with Conflict-Affected Populations: A Systhematic Review

Health system governance has been recognised as critical to strengthening healthcare responses in settings with conflict-affected populations. The aim of this review was to examine existing evidence on health system governance in settings with conflict-affected populations globally. The specific objectives were: (i) to describe the characteristics of the eligible studies; (ii) to describe the principles of health system governance; (iii) to examine evidence on barriers and facilitators for stronger health system governance; and (iv) to analyse the quality of available evidence. A systematic review methodology was used following PRISMA criteria. We searched six academic databases, and used grey literature sources. We included papers reporting empirical findings on health system governance among populations affected by armed conflict, including refugees, asylum seekers, internally displaced populations, conflict-affected non-displaced populations and post-conflict populations. Data were analysed according to the study objectives and informed primarily by the Siddiqi et al. (2009) governance framework. Quality appraisal was conducted using an adapted version of the Mixed Methods Appraisal Tool. Of the 6,511 papers identified through database searches, 34 studies met eligibility criteria. Few studies provided a theoretical framework or definition for governance. The most frequently identifiable governance principles related to participation and coordination, followed by equity and inclusiveness and intelligence and information. The least frequently identifiable governance principles related to rule of law, ethics and responsiveness. Across studies, the most common facilitators of governance were collaboration between stakeholders, bottom-up and community-based governance structures, inclusive policies, and longer-term vision. The most common barriers related to poor coordination, mistrust, lack of a harmonised health response, lack of clarity on stakeholder responsibilities, financial support, and donor influence. This review highlights the need for more theoretically informed empirical research on health system governance in settings with conflict-affected populations that draws on existing frameworks for governance.

Disaster risk management during COVID-19 pandemic

Disaster causing threats and damages to human lives and properties leading toward economic losses can be classified as natural, biological, technological, and societal disasters. Disaster risk management primarily include (i) limiting exposure to hazardous preagents and reducing vulnerabilities and, therefore, chances for disaster to occur; (ii) formulating strategies and preparedness in terms of gathering resources and making a blueprint of actions; (iii) real-time response during a disaster, and (iv) recovery and rehabilitation of affected people. The current pandemic in the form of COVID-19 has given rise to integrating health into the overall disaster risk management strategies. The current chapter aims to develop a framework for integrating health or biological disaster management into the overall disaster risk management protocols and principles. It also suggests a shift from the traditional approach of reactive response after the outbreak/occurrence of the health disaster to a more proactive approach of health risk mitigation by building capabilities across the nation through the development of healthcare services and infrastructure to combat health disasters. Health emergencies or disasters occur due to outbreaks of diseases and indirectly due to other natural calamities or disasters, causing disruption and collapse of healthcare facilities and limiting the access of the majority of people to healthcare services. Sustainable Development Goal-13 mentions the need of urgent actions to be taken and sets targets to combat the impact of climate change causing natural disasters. It is also discussed how to minimize risk and losses during COVID-19 and the required preventive measures to be taken during pandemic in the light disaster risk reduction (DRR) framework. Therefore the guidelines developed in this chapter aim at building a resilient healthcare infrastructure alongside assuring the supply of basic needs viz. water, medicine, food, electricity, and communication during emergencies. It also estimates cost relative to the country’s budget or Gross Domestic Product (GDP) required to build an appropriate healthcare infrastructure for disaster management and performs an economic analysis of cost and benefit.

Health priority-setting for official development assistance in low-income and middle-income countries: a Best Fit Framework Synthesis study with primary data from Ethiopia, Nigeria and Tanzania

BACKGROUND

Decision making process for Official Development Assistance (ODA) for healthcare sector in low-income and middle-income countries involves multiple agencies, each with their unique power, priorities and funding mechanisms. This process at country level has not been well studied.

METHODS

This paper developed and applied a new framework to analyze decision-making process for priority setting in Ethiopia, Nigeria, and Tanzania, and collected primary data to validate and refine the model. The framework was developed following a scoping review of published literature. Interviews were then conducted using a pre-determined interview guide developed by the research team. Transcripts were reviewed and coded based on the framework to identify what principles, players, processes, and products were considered during priority setting. Those elements were further used to identify where the potential capacity of local decision-makers could be harnessed.

RESULTS

A framework was developed based on 40 articles selected from 6860 distinct search records. Twenty-one interviews were conducted in three case countries from 12 institutions. Transcripts or meeting notes were analyzed to identify common practices and specific challenges faced by each country. We found that multiple stakeholders working around one national plan was the preferred approach used for priority setting in the countries studied.

CONCLUSIONS

Priority setting process can be further strengthened through better use of analytical tools, such as the one described in our study, to enhance local ownership of priority setting for ODA and improve aid effectiveness.

An exploratory study of the barriers and facilitators to the implementation of community health worker programmes in conflict-affected South Sudan

Background

Community health workers (CHWs) are crucial for increasing access to health services to communities. Due to decades of conflict and under-funding, access to health care in South Sudan remains severely limited. To improve equitable access to healthcare, the government has introduced “the Boma Health Initiative (BHI)”, a strategy to harmonise community health programmes across the country. In order to scale up the BHI, it is necessary to assess the recent CHW programmes and draw lessons for future implementation. This study aimed to explore the characteristics, barriers, and facilitators to the implementation of CHW interventions in South Sudan between 2011 and 2019.

Methods

The study used a qualitative approach drawing from 26 key informant interviews and a scoping review of 21 Health Pooled Fund (HPF) programme reports from October 2016 to June 2018 and policy documents from 2011 to 2019. The results were thematically analysed based on a conceptual framework on factors influencing the performance of CHWs.

Results

Funding of CHW programmes has come from international donors, channelled through non-governmental organisations (NGOs) that have implemented a variety of CHW programmes. Communities have been participating in the selection of voluntary CHWs, intervention areas, and occasionally in the supervision of activities performed by CHWs. The coordination mechanisms among stakeholders have been weak, leading to wastage and duplication of resources. Although training of CHWs is done, training duration was short, and refresher-trainings were rare. There were and still are disparities in the type of incentives provided to CHWs. Monitoring and supportive supervision activities have been insufficient; drug misuse and stock-outs were common.

Conclusion

Despite their challenges, CHW programmes can be implemented in conflict-affected South Sudan if the local human capital is leveraged and engaged by NGOs as implementing partners. Robust coordination efforts are required to build synergies among stakeholders for the effective implementation of the BHI strategy.

Lessons learned from implementation of a national hotline for Ebola virus disease emergency preparedness in South Sudan

Background

The world’s second largest Ebola outbreak occurred in the Democratic Republic of Congo from 2018 to 2020. At the time, risk of cross-border spread into South Sudan was very high. Thus, the South Sudan Ministry of Health scaled up Ebola preparedness activities in August 2018, including implementation of a 24-h, toll-free Ebola virus disease (EVD) hotline. The primary purpose was the hotline was to receive EVD alerts and the secondary goal was to provide evidence-based EVD messages to the public.

Methods

To assess whether the hotline augmented Ebola preparedness activities in a protracted humanitarian emergency context, we reviewed 22 weeks of call logs from January to June 2019. Counts and percentages were calculated for all available data.

Results

The hotline received 2114 calls during the analysis period, and an additional 1835 missed calls were documented. Callers used the hotline throughout 24-h of the day and were most often men and individuals living in Jubek state, where the national capital is located. The leading reasons for calling were to learn more about EVD (68%) or to report clinical signs or symptoms (16%). Common EVD-related questions included EVD signs and symptoms, transmission, and prevention. Only one call was documented as an EVD alert, and there was no documentation of reported symptoms or whether the person met the EVD case definition.

Conclusions

Basic surveillance information was not collected from callers. To trigger effective outbreak investigation from hotline calls, the hotline should capture who is reporting and from where, symptoms and travel history, and whether this information should be further investigated. Electronic data capture will enhance data quality and availability of information for review. Additionally, the magnitude of missed calls presents a major challenge. When calls are answered, there is potential to provide health communication, so risk communication needs should be considered. However, prior to hotline implementation, governments should critically assess whether their hotline would yield actionable data and if other data sources for surveillance or community concerns are available.

Quality in crisis: a systematic review of the quality of health systems in humanitarian settings

Background

There is a growing concern that the quality of health systems in humanitarian crises and the care they provide has received little attention. To help better understand current practice and research on health system quality, this paper aimed to examine the evidence on the quality of health systems in humanitarian settings.

Methods

This systematic review was based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) protocol. The context of interest was populations affected by humanitarian crisis in low- and middle- income countries (LMICs). We included studies where the intervention of interest, health services for populations affected by crisis, was provided by the formal health system. Our outcome of interest was the quality of the health system. We included primary research studies, from a combination of information sources, published in English between January 2000 and January 2019 using quantitative and qualitative methods. We used the High Quality Health Systems Framework to analyze the included studies by quality domain and sub-domain.

Results

We identified 2285 articles through our search, of which 163 were eligible for full-text review, and 55 articles were eligible for inclusion in our systematic review. Poor diagnosis, inadequate patient referrals, and inappropriate treatment of illness were commonly cited barriers to quality care. There was a strong focus placed on the foundations of a health system with emphasis on the workforce and tools, but a limited focus on the health impacts of health systems. The review also suggests some barriers to high quality health systems that are specific to humanitarian settings such as language barriers for refugees in their host country, discontinued care for migrant populations with chronic conditions, and fears around provider safety.

Conclusion

The review highlights a large gap in the measurement of quality both at the point of care and at the health system level. There is a need for further work particularly on health system measurement strategies, accountability mechanisms, and patient-centered approaches in humanitarian settings.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13031-021-00342-z.

HIV/AIDS knowledge and attitudes assessment among women of child-bearing age in South Sudan: Findings from a Household Survey

This study assessed the determinants that shape HIV knowledge and attitudes among South Sudanese women by analysing a Multiple Indicator Cluster Survey collected from 9,061 women in 9,369 households. Generalised linear mixed model regression was performed. Fifty percent of respondents were aware of HIV/AIDS, with 21% and 22% exhibiting good knowledge and positive attitudes towards people with HIV/AIDS, respectively. When controlled for individual and community-level variables, younger women (AOR = 1.28, 95% CI: 1.01-162), women with primary (AOR = 2.19; 95% CI: 1.86-2.58) and secondary (AOR = 4.48; 95% CI: 3.38-5.93) education, and those living in urban areas (AOR = 1.40; 95% CI: 1.12-1.76) had significantly good knowledge. Women in the richer (AOR = 1.60; 95% CI: 1.08-2.36) and the richest (AOR = 2.02; 95% CI: 1.35-3.02) wealth quintiles had significant positive attitudes towards people with HIV/AIDS. Well-designed social and behavioural campaigns targeting uneducated women and those living in rural and remote settings will enhance knowledge of perceived risk, awareness, and ability to carry out preventive behaviours.

Health care workers in conflict and post-conflict settings: Systematic mapping of the evidence

BACKGROUND

Health care workers (HCWs) are essential for the delivery of health care services in conflict areas and in rebuilding health systems post-conflict.

OBJECTIVE

The aim of this study was to systematically identify and map the published evidence on HCWs in conflict and post-conflict settings. Our ultimate aim is to inform researchers and funders on research gap on this subject and support relevant stakeholders by providing them with a comprehensive resource of evidence about HCWs in conflict and post-conflict settings on a global scale.

METHODS

We conducted a systematic mapping of the literature. We included a wide range of study designs, addressing any type of personnel providing health services in either conflict or post-conflict settings. We conducted a descriptive analysis of the general characteristics of the included papers and built two interactive systematic maps organized by country, study design and theme.

RESULTS

Out of 13,863 identified citations, we included a total of 474 studies: 304 on conflict settings, 149 on post-conflict settings, and 21 on both conflict and post-conflict settings. For conflict settings, the most studied counties were Iraq (15%), Syria (15%), Israel (10%), and the State of Palestine (9%). The most common types of publication were opinion pieces in conflict settings (39%), and primary studies (33%) in post-conflict settings. In addition, most of the first and corresponding authors were affiliated with countries different from the country focus of the paper. Violence against health workers was the most tackled theme of papers reporting on conflict settings, while workforce performance was the most addressed theme by papers reporting on post-conflict settings. The majority of papers in both conflict and post-conflict settings did not report funding sources (81% and 53%) or conflicts of interest of authors (73% and 62%), and around half of primary studies did not report on ethical approvals (45% and 41%).

CONCLUSIONS

This systematic mapping provides a comprehensive database of evidence about HCWs in conflict and post-conflict settings on a global scale that is often needed to inform policies and strategies on effective workforce planning and management and in reducing emigration. It can also be used to identify evidence for policy-relevant questions, knowledge gaps to direct future primary research, and knowledge clusters.

Maternal and child health service delivery in conflict-affected settings: a case study example from Upper Nile and Unity states, South Sudan

BACKGROUND

Decades of war left the Republic of South Sudan with a fragile health system that has remained deprived of resources since the country's independence. We describe the coverage of interventions for women's and children's health in Upper Nile and Unity states, and explore factors that affected service provision during a protracted conflict.

METHODS

We conducted a case study using a desk review of publicly available literature since 2013 and a secondary analysis of intervention coverage and conflict-related events from 2010 to 2017. During June through September 2018, we conducted 26 qualitative interviews with technical leads and 9 focus groups among health workers working in women and children's health in Juba, Malakal, and Bentiu.

RESULTS

Coverage for antenatal care, institutional delivery, and childhood vaccines were low prior to the escalation of conflict in 2013, and the limited data indicate that coverage remained low through 2017. Key factors that determined the delivery of services for women and children in our study sites were government leadership, coordination of development and humanitarian efforts, and human resource capacity. Participants felt that national and local health officials had a limited role in the delivery of services, and financial tracking data showed that funding stagnated or declined for humanitarian health and development programming during 2013-2014. Although health services were concentrated in camp settings, the availability of healthcare providers was negatively impacted by the protracted nature of the conflict and insecurity in the region.

CONCLUSIONS

Health care for women and children should be prioritized during acute and protracted periods of conflict by strengthening surveillance systems, coordinating short and long term activities among humanitarian and development organizations, and building the capacity of national and local government officials to ensure sustainability.

Is development aid to strengthen health systems during protracted conflict a useful investment? The case of South Sudan, 2011-2015

Introduction

Is achievement of Sustainable Development Goal (SDG) 16 (building peaceful societies) a precondition for achieving SDG 3 (health and well-being in all societies, including conflict-affected countries)? Do health system investments in conflict-affected countries waste resources or benefit the public’s health? To answer these questions, we examine the maternal, newborn, child and reproductive health (MNCRH) service provision during protracted conflicts and economic shocks in the Republic of South Sudan between 2011 (at independence) and 2015.

Methods

We conducted two national cross-sectional probability surveys in 10 states (2011) and nine states (2015). Trained state-level health workers collected data from households randomly selected using probability proportional to size sampling of villages in each county. County data were weighted by their population sizes to measure state and national MNCRH services coverage. A two-sample, two-sided Z-test of proportions tested for changes in national health service coverage between 2011 (n=11 800) and 2015 (n=10 792).

Results

Twenty-two of 27 national indicator estimates (81.5%) of MNCRH service coverage improved significantly. Examples: malaria prophylaxis in pregnancy increased by 8.6% (p<0.001) to 33.1% (397/1199 mothers, 95% CI ±2.9%), institutional deliveries by 10.5% (p<0.001) to 20% (230/1199 mothers, ±2.6%) and measles vaccination coverage in children aged 12–23 months by 11.2% (p<0.001) to 49.7% (529/1064 children, ±2.3%). The largest increase (17.7%, p<0.001) occurred for mothers treating diarrhoea in children aged 0–59 months with oral rehydration salts to 51.4% (635/1235 children, ±2.9%). Antenatal and postnatal care, and contraceptive prevalence did not change significantly. Child vitamin A supplementation decreased. Despite significant increases, coverage remained low (median of all indicators = 31.3%, SD = 19.7). Coverage varied considerably by state (mean SD for all indicators and states=11.1%).

Conclusion

Health system strengthening is not a uniform process and not necessarily deterred by conflict. Despite the conflict, health system investments were not wasted; health service coverage increased.

Health policy mapping and system gaps impeding the implementation of reproductive, maternal, neonatal, child, and adolescent health programs in South Sudan: a scoping review

BACKGROUND

Pregnant women, neonates, children, and adolescents are at higher risk of dying in fragile and conflict-affected settings. Strengthening the healthcare system is a key strategy for the implementation of effective policies and ultimately the improvement of health outcomes. South Sudan is a fragile country that faces challenges in implementing its reproductive, maternal, neonatal, child, and adolescent health (RMNCAH) policies. In this paper, we map the key RMNCAH policies and describe the current status of the WHO health system building blocks that impede the implementation of RMNCAH policies in South Sudan.

METHODS

We conducted a scoping review (39 documents) and individual interviews (n = 8) with staff from the national Ministry of Health (MoH) and implementing partners. We organized a workshop to discuss and validate the findings with the MoH and implementing partner staff. We synthesized and analyzed the data according to the WHO health system building blocks.

RESULTS

The significant number of policies and healthcare strategic plans focused on pregnant women, neonates, children, and adolescents evidence the political will of the MoH to improve the health of members of these categories of the population. The gap in the implementation of policies is mainly due to the weaknesses identified in different health system building blocks. A critical shortage of human resources across the blocks and levels of the health system, a lack of medicines and supplies, and low national funding are the main identified bottlenecks. The upstream factors explaining these bottlenecks are the 2012 suspension of oil production, ongoing conflict, weak governance, a lack of accountability, and a low human resource capacity. The combined effects of all these factors have led to poor-quality provision and thus a low use of RMNCAH services.

CONCLUSION

The implementation of RMNCAH policies should be accomplished through innovative and challenging approaches to building the capacities of the MoH, establishing governance and accountability mechanisms, and increasing the health budget of the national government.

Health financing in fragile and conflict-affected settings: What do we know, seven years on?

Over the last few years, there has been growing attention to health systems research in fragile and conflict-affected setting (FCAS) from both researchers and donors. In 2012, an exploratory literature review was conducted to analyse the main themes and findings of recent literature focusing on health financing in FCAS. Seven years later, this paper presents an update of that review, reflecting on what has changed in terms of the knowledge base, and what are the on-going gaps and new challenges in our understanding of health financing in FCAS. A total of 115 documents were reviewed following a purposeful, non-systematic search of grey and published literature. Data were analysed according to key health financing themes, ensuring comparability with the 2012 review. Bibliometric analysis suggests that the field has continued to grow, and is skewed towards countries with a large donor presence (such as Afghanistan). Aid coordination remains the largest single topic within the themes, likely reflecting the dominance of external players, not just substantively but also in relation to research. Many studies are commissioned by external agencies and in addition to concerns about independence of findings there is also likely a neglect of smaller, more home-grown reforms. In addition, we find that despite efforts to coordinate approaches across humanitarian and developmental settings, the literature remains distinct between them. We highlight research gaps, including empirical analysis of domestic and external financing trends across FCAS and non-FCAS over time, to understand better common health financing trajectories, what drives them and their implications. We highlight a dearth of evidence in relation to health financing goals and objectives for UHC (such as equity, efficiency, financial access), which is significant given the relevance of UHC, and the importance of the social and political values which different health financing arrangements can communicate, which also merit in-depth study.

Perspectives on Rebuilding Health System Governance in Opposition-Controlled Syria: A Qualitative Study

Background: Ongoing conflict and systematic targeting of health facilities and personnel by the Syrian regime in opposition-controlled areas have contributed to health system and governance mechanisms collapse. Health directorates (HDs) were established in opposition-held areas in 2014 by the interim (opposition) Ministry of Health (MoH), to meet emerging needs. As the local health authorities responsible for health system governance in opposition-controlled areas in Syria, they face many challenges. This study explores ongoing health system governance efforts in 5 oppositioncontrolled areas in Syria.

Methods: A qualitative study design was selected, using in-depth key informant interviews with 20 participants purposely sampled from HDs, non-governmental organisations (NGOs), donors, and service-users. Data were analysed thematically.

Results: Health system governance elements (ie, strategic vision, participation, transparency, responsiveness, equity, effectiveness, accountability, information) were considered important, but not interpreted or addressed equally in opposition-controlled areas. Participants identified HDs as primarily responsible for health system governance in opposition-controlled areas. Main health system governance challenges identified were security (eg, targeting of health facilities and personnel), funding, and capacity. Suggested solutions included supporting HDs, addressing health-worker loss, and improving coordination.

Conclusion: Rebuilding health system governance in opposition-controlled areas in Syria is already progressing, despite ongoing conflict. Local health authorities need support to overcome identified challenges and build sustainable health system governance mechanisms

Health system functionality in a low-income country in the midst of conflict: the case of Yemen

Background

 Although the literature on effects of armed conflict on population health is extensive, detailed assessments of effects on public health 'systems' are few. This article aims to help address this deficit through the medium of a case study on Yemen, describing health system and health outcome performance prior to the internationalisation of the conflict there in March 2015, before assessing the impact of war on health system functionality since that time.

Method 

Review of peer- and non-peer reviewed literature from 2005 to 2016 from academic sources, multilateral organizations, donors and governmental and non-governmental organizations, augmented by secondary data analysis.

Results 

Despite significant health system weaknesses and structural vulnerabilities pre-conflict, there were important improvements in selected health outcome measures in Yemen up to early 2015 (life expectancy, and infant and maternal mortality, e.g.), partly driven by a fragile health sector that was heavily reliant on out-of-pocket expenditure, and hampered by weak service penetration especially in rural areas. High intensity conflict has resulted in rising mortality and injury rates since March 2015, the first decline in life expectancy and increase in child and maternal mortality in Yemen for some years, and worsening levels of malnutrition. Service delivery has become increasingly challenging in the context of a funding crisis, destruction of health facilities, widespread shortages of essential medicines and equipment across the country, and governance fragmentation.

Conclusion 

Conflict in Yemen has resulted in humanitarian disaster on a wide scale in a short period of time, and crippled an already weak health system. Important areas of uncertainty remain, however, including the scale of health worker flight, and the extent to which alternative providers have stepped in to fill widening service gaps as the conflict has unfolded. Planning for longer-term health system reconstruction should begin as soon as possible.