"Demand is key to a working health system. Yet too often, as can be seen in the case of South Sudan in recent years, financing and policy focus on the supply-side factor."
Published by World Vision United Kingdom (UK) with funding from UKaid through the Department for International Development (DFID), this research report shares the results of a scoping study carried out by the IDLgroup in an effort to help address the crisis of maternal, newborn, and child health (MNCH) in South Sudan. Data from 2010/2011 indicate that over 2,000 women per 100,000 die in childbirth each year, and 1 in 10 babies will not live to see his or her fifth birthday. Access to care among pregnant women and young children is very low, at between 20% and 40% of need, with a likelihood of still lower rates for dispersed villages. Less than 2% of children (12-23 months) are fully immunised. Malnutrition is a significant cause of poor MNCH in South Sudan. Gender inequity is reflected in the fact that family planning and wider attention to sexual health are negligible elements of local health practice and systemic support. (Editor's note, July 2017: The context has clearly changed and gotten quite a bit worse.)
In that context, the purpose of the study was to: explore the major drivers of poor MNCH in South Sudan; look at gaps in knowledge (or effective implementation) with regard to those drivers; identify priorities for World Vision policy advocacy (including research priorities); and map out important actors in the development of such policy advocacy. The paper argues that improving MNCH in a timeframe that is meaningful to families depends on strengthening and focusing health care in ways that bring quality services within people's reach, allowing them to experience their right to health.
This study included a desk-based review of relevant literature on MNCH in fragile contexts, as well as on post-Comprehensive Peace Agreement conditions in South Sudan and on South Sudanese approaches to health system strengthening in general and MNCH in particular. This was complemented by quantitative and qualitative information gathered during a 2-week field visit in September/October 2011 to South Sudan (Juba and Warrap State), largely using a semi-structured interview format.
This paper sets out 6 challenges that, together, the researchers contend should constitute priorities for action on healthcare and MNCH in South Sudan. From their perspective:
- Challenge 1: Understanding community demand for MNCH care - The social context, determinants, and barriers to demand for MNCH care are not, as yet, adequately understood in South Sudan. Investing in grounded research to comprehend these demand-side dynamics is critical to improving the potential impact of health policy, strategy, and system building. But, in addition to local drivers of MNCH thinking and behaviour, this paper argues that the way services are supplied is itself a key determinant of community perceptions and demand for care.
- Challenge 2: Improving access to care
- Challenge 2a: At present, the level of the health system physically most accessible to the majority population (the Primary Health Care Unit, or PHCU) is the weakest and least mandated to supply critical MNCH services. Where pregnancies cannot be catered for at the PHCU (which is frequently the case), women and families are expected to pursue a referral process to often-distant clinics. Constraints on transport and costs associated with referral as a whole act as disincentives to care-seeking, especially where the expectation of quality care is fairly poor.
- Challenge 2b: A corollary to this is the need to increase qualified facility-based and better trained community-based health staff. There is an argument for building qualified capacity at the PHCU level (sourced locally where possible but internationally where not), providing core facility services but simultaneously supporting and coordinating a more coherent, trained, supervised, and appropriately incentivised community outreach health worker cadre.
- Challenge 3: Focusing policy on impact and equity - National health policy, including the Health Sector Development Plan (HSDP), Basic Package of Health Services (BPHS), and Maternal, Newborn, and Reproductive (MNRH) strategy, are fitted for the long-term construction of a mature, universalist health system. If poor MNCH is to be addressed in the shorter term, national MNCH-oriented policy should focus on improving locally available and accessible antenatal, intra-partum, and immediate perinatal care. This includes promoting appropriate nutritional practices for mothers and their infants, contextualised by greater emphasis, through community outreach, on family planning and sexual health.
- Challenge 4: Strengthening data at the local level - Better health data - systematically gathered, sufficiently granular to capture the realities of health needs at the local level, and publicly available - would help focus policy on the right problems and be useful when evaluating the effectiveness and cost-effectiveness of interventions. The development of a national health information system and the periodic implementation of national census surveys are positive moves in South Sudan but need to be complemented by more localised, sentinel surveys of MNCH conditions, such as qualitative analysis of community conditions, perceptions of health need, and behaviour in MNCH care-seeking. International non-governmental organisations (INGOs) and other actors are likely to have a substantial reserve of data, case studies, and evaluations that should be brought together to form an MNCH evidence platform for dialogue around effectiveness and design, as well as use in collective advocacy.
- Challenge 5: Focusing aid and increasing national spending - Communication-related actions include: call Health Pooled Fund (HPF) donor dialogue on evidence-based MNCH priorities; promote Republic of South Sudan (RoSS) commitment to the Abuja Declaration; and the strengthen RoSS/Ministry of Health (MoH) stewardship role through joint contract performance assessments.
- Challenge 6: Understanding the imperatives of security, development, and health in South Sudan - International partners working with the government in South Sudan, especially in cases where they engage in policy dialogue, need a detailed and clear understanding of the institutions, imperatives and policy processes ongoing within RoSS itself. This would involve an analytical approach to key policy issues, including the balance of priority between security and social spending, and the ways in which intersectoral coordination is being achieved across ministries within RoSS as a basis for action on the structural social determinants of health and MNCH.
"Ultimately, action falls into two parts: on one hand, improving the underlying structural drivers of poor MNCH, in particular around the question of gender equity, addressing the social standing of girls and women, their education and their reproductive choices; on the other, and central to this paper, strengthening both supply of and demand for accessible and acceptable professional and trusted obstetric, antenatal and neonatal health services, close to communities, and embedded in wider community-based work to extend family planning, sexual health and MNCH education."
A principal feature of the report is the identification of areas in which further, more substantial research could be developed as a means to strengthening both policy-thinking and programme and project design to improve MNCH in South Sudan. For example, greater understanding of community MNCH demand requires more applied ground-level research. First, research could be designed to assess the level of awareness and demand for healthcare calibrated against the remoteness of communities. A potentially interesting outcome of this research would be a clearer sense of how remoteness mediates communities' orientation to modern and traditional healthcare models. (Distance between villages and health centres, potential costs, and low expectations of quality effective service have been raised as major barriers to demand, even where awareness is strong. However, attendance at a health facility is, in a sense, the end stage of a process of thinking and decision-making.) A second piece of research could be designed to capture and understand how decisions are made within households, and within wider community structure, about when and under what circumstances to seek external support. "An intriguing insight into the demand side of MNCH came up in village and TBA [traditional birth attendant] interviews - that complications in pregnancy were largely unknown during the period of conflict, and have arisen in the period after the peace. These findings...point to the possibility that communities associate increased risk in pregnancy and childbirth now, with the establishment and extension of a formal healthcare system. They certainly suggest that communities monitor MNCH conditions among their own households, and are engaged with seeking possible causes and solutions. This analysis supports the idea that improving community perceptions of the quality and accessibility of healthcare can strengthen the tendency of households to value and seek out such care."
In conclusion, it is noted that "[t]he emphasis on health systems is not intended in any way to detract from the long-term goal of changing deep structural drivers of poor MNCH, including gender inequity which flows through into both greater exposure to risk among girls and women, and less power to determine a safer reproductive pathway. However, the health system in South Sudan represents a kind of governance space in which technical interventions intersect with social attitudes, with policy as an expression of accountability between state and citizen. In that sense, the health system constitutes a perfect confluence of humanitarian protection, statebuilding, and sustainable institutional development - concentrated on the life chances of women, infants and children."
World Vision UK website, February 3 2017; and email from Sebastian Taylor to The Communication Initiative on July 26 2017. Image credit: © World Vision