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Getting healthcare to hard-to-reach areas

A new birth at Juba Teaching Hospital, South Sudan Elizabeth Deacon/IRIN
A new birth at Juba Teaching Hospital, South Sudan (July 2012)
Decades of war and a lack of development have left a majority of South Sudan’s population without access to any form of healthcare, resulting in some of the world’s worst health indicators. In a country where only one in four people has access to medical facilities, virtually everyone qualifies as "hard to reach", and those attempting to expand healthcare access face daunting challenges.

In the isolated, mountainous Boma District, in Jonglei State, rains cut off vehicular transport for eight months of the year. The only way in is by foot or on a weekly UN flight that takes place only when the rains have let up enough to allow aircraft to land. 

"We are working in one of the most difficult environments in one of the most challenging countries in the world. Instead of expecting people to come to us, we reach out to them to give vaccinations, health education, primary health care and referrals," said Collins Kyererezi, health agency Merlin’s primary healthcare supervisor in Boma.

"The major challenge we are facing is logistics, because from April to December the rains set in and reduce accessibility, with virtually no road access to any of the locations we are serving outside of the town. Maintaining logistical support for the clinics is virtually impossible during the rains, so everything needs to be stockpiled in advance." 

Local health workers

Only one of the four primary health units Kyererezi supervises is less than a day's walk from the Merlin hospital in Boma. The Merlin clinic at the area of Labarap, for example, is three day’s distance away. Anyone requiring hospital treatment during the rains has to be carried on foot. 

Many in Boma are nomadic pastoralists, whose movements further complicate healthcare access. And security is major a concern. In Jonglei State, violent clashes between various ethnic groups is common. 

"For me personally, my greatest concern is supervising the clinics during the wet season due to inaccessibility and banditry - sometimes it is unsafe to walk without [an armed] escort," Kyererezi said. 

Merlin, the only healthcare provider in Boma, works with a team of home-based hygiene promoters who, in addition to providing the population with basic health education and first aid, screen children under age five for malnutrition and refer complex pregnancies to Boma's basic hospital. 

But low literacy rates in Boma make it difficult to recruit local staff, and qualified staff elsewhere in the country regard the area as a hardship duty station. To meet the gap, Merlin ‘mentors’ even those with rudimentary English-language skills, providing them with a two-week crash course in the integrated management of childhood illnesses, immunization services, and maternal and child healthcare, according to Kyererezi. 

''Instead of expecting people to come to us, we reach out to them to give vaccinations, health education, primary health care and referrals ''
This approach has seen about 75 percent of children under five in Boma being reached in routine house-to-house immunization campaigns, well above the national average of 37 percent. With village health workers able to screen for pregnancy complications, about 25 percent of deliveries now take place at Boma Hospital, an improvement over past rates. A 2012 report entitled Women’s Security in South Sudan: Threats in the Home by Geneva-based think-tank Small Arms Survey (SAS)  states that 90 percent of women in South Sudan give birth away from formal medical facilities and without the help of professionally trained assistants.

Helping women

Sarah Kasoga, a doctor from Uganda who has been working in Boma for the past eight months, attributed some of the health problems in Boma to a lack of women's education and empowerment. Harmful traditional practices, such as early marriage, persist, resulting in underage pregnancies. Women are often required to obtain permission from their husbands before seeking healthcare.

"The problem is that illiteracy levels are so high, so many of our patients don't really understand about disease, and then if they do decide to seek treatment, the road network is so poor, with a lot of insecurity around, so it is very difficult for them to [access] healthcare,” she said. “Most patients only come to the hospital very late, after complications have set in, so we are generally dealing with more complicated cases that would have been easier to treat in their early stages."

Besides widespread malnutrition and pregnancy-related complications, other common illnesses in Boma include malaria, acute respiratory tract infections, acute watery diarrhoea, sexually transmitted infections, skin diseases and intestinal parasites, Kasoga said.

But the job is rewarding. The work “gives me the feeling that I am providing services to those who need them the most. I am the only doctor in a 150km radius, and I get immense satisfaction by delivering quality healthcare to the most vulnerable and marginalized groups in such an underserved area," she said.


This article was produced by IRIN News while it was part of the United Nations Office for the Coordination of Humanitarian Affairs. Please send queries on copyright or liability to the UN. For more information:

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