South Sudan ContextOn 9 July 2011 the newest post conflict country in the world wasborn: ‘Republic of South Sudan’Socio demographic profile of Southern Sudanese has been changingrapidly in the last few years due people movement, development,and influx of NGOs and companies working in oil industry.In the last year hundreds of thousands of refugees and IDPs returnedto South Sudan from all over the world to build the new countrySouth Sudan has suffered from civil conflict for 50 years. > 2 million people died > 4 million are IDP or refugeesPeace agreement was signed in 2005
South Sudan ContextHealth services in South Sudan, not well-developed even before the war, havedeteriorated further over the decades of conflictCurrently provided largely by a patchwork ofinternational and local NGOs, to cover 25 % ofthe populationThese existing health facilities are in poorcondition, inadequately equipped, with minimaloperational capacity, and scarce humanresources. (USAID 2006)
The women in South Sudan face alarmingly lowmaternal health status to the extent that UNICEFsurvey found that:Girls in southern Sudan are morelikely to die in pregnancy andchildbirth than to finish primary school (UNFPA 2006).
Maternal health indicators (SHHS, 2006)MMR in South Sudan 2054 per 100,000 live births10 % delivered by Skilled Birth Attendants23% get ANC by any qualified personnelAccessibility to Emergency Obstetric Care is low as indicated byCaesarean Section rate of 2%
Most of the efforts of Health System includingInternational and National NGOs have been done toreduce supply side barriersUSAID, 2007: “Most of the attention is focused at thefacility level -- waiting for clients to come into thefacility, and the facilities appear to be underutilized.”However, very low utilization of accessiblematernal health care facilities in South Sudan is one ofthe major obstacles to improve maternal survival,....which is much influence by DEMAND side barriers.
A case from South Sudan • Martha is 26 years old. She lives in Malout, a small rural town in Upper Nile State in South Sudan that just emerged from 50 years of civil war conflict. • She did not receive formal education. • Her husband has a relatively good job with a Chinese oil company in a nearby village
A case from South Sudan • During her current pregnancy she didn’t get any antenatal care because she didn’t get ill. • There is one trained midwife in the town, but since this is her fifth pregnancy, she feels that there is no need to visit the midwife, particularly, she charges much more than the Daia (TBAs).
• It was September; a heavy rainy season, the woman started having pain around 9 o’clock in the evening (0hr).• The Daia was called to examine her. The Daia said that she doesn’t have a problem.• The woman didn’t deliver till the 3 o’clock afternoon of the next day (18 hrs).
• Her mother decided to go to the market to get a tractor to take her to the Hospital in Renk City (Distance: 5 hours) since the small cars can’t go through the bad and muddy road.• So she went and brought a tractor and put the woman on the back in mattress. The tractor was rented with a cost of $150 USD.
• In the midway between Malout and Renk they stopped the tractor and got down under a tree and the woman gave birth about 6 o’clock (21hrs).• The Daia went to a nearby village and brought water and cleaned the baby and the mother. The Daia couldn’t deliver the placenta and the woman started to bleed.
• They moved to the hospital and arrived there at night around 10 o’clock and the doctor was not around (25hrs).• Someone went to call the doctor, who came quickly to examine her. The doctor decided to operate immediately.• The woman didn’t cope with the bleeding and died before the operation.
ReflectionWomen should be able to stayhealthy, to make healthydecisions, and to act on thosehealthy decisions.Decision making at the level ofhousehold to seek appropriatehealth care is a very complexprocess.
ReflectionBehaviour is contextualized in thecomplexity of social institutions andcultures which determine the healthoutcome of people in eachcommunity.
ReflectionEach community has its own uniquecontext, in which we need tounderstand in order to address theirneeds and plan for accessiblematernal health care services thatcan reduce the maternal mortality.
ReflectionBetter information leads tobetter decisions whichultimately result in better health(Health Metrics Network, 2008).
But! The efforts of identifying and implementing solutions that:• Handed down from OUTSIDE• Are not rooted in the HISTORY and CULTURE• Are lacking OWNERSHIP of African countries Have repeatedly failed and in somecases, have done more harm than good (Lush et al., 2003, Ogden et al., 2003)
Research, if correctly framed anddisseminated, can provide Betterinformation
Research, if target thosewhich are hardest to reach,can provide that evidence
Research challenges Trust Illiteracy – A lack of mutual trust between the researcher (outsider) and thecompetition TRUST respondents remains the main challenge to obtain reliable information.Complexity Overcome the lack of trust and sensitive issues
Research challenges Trust – Power differences between researcher and participant, the researcher alone Illiteracy contributes the thinking that goes intocompetition ILLITERACY the project, and the subjects contribute the contents to be studied. – Dealing with sensitive issuesComplexity Increase community readiness
Research challenges Trust – Competing with NGOs that Illiteracy provide services and Food COMPETITIONcompetition – Lack of motivation to participate in any research (low response rate)Complexity Engage communities
Research challenges Trust Illiteracy – Complexity of social institutionscompetition COMPLEXITY and cultures in which behaviour is contextualized.Complexity Listen to hard to reach population
Innovative approachesReReCHI: InstitutionalizationPEER:Research & EmpowerIPHE:Local problems, local solutionsRHPM: Research & AdvocacyUCPP: Innovation for Health