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

Abstract

IntroductionIs 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.MethodsWe 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).ResultsTwenty-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%).ConclusionHealth 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.

Assessing the Impact of Integrated Community-Based Management of Severe Wasting Programs in Conflict-Stricken South Sudan: A Multi-Dimensional Approach to Scalability of Nutrition Emergency Response Programs

“…The country did not record significant gains during the millennium development goals era and is predicted to fall behind in the sustainable development goals era [36]. With a shrinking fiscal policy space and inadequate health spending, health governance and service models are compromised, often compounded by a fragmented health system that depends heavily on UN agencies, international NGOs, and other humanitarian aid organisations [37]. These challenges make it difficult to engage communities and government departments as co-designers and co-implementers and to embed CMSW programs fully into national health systems.…”

Strengthening vaccination delivery system resilience in the context of protracted humanitarian crisis: a realist-informed systematic review

“…Finally, one ecological study looked at the effectiveness of development financing for health in South Sudan, linking macro-level donor and government investment in health to outcomes at national level through a population survey. This study concluded that despite considerable domestic instability, donor funding to support HSS had resulted in statistically significant improvements in measles (11.2% improvement in coverage, +/- 4.2%, p<0.001), DTP3 (13.1 +/- 3.6, p<0.001) and all-vaccination coverage (11.3, +/- 3.0, p<0.001) over 5 years from 2011-2015, albeit from low levels (48). These global findings covered marked variation at sub-national level, for which the study could offer not mechanism-based explanation as data on information on service delivery models and partnerships at this level were not gathered.…”

“…Seven studies considered health financing interventions that ranged in focus from adaptive capacity building, to potentially transformative activities. These included two that looked at macro-level financing -specifically the value or otherwise of development aid in promoting improved health outcomes, including for vaccination, and system-strengthening in Gavi supported countries (47,48); one study that considered private sector provider engagement in routine immunisation provision (49); and four that considered in one way or another improvements to local level incentives for vaccination delivery (50)(51)(52)(53). Of these four, three studies considered explicit incentivisation to facilities or health workers via pay for performance (P4P) (50)(51)(52); and one considered improvements to disbursement of programme funds to local level to promote vaccination delivery as a means of reducing the risk of delayed payment to HCWs (53).…”

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

“…South Sudan experiences a high volume of population movements and cross-border travel from both DRC and Uganda [8][9][10]. Nascent health and public health infrastructure, ongoing conflict, insecurity, population displacement and poor infrastructure limit the country's ability to rapidly respond and contain or limit an outbreak [11][12][13]. As South Sudan's health infrastructure works to recover from a protracted complex humanitarian emergency, the impact can be severe if an Ebola outbreak is not detected and contained early.…”