Roles of local healthcare workers in the humanitarian response in South Sudan: a literature review

Abstract

Introduction: Armed conflict is devastating to the health system, is a public health concern and recovery is an enormous challenge. The independence of South Sudan in 2011 brought much hope. However, eight years later, the country is still at conflict with itself. Although rich in resources, it is ranked among the poorest in the world and depends on donor funding for most service delivery, especially health. In an international context, promoting the localisation of humanitarian aid and the integration of health services, there is a lot to learn from the roles being played by healthcare workers (HCWs) throughout the conflict in South Sudan.

Method: A literature review was conducted to identify the roles of local HCWs in South Sudan since 2011. Four databases were searched, grey literature sourced, and snowballing done to capture additional documents for a comprehensive analysis. Questions were adapted from the Critical Appraisal Skills Programme for qualitative and systematic reviews guided appraisals of the articles. Results were systematically coded, synthesised and summarised using a priori and emergent themes.

Results: The health system in South Sudan is very fragmented with heavy dependence on humanitarian aid. There is serious shortage in health workforce with heavy reliance on unskilled workers to fill in the gaps, mainly in rural settings. Although close collaboration exists among different stakeholders to deliver integrated services, poor infrastructure, insecurity, lack of capacity and donor dependency still poses a challenge towards localisation of aid and sustainability. 

Conclusions: The literature reviewed for this study indicates that the road towards localisation of health care is possible but will depend highly on continued collaboration between the different contributors, integration of services, building capacity of the nationals, increased government funding and infrastructural development. Local involvement of HCWs by international agencies is paramount in ownership and sustainability of services.

Keywords: localisation, sustainability, health system, conflict, South Sudan

Introduction

Health care workers (HCWs) operating in conflict areas are often in danger.^[1] As noted by Jones et al, “Resurgent conflict and political tensions negatively impact all health system components and maintaining, or continuing health system strengthening becomes extremely challenging.”^[2]

As a result of an underfunded health care system, humanitarian agencies often come in to meet the needs.^[3] Donors, however, have their own priorities with little flexibility.^[4] 

South Sudan has known conflict for a very long time and is classified among the world’s poorest countries with a long history of humanitarian intervention.^[5] The most recent conflicts in 2013 and 2016 resulted in more devastation by displacing over 2.3 million and putting about 3.9 million in danger of starvation.^[5] 

The main objective of this study was to explore information reported on the role(s) of local HCWs and the humanitarian response in the protracted conflict in South Sudan. 

The specific objectives of this study were to:

• Understand the roles of HCWs in facilitating or hindering the delivery of services.
• Identify the roles played by the local HCWs in the protracted conflict, and how they evolved across different health networks (public/private/non for profit/informal/transnational).
• Learn from this narrative synthesis to inform future humanitarian responses.

METHOD

Literature search

A scoping review of peer-reviewed published literature was done in late July 2019 in the databases EMBASE, Medline, Global Health and CINAHL (Cumulative Index for Nursing and Allied Health Literature) using terms and search strategies, to identify how much literature was available on the subject matter. This was followed by an in-depth review of published and grey literature with a focus on South Sudan and available policy documents related to the health sector in South Sudan over the course of the conflict. Literature specific to South Sudan not available in bibliographic database searches was obtained through Google scholar, snowballing and other search engines by a combination of words around the key concepts. 

The Critical Appraisal Skills Programme (CASP)^[6] tool was used as a guideline to create basic questions against which the literature was assessed. All literature considered for a full text read were appraised using the inclusion and exclusion criteria shown in table 1.

Table 1. Detail of the inclusion and exclusion criteria

	Inclusion	Exclusion
Topic	Articles on the health sector that mentioned the health workforce (both skilled and unskilled)	Articles that are broadly on health but no specific mention of health care workers
Participants	Health care workers and national governmental and non-governmental organisations implementing health	Articles detailing the work of international health workers only
Setting/Study designs	All relevant study designs were included	None
Study area/region	South Sudan	Outside the boundaries of South Sudan
Timeline	From 2011 onwards (This is when South Sudan voted for and became an independent state)	Studies conducted before 2011
Language	English	Non-English

Data analysis

Citations of all studies that met the inclusion criteria were exported or added manually to Mendeley but only those with available full text were considered for analysis. Narrative in-depth case studies were built into the review to document the roles of HCWs in the humanitarian response. Reports were analysed systematically 

Ethics Approval

The London School of Hygiene and Tropical Medicine’s Ethics Committee confirmed that none was required because it is a study drawing information in the literature already available publicly.

RESULTS

A total of 190 abstracts were reviewed and screened. Fifty-two articles were fully assessed, and 24 met the eligibility criteria for inclusion (Figure 1). The analysis was based on a priori themes identified in the initial stages of the project and some emergent themes that were added during the review.

Figure 1. Summary of literature search results Adapted from: Moher D, Liberati A, Tetzlaff J, Altman DG. The PRISMA Group 2009 ^[7]

DISCUSSION

Key Findings

Most researchers focused on mid- or low-cadre HCWs, who are used to fill the gaps and ensure continuity of care mainly in the Internally Displaced People’s camps and the rural areas. The Boma Health Initiative – a community centred health care program, was fully adopted and rolled out in 2016 with the central focus of strengthening health care delivery at the community level with the Community Health Workers (CHWs) at the forefront.^[8] 

Partnership: It was found that active involvement and inclusion of the government and local authorities in the design and implementation of any project promoted harmonious working relationship with the humanitarian actors.^[9] Also international NGOs who shifted their approach from implementation to work hand in hand with authorities at all levels and communities has been lauded by many as a vital step to ensure continuity of care and smooth transition to sustainability once the NGO leaves.^[9,10,11,12]

Task Shifting: One way of tackling the shortage of skilled health workforce post conflict is through task shifting. A major bottleneck identified in implementing quality maternal and newborn care was shortage of Skilled Birth Attendants, especially midwives.^[13] Trained midwives were found exclusively in facilities within the capital city while Traditional Birth Attendants were found to be common in running the facilities in remote settings.^[13] This indicates the need for appropriate task-shifting in which low level cadres are trained to deliver unmet services in remote settings. Such an initiative will require strong commitment, investment in training institutes and development of suitable curricula.^[13] 

Insider/Outsider role: Attacks or threats on health workers and health facilities were common and this deterred HCWs to go to certain areas. Some ended up as easy targets for revenge killings in some regions including in health centres.^[2] As pointed out by Sachiko et al, ethnicity can play a key role in the level of support a community may render to a programme.^[10] Buhman et al pointed out that, “The deficits of an insider may be the strengths of an outsider and vice versa.” Hence it is important for the two to work together in order to achieve a common objective.^[14] 

Localisation: Although there is a push for localisation of the health workforce to attain sustainable development post conflict, this will require commitment from all stakeholders. The new initiative being adopted by the government to focus on community health care by taking a bottom-up approach is very encouraging because CHWs are now considered core to achieving Universal Health Coverage (UHC) and the Sustainable Development Goals.^[10]

Limitations of the review

The central limitation of this review was the lack of specific studies conducted on the topic. The available literature drew from a wide scope of objectives in which maternal and child health was a major topic. There was insufficient data on specific cadres, their work, number, capacity, and responsibilities. 

Strengths of the review

All the studies reviewed were recently conducted meaning that the information contained therein are still fresh and recommendations given can be worked upon as opportunities to conduct more research awaits. The hope is that the findings generated will help change the way in which aid is being delivered in conflict prone nations. 

CONCLUSIONS AND RECOMMENDATIONS

South Sudan has been faced with difficult times since its independence from Sudan in 2011. The health sector has been much affected with poor services, frequent outbreaks of vaccine preventable diseases and shortage of HCWs. There are various humanitarian actors who have come to fill in the gaps and support the government deliver quality services. There is need for a proper coordinating mechanism and integration of services if the suffering of those most vulnerable are to be alleviated. 

We recommend the following:

1. The government must start looking into feasible ways of financing the health system. An element of cost sharing, for example the social health insurance scheme, even on a small scale like the community-based health insurance scheme, should be adopted. 
2. Develop materials on the cadres and responsibilities of the HCWs to define localisation and humanitarian responses in the context of the country. 
3. The MOH and Ministry of Education should work closely to develop relevant curricula that will support the rapid development of a health workforce to cover the existing gaps. 
4. On the global scale, humanitarian aid must be delivered with dignity and due consideration of the local context to increase the acceptability of the services being offered, build harmony between HCWs and organisations and therefore ensure greater impact of a given response.
5. Involvement of the local people at all levels from the planning and implementation of a given program by an international NGO will allow for easy transition and sustainability of the program once the NGO decides to withdraw its funding.

References

1. Colombo S, Pavignani E. Health in humanitarian crises. 3 Recurrent failings of medical humanitarianism : intractable, ignored, or just exaggerated? Lancet 017;390(10109):2314–24. http://dx.doi.org/10.1016/S0140-6736(17)31277-1 
2. Jones A, Howard N, Legido-Quigley H. Feasibility of health systems strengthening in South Sudan: a qualitative study of international practitioner perspectives. BMJ Open 2015;5(12):1–9. https://pubmed.ncbi.nlm.nih.gov/26700280/ 
3. Debarre A. Providing Healthcare in Armed Conflict : The Case of Mali. International Prce Institute Policy Brief 2019. https://www.ipinst.org/wp-content/uploads/2019/01/IPI-E-RPT-Providing-HealthcareMali.pdf
4. Debarre A. Hard to Reach: Providing Healthcare in Armed Conflict: December 2018. p14-15 https://www.ipinst.org/wp-content/uploads/2018/12/1812_Hard-to-Reach.pdf 
5. Tanner L, Moro L. Missed Out : The role of local actors in the humanitarian response in the South Sudan conflict. Report April 2016;6. https://reliefweb.int/sites/reliefweb.int/files/resources/rr-missed-out-humanitarian-response-south-sudan-280416-en.pdf
6. Critical Appraisal Skills Programme (2018). CASP (Systematic Review) Checklist (1994). Accessed: 17.06.2019. https://casp-uk.net/images/checklist/documents/CASP-Systematic-Review-Checklist/CASP-Systematic-Review-Checklist-2018_fillable-form.pdf
7. Moher D, Liberati A, Tetzlaff J, Altman DG, Altman D, Antes G, et al. Preferred reporting items for systematic reviews and meta-analyses: The PRISMA statement. PLoS Med. 2009;6(7) e1000097 https://prisma-statement.org//documents/PRISMA%202009%20flow%20diagram.pdf
8. The Republic of South Sudan. The Community Health System in South Sudan: “The Boma Health Initiative.” Juba; 2015. 
9. Erismann S, Gurler S, Wieland V, Prytherch H, Kunzli N, Utzinger J, et al. Addressing fragility through community-based health programmes: Insights from two qualitative case study evaluations in South Sudan and Haiti 11 Medical and Health Sciences 1117 Public Health and Health Services. Heal Res policy Syst 2019;17(1):20. http://www.health-policy-systems.com/home/
10. Miyake S, Speakman E M, Currie S, et al. Community midwifery initiatives in fragile and conflict-affected countries: a scoping review of approaches from recruitment to retention. Health Policy Plan 2017;32(1):21–33. http://ovidsp.ovid.com/ovidweb.cgi?T=JS&PAGE=reference&D=med13&NEWS=N&AN=27470905 
11. Mugo NS, Dibley MJ, Damundu EY, Alam A. Barriers Faced by the Health Workers to Deliver Maternal Care Services and Their Perceptions of the Factors Preventing Their Clients from Receiving the Services: A Qualitative Study in South Sudan. Matern Child Health J 2018 Nov 28;22(11):1598–606. http://www.ncbi.nlm.nih.gov/pubmed/29956127 
12. Rull M, Masson S, Peyraud N, Simonelli M, Ventura A, Dorion C, et al. The new WHO decision-making framework on vaccine use in acute humanitarian emergencies: MSF experience in Minkaman, South Sudan. Confl Health 2018;12(11). https://conflictandhealth.biomedcentral.com/track/pdf/10.1186/s13031-018-0147-z 
13. Sami S, Amsalu R, Dimiti A, Jackson D, Kenyi S, Meyers J, et al. Understanding health systems to improve community and facility level newborn care among displaced populations in South Sudan: A mixed methods case study. BMC Pregnancy Childbirth 2018;18(1):325. http://www.biomedcentral.com/bmcpregnancychildbirth/ 
14. Buhmann C, Barbara JS, Arya N, Melf K. The roles of the health sector and health workers before, during and after violent conflict. Med Confl Surviv 2010;26(1):4–23. http://dx.doi.org/10.1080/13623690903553202

More from the November 2022 issue