In 2018, South Sudan entered its fifth year of conflict, a humanitarian crisis endured by the country and one that continues to intensify and expand: the spread of violence and economic decline threatens the population’s health, security and subsistence. An estimated 5.1 million people will suffer from food insecurity this year, with the most vulnerable among the country’s population — minors, women, people with disability, old people — still suffering conflict-related repercussions such as violence or a lack of access to basic services. Insecurity and forced displacement have undermined an already precarious farming production, destroying livelihoods in agriculture and shepherding and causing food shortages. The nutritional situation has continued to deteriorate over the past four years and hunger and malnutrition have intensified in scale and severity: close to 1.1 million children under five and around 672,500 pregnant women or women breastfeeding are estimated to suffer from acute malnutrition.
This crisis also affects the resources available to public authorities and delays in civil servants’ salary payments translates into the fractured delivery of basic services such as health care. The destruction of medical centres, attacks on health personnel, and a shortage of medicines and health care professionals means that access to health care services is scarce for the South Sudan population — only 22% of health care facilities are in operation, with the absence of services constituting an increase in the population’s morbidity and mortality. Close to 80% of services are NGO run and depend on the availability of funds from donors/humanitarian agencies. Moreover, the ongoing conflict and insecurity have made people reluctant to seek medical assistance, thereby impeding timely medical care and contributing to the spread of diseases.
This complex situation also affects the nutritional situation of the population, and more acutely minors, who are susceptible to a combination of malnutrition and water-related illnesses, for instance cholera, which are difficult to treat simultaneously. The low supply of health services also hinders the capacity to pinpoint and treat severe acute malnutrition (SAM) and moderate acute malnutrition (MAM) before they worsen. The conflict has also exposed part of the population at risk in terms of protection: while men and boys run the risk of being recruited by armed actors, detained and even murdered, women and girls face the possibility of being kidnapped, injured and/or murdered, or being victims of every form of gender-based violence, including sexual violence, both in the home and in public spaces. Women and female children, especially homes headed by women and minors, are more exposed and vulnerable to sexual assaults while they carry out daily tasks such as fetching water or firewood.
The health sector is the most affected by the current conflict, which has destroyed an already weak system. Inside medical facilities, violence against patients and health care workers is commonplace, and these facilities have also been looted, occupied and destroyed, with health personnel displaced inside and outside the country, while the allocation of governmental resources for health has been redirected to military and security expenditure. In 2018, 472 attacks have been documented on medical services, including the death of 115 health workers.
Today only a fraction of existing health establishments are still in operation. Primary health care services and Basic Emergency Obstetric and Newborn Care (BEmONC) are extremely limited, while secondary and tertiary hospitals have a limited or non-existent capacity for diagnosis and lack specialist equipment and facilities.
This is in addition to the widespread shortage of essential medicines, despite the re-stocking of medicines led by OMS, UNFPA and UNICEF to render a service to all health care facilities in operation, albeit with severe limitations.
Internally displaced people, who make up a significant percentage of the population given the violence and conflict in the country, have moved into informal settlements that receive no aid or protection from the international community and which are often inaccessible due to security concerns. Generally speaking, in these environments health services are limited to emergency mobile clinics providing very basic primary health care services, and there is a huge shortage of the health-care-related human resources needed to offer essential services. On average, a doctor tends to a population of 100,000 people, while two nurses assist 1,000 people. In addition, a large percentage of health staff are under-qualified and are often absent from their posts due to poor wages and delayed salary payments.
The Peace Agreement signed on 30 October last year opened up a small window of hope, although without inclusive and sustainable peace the current humanitarian crisis will continue to intensify. Beyond the signed agreement, conflicting parties must take concrete steps to consolidate the said agreement, such as respecting international law and ending attacks on humanitarian personnel and civilians.
In the meantime, four million women, men and minors from South Sudan will need health care humanitarian services in 2019. However, a lack of sufficient funding (in 2018, only 40% of funds requested by the United Nations [UN] were acquired) will leave almost half the population without the health care they need and, according to the UN, only 2.2 million people will receive support. These needs will almost certainly be heightened if we include the 300,000 refugees and returnees — a result of the Peace Agreement — who are all expected to require health services. The existing challenges to health systems, already significant in their own right, will be compounded by a lack of control over water quality, measures to prevent and control infections, the management of sanitary waste and widespread malnutrition.
The number of people to be allocated medical care in 2019 will increase by 8% in comparison to 2018; this is on account of a number of factors: displacement, malnutrition, the high amount of ailments from communicable diseases, vaccine-preventable diseases, and planning with regard to viral haemorrhagic fevers, including the threat of Ebola in 12 of the country’s counties. Moreover, seasonal outbreaks of communicable diseases, such as cholera and measles, and the ongoing endemicity of malaria, will pose a huge challenge to an extremely fragile health system.
Displaced populations face the most complex challenges in accessing health services. Among the country’s population, children under five are the most vulnerable to vaccine-preventable diseases due to malnutrition and low levels of coverage for immunisation and immunity. In 2017 and 2018, coverage for all vaccine-preventable diseases was still below 50%, making 42% of children under a year old at risk of catching measles. Furthermore, women of reproductive age face serious health risks, owing to limited access to qualified health staff during pregnancies and births. Finally, sexual violence and gender violence have worsened, with an increase in numbers that were already high: 4,310 cases in 2016 and 5,732 in 2017, and still without access to suitable services. Transversal problems such as HIV and AIDS, tuberculosis, mental health, disabilities and non-communicable disease, including care for traumas, are being withdrawn from vital services.
At the present time, NGOs are managing four out of every five health care establishments, which means that the continuity of services depends on the funds available. In Jonglei (where Médicos del Mundo works) and Upper Nile, only 211 of the 318 establishments currently have some form of sustainable funding, and without any real guarantee of financing in 2019; even if funds are available, they only go to 150 establishments.
IPC forecasts (Integrated Food Security Phase Classification) show that eight counties could reach catastrophic levels that cause further diseases. The high risk of Ebola in 12 counties demands strict health measures, if not the spread of the disease could lead to an epidemic across the whole country. Recommendations stemming from a needs analysis indicate that 10 counties are at risk of high rates of General Acute Malnutrition, GAM, (> 15%), displacements (> 5,000) and IPC (Phase 5), leading to a greater risk of diseases.
In 2017, MdM España began working in the country following the alarming famine declared in February and April 2017. The Médicos del Mundo project is implemented in the Bor district, located in the south-east of Jonglei State, with the counties of Fangak, Ayod, Nyirol, Uror and Pibor inside this zone the worst affected, and, in the absence of humanitarian aid, reaching famine (IPC phase 5).
There are countless humanitarian needs regarding the situation in South Sudan, which is why MdM is committed to strengthening its current intervention. Rights-holders and particularly vulnerable groups such as children under five and women of reproductive age will be the specific focus of services provided on nutrition, child health care and sexual and reproductive health in maternity, as well as in paediatric hospital wards. Furthermore, community activities have been set up to strengthen effective access to hospital services and with gender- and psychosocial-based approaches, and to strengthen advocacy actions aimed at the international community and South Sudan government. MdM sets out to create awareness on the nutritional situation and emergency health, providing information on gaps in health services and the emergency response to gain funds in order to guarantee coverage for reproductive, mental health, psychosocial support, gender, paediatrician and nutritional services.