Impassable Not Impossible: South Sudan Expands Primary Health Care System Despite Obstacles

Impassable Not Impossible: South Sudan Expands Primary Health Care System Despite Obstacles

Trying to cross through a flooded section of road in South Sudan. {Photo credit: E. Polich/MSH.}Photo credit: E. Polich/MSH.

“We’re going to try to drive through that?”

After spending nearly two years working in South Sudan, I was on my way with two colleagues to one final meeting. The USAID-funded second phase of the Sudan Health Transformation Project (SHTP II), led by Management Sciences for Health (MSH), ended activities on July 31, 2012, and three of us needed to travel 360 kilometers (220 miles) to a results dissemination meeting. A flight booking mishap meant we had no choice but to drive --- during rainy season.

With a key bridge washed out.

And it rained --- down poured --- for over an hour the morning we left.

After passing several toppled trucks, overtaking pickups irrevocably mired in mud, and crossing through a river, we came across the point where I uttered the above quote (“We’re going to try to drive through that?”).

Rain had washed away any semblance of a road, and tire tracks sank down waist-deep, newly flooded. Trucks lined the road for kilometers approaching this point, and other vehicles sat sporadically abandoned or buried in mud, like a foreboding vehicle cemetery. One driver we spoke with had been stuck there for 50 days.

I watched as other four-by-four trucks and Land Cruisers roared off through the quagmire, sank down to their windows in mud tracks and ponds of water, spewed muck and exhaust, and fishtailed out. Or didn’t, in some cases, at which point drivers grudgingly got out shovels to dig enough water and mud out of the way to find traction.

Moses, our driver, assured me that we would make it through --- after all, we had four wheel drive. Despite his confidence, after watching the car in front of us get stuck, my colleagues and I opted to walk through the nearby farmer’s field, battling burrs and hoping to avoid snakes as we made our way to reunite with the car on the opposite end. Moses powered the vehicle through the swamp, fishtailing and sliding along the mud tracks, like some broken amusement park ride.

After 11 straight hours of driving, we arrived in Yambio. The next day, we met with state Ministry of Health officials, county health department staff, local implementing partners, and various other stakeholders to share results from SHTP II’s three years.

We started by discussing the improvements documented in SHTP II-supported counties from these three years. Coverage rates for children immunized with a third dose of the diphtheria, pertussis, and tetanus vaccine increased from 20 percent in 2006 to 86 percent in 2012. Pregnant women attending one antenatal care visit increased from 40 percent to 83 percent. Vitamin A for children under five rose from 40 percent to 51 percent.

SHTP II also provided over 66,000 family planning counseling visits, and reached more than 400,000 people with education and prevention messages about HIV & AIDS.

And as I sat in the meeting, looking over charts and data that represent real people, I felt grateful that we’d driven here instead of flying. The perilous ride reminded me that each of those achievements is possible, despite the challenges of working in fragile states like South Sudan.

In public health, we tend to write about the things that go right, but rarely do we acknowledge that part of the reason these are such tremendous accomplishments is that they happen in the face of a myriad of things that go wrong.

In South Sudan, the reality is that roads are often impassable --- vehicles get stuck in the mud. Where not even motorbikes can pass, women carry boxes of pharmaceuticals on their head dozens of kilometers to deliver quarterly consignments to facilities. Midwives travel in darkness, through swamps, without flashlights or rain boots to deliver babies in mud homes. Facilities relocate to meet the needs of people when tribal fighting or refugee influx change communities in sweeping and often unpredictable ways. Medical assistants continue conducting family planning counseling, even after they are threatened with imprisonment for providing commodities without the husband's overt consent.

Every number, chart, and graph (PDF) that came out of this project is a testament to progress in the face of great challenges like these. It is evidence of thousands of hours of work to improve service delivery, increase provider capacity, change behavior, and engage communities as South Sudan expands its primary health care system. It is evidence of partnerships forged with communities, providers, Ministry of Health officials, and other actors in the health system. It is evidence of vaccinators, health educators, logistics officers, program advisors, and drivers working together.

There are still areas for improvement, but the achievements of the past three and a half years should not be understated.  MSH is honored to have been a part of the progress achieved together with partners, and demonstrated by the project results.

As SHTP II closes its doors, I am grateful that, not only will one of my final project memories be the arduous journey to this meeting, but also the thousands of people who have been --- and are continue to be --- helped by this project.

Erin Polich, MPH, is SHTP II senior communications specialist for Management Sciences for Health in Juba, South Sudan.