Swiss Red Cross support to Rural Health Services in Post Conflict South Sudan
From Humanitarian Relief to Sustainable Development
Von Ursula Schmid / Schweizerisches Rotes Kreuz SRK
Can you imagine a situation in 2011 where the majority of a population of 120’000 people in a rural district have never had access to basic health services in their life time? This was the starting point of the Swiss Red Cross funded Community Based Health Care Project in 2008 described in this article. This article will raise the question what an international NGO such as the Swiss Red Cross cooperating with a National Non-Governmental Partner needs to consider when implementing a systemic health services approach in a post war scenario.
The conclusions of this article will argue that in the transition from emergency relief to rehabilitation and sustainable development the success and sustainability of a jointly implemented project with a National Red Cross Society depends on the National Society’s role as ‘transmitter’ within the frame of acting as an auxiliary to the state. Swiss Red Cross as a funding partner needs to be aware of and prepared for long-term commitments to carry the National Society forward to be able to go beyond their core mandate and core competencies.
The 2005 Comprehensive Peace Agreement between the Government of Sudan and the Sudan People's Liberation Movement ended a 20 year war during which 2 million people lost their lives and 4 million people were displaced. Now, in 2011 the country can look back on six years of more or less stabile peace. The declaration of independence on July 9th started a new chapter in South Sudan’s history and for the first time in a century the country will be master of its own destiny. First assessments in 2006 confirmed that South Sudan is at the bottom of all human development indicators with maternal and infant mortality rates comparable to Afghanistan and the Democratic Republic of Congo. The international community has pledged its support to address the overwhelming transitional challenges from a war torn country to a functioning state.
How does the Swiss Red Cross strengthen the health delivery and systems?
In cooperation with the South Sudan Red Cross and the State Ministry of Health the Community Based Health Care Project started in 2008 and delivers the basic package of health services in accordance with the Government of South Sudan’s Health Policy. According to these policies and standards every 15’000 inhabitants refer to a Primary Health Care Unit staffed by 4 medical staff. Every 500 people or 100 households should have access to a safe water source. Latrines should be available at every school and household. Health surveillance data are reported to the Ministry of Health, supportive supervision is done through the State Ministry of Health and if possible through the County Health Department. The health policy entails a strong pro-poor approach. Presently it is impossible to introduce any system of user fees at health facility level. This policy is currently being revised and long-term health financing strategies will be launched. Swiss Red Cross together with the South Sudan Red Cross participates in the well established health cluster meetings.
The target population of the project is presently about 116’000 inhabitants and receives steadily increasing numbers of returnees and internally displaced people since the end of 2010 due to border conflicts and new laws for citizenship in North Sudan.
In four health facilities with trained health staff services such as treatment of communicable diseases (malaria, watery diarrhea, tuberculosis, measles, polio, sexually transmitted diseases) and maternal and child health interventions are provided. Outpatient numbers are at around 800 to 1000 patients per health facility per month. About 30’000 people have gained access to safe water sources through borehole drilling and rehabilitation of boreholes. Household latrines have been introduced for the first time in the area. Community activities include hygiene promotion activities by volunteers and village committees as well as reproductive health support through village based birth attendants.
Challenge 1: The danger of oversupply out of an emergency situation
The humanitarian suffering of the Nuer cattle herders and their families in the rural district of Mayendit was the initial trigger for the primary health care project. Hit by flooding and a malaria epidemic in 2008, morbidity and mortality rates in the local population were rapidly deteriorating. The civil war had left no functioning health facility and in the years since the Comprehensive Peace Agreement no government services were brought to this remote rural district.
The Swiss Red Cross and the South Sudan Red Cross found this the appropriate entry point to support the rehabilitation of health services. Within a year funding was obtained and first results in terms of infrastructure were delivered. This is a major achievement under post-war conditions with poorly functioning supply ways and low skills, and came at high costs with a strong involvement of the Swiss Red Cross and the South Sudan Red Cross. The local authorities have been consulted and as much as possible involved at all times. They were together with the communities the final decision makers on location of infrastructure.
The local authorities realised that the delivery of health services by the project would enable them to build legitimacy amongst their citizens. The conflicting demands of building political legitimacy and implementing the health policy meant that the guidelines were not followed closely enough and facilities were planned too close to each other with too small catchment areas. The project team realised that the overall disastrous health situation and the lack of governance compromised clear decision making.
Challenge 2: Security and its relevance of community involvement and vice versa
After the war free movement within the target district in Mayendit for the Nuer people and the government was not possible. Besides the lack of transport, the danger of mines, and especially the level of tension within and between the communities, limited exchange and even gatherings of the community members. Regular rattle raiding attacks and subsequent revenge attacks happened in 2008 and 2009 and often resulted in serious injuries and death.
The project team found that sub-district committees for health, water and the elderly could not meet and therefore function because the committee members feared inter-communal violence. The trauma of war and deterioration of the social fabric undermined inter-communal trust and the ability or willingness of communities to cooperate with each other. In this situation, the limited capacity, fuelled by distrust, undermined the role which local communities were able to play and slowed the project down.
The project team realised that a stable environment is necessary to reduce the risk of conflict recidivism. It was found that standard health activities could build trust and increase a feeling of security. For example the gathering of crowds for immunisation campaigns, or the showing of governance through the existence of functioning health facilities, permits a feeling of security to be established. Small activities such as the example of health staff in travelling around the county or to other states, or the exchange between the health centres, proved to be vital in building confidence and a feeling of security within the population which allowed them to play an increasingly positive role in the delivery of the project.
Challenge 3: Capacity Building versus showing results
At the start of the project the Swiss Red Cross and the South Sudan Red Cross found that the post war situation made it very difficult to recruit qualified staff for the project and the new health facilities. The project staff employed by the South Sudan Red Cross had recently returned from refugee camps and there were no graduates amongst them. The staff engaged by the Ministry of Health from the local communities at the new health facilities was in general sub-standard, and only two out of 16 staff had a nursing degree. The average length of training received was nine months.
The nature of rehabilitation interventions prioritise physical infrastructure over capacity strengthening in the short-term to produce visible outcomes. However the project team found the quality of service delivery at well equipped health facilities was being compromised by the lack of training and inadequate skills of the staff.
The project now enters into its third year and focuses stronger on skills development than in the first years. Experience suggests that due to funding and visibility requirements a long-term commitment with solid capacity building is frequently a challenge for humanitarian agencies beside the turnover of local health staff.
Conclusion: The Red Crescent/ Red Cross as partner in rehabilitation and development.
Per definition the core task of the Red Cross/ Red Crescent is disaster preparedness and management as well as volunteer training and mobilisation. However, the partners are often involved in medium to long-term projects which go beyond their core competencies and mandate. Can they fulfil this role?
The Red Cross/ Red Crescent is a local organisation and belongs to the people; its existence is neither questioned by the people nor by the government. Its strength is that donor funding can be accessed where no government funding exists. The backbones of the movement are the volunteers. That ensures a presence down to the grassroots. The fundamental principles set the non-debatable ground rules; one of them, neutrality allows it to move freely in tense security situation. Based on this the Red Cross/ Red Crescent can bridge the phase between emergency and rehabilitation until a strengthened government is able to take over.
In South Sudan the Red Cross/ Red Crescent has a greater legitimacy compared to local NGO’s. The standardised setup makes it a suitable partner for a transitional project and allows the organisation to act as a transmitter where the state does not exist. Baring in mind the above mentioned challenges, the Red Cross can support health service delivery for a limited time until the official health system can provide policies, protocols and infrastructure to the staff of the Ministry of Health.
*Ursula Schmid is Country Representative of Swiss Red Cross in the Republic of Sudan and the Republic of South Sudan. The project started in 2008 and at that time the Sudanese Red Crescent was the national partner. Since July 2011 an independent South Sudan Red Cross has been founded