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The 7 plagues devastating South Sudan’s health system

Born in 2011, South Sudan is the world’s newest nation. But it has been engulfed by a self-inflicted war that has torn apart its social fabric and threatened the fledgling country’s very existence.

2018 saw the emergence of tentative signs of hope, in the form of the Revitalised Agreement on the Resolution of Conflict. But post-conflict recovery won’t be easy: out of the 189 countries on the Human Development Index, South Sudan is 186th. The country faces a myriad of challenges.

One fundamental challenge is, quite simply, to ensure its children survive. South Sudan has an under-five mortality rate of 99 per 1,000 live births – or one child in ten.

20% of those deaths are due to pneumonia, the biggest killer of children. If South Sudan continues reducing pneumonia deaths at its current rate of just 3%, it will not reach the global target of 3 pneumonia-related under five deaths per 1,000 live births – set out in the Global Action Plan for Pneumonia and Diarrhoea –  until after 2050[i].  

South Sudan’s seven plagues

Just as the country is coming to terms with the devastation wreaked by the recent locust swarms, South Sudan must now urgently respond to the COVID-19 pandemic.

It comes at a moment when – like the seven biblical plagues – South Sudan faces seven socioeconomic, political, cultural and environmental threats to the health of its children and their families.

1 Conflict

South Sudan has experienced protracted political and inter-communal conflicts have exerted a heavy toll: thousands of families forced out of their homes; horrendous human rights violations; public health services reduced to rubble. In the Fragile States Index, South Sudan is currently ranked 3rd of 178 countries and has remained in the top five for the past eight years. Any further conflict will exacerbate the impact COIVD-19 and put children who are already at high risk into greater danger.

2 Continuing political instability

Despite the signing of the peace agreement, inter-communal violence continues in Jonglei, Pibor and Warap states. The parties to the agreement have yet to unify their forces and clarify their positions, threatening the fragile peace.

As long as people are forced to live in constant fear, recovery is impossible. Political instability undermines efforts at reconciliation, nation-building, and social accountability. Uncertainty derails critical reform agendas as well as the much-awaited process to create a national constitution.

3 Weak economy

Conflict and dependency on oil revenues – whose value has plunged during the COVID-19 pandemic – have led to the collapse of South Sudan’s economy. As the next point shows, the impact on the health system and on children is devastating.

4 Chronic under-resourcing of health

With national fiscal space shrinking, critical child health services are at risk. Coverage of essential health services stands at just 44%. Many children are missing out on critical services, such as immunisation and pneumonia treatment.

The government spent just $311 million on health in 2016, a mere 1.2% of gross domestic product. Given the parlous state of the economy, health spending may shrink even further.

Compared with security and defence, which received 50% of the national budget in 2018–19, healthcare was allocated just 7%, and even less – 3% – was actually disbursed[ii]. Child mortality has increased. Many health workers have abandoned the government health sector to work with donors, international organisations or in the private sector. And out-of-pocket expenditure on health was 36% in 2016 and has been steadily increasing.

5 Weak governance and accountability

Poor governance and accountability systems have led to corruption, compounded by weak economic policies and oversight. Endemic corruption and weak institutions deprive public health services of critical investment that could have built resilience capacity to deal with COVID-19.

6 Lack of democratic institutions and civic space

South Sudan has one of the highest levels of illiteracy in the world. Right now, that means children risk missing out on information about COVID-19.

Building strong health systems and fighting pandemics requires a vibrant well-informed civil society that engages with and questions the government. An unbiased media is required that holds government accountable and creates awareness in the community. Fighting these plagues requires freedom to engage and opportunity for dialogue – building blocks for nation-building. Yet in South Sudan, they are sadly lacking. 

7 Lack of donor coordination and commitment

According to the UN Office for the Coordination of Humanitarian Affairs, in 2019, donors had only met 26% of their commitment[iii] to the South Sudan health sector. A new nation, post-conflict and on a quest to build its health systems, requires long-term predictable funding to be able to build from the ground up.  

Unless there is concerted effort from donors to support South Sudan with this mission, the country will continue to be besieged by chronically weak systems that most harm poor women and children. Humanitarian coordination – including the Humanitarian Country Team, the NGO Forum and UN Clusters – requires building local mechanisms that include South Sudanese citizens and help a stable state to emerge.

COVID-19: fuel to the fire

In a fragile country like South Sudan – with a post-conflict economy, weakened workforce, destroyed infrastructure, inadequate service delivery, weak governance, and continuing conflict and inter-communal violence – a pandemic can have a devastating impact on livelihoods and health. And on vulnerable children and their communities.

South Sudan ordered a partial lockdown to prevent the spread of the virus, in the full knowledge that its weak health system would not be able to cope. The airport was closed. Schools and other institutions were closed. But these measures were taken without any social protection plans to ensure people had money in their hands to feed their families.

The result is an economic slowdown and the threat of widespread hunger, especially as COVID-19 has arrived hot on the heels of the devastating locust attacks. At the start of June there are 994 confirmed coronavirus cases and ten deaths. Development agencies warn the worst is yet to come.

Bold action now

But right now, hunger and vaccine-preventable diseases are a more deadly danger to children than COVID-19. There is an urgent need for government, donors and civil society to work together to mitigate the effects of the seven plagues mentioned above.

  • We need to ensure adequate funding so that routine child health and immunisation services are not interrupted.
  • We need to build strong civil society voice to demand transparency and accountability from the government to ensure that health resources are used to build and strengthen the health system and not wasted in other ways.
  • The government needs to step up and put in place a social protection plan that will ensure people’s livelihoods and food security.

If we are not to be judged by history as having been negligent and irresponsible, we must be bold during this crisis.

 

 

[i] UNICEF analysis based on WHO Maternal and Child Epidemiology Estimation Group (MCEE) interim

estimates produced in September 2019, applying cause fractions for the year 2017 to United Nations Inter-agency Group for Child Mortality Estimation, estimates for the year 2018

[ii] Baseline report of the East Africa Child Policy in South Sudan, The African Child Policy Forum, 2019

[iii] HDX-OCHA Services

South Sudan's 7 plagues