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Original research
Is development aid to strengthen health systems during protracted conflict a useful investment? The case of South Sudan, 2011–2015
  1. Joseph James Valadez1,
  2. Sima Berendes1,
  3. Jackline Odhiambo1,
  4. William Vargas1,
  5. Baburam Devkota1,
  6. Richard Lako2,
  7. Caroline Jeffery1
  1. 1 International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
  2. 2 Division of Research, Monitoring and Evaluation, Government of the Republic of South Sudan Ministry of Health, Juba, South Sudan
  1. Correspondence to Dr Joseph James Valadez; joseph.valadez{at}lstmed.ac.uk

Abstract

Introduction Is achievement of Sustainable Development Goal (SDG) 16 (building peaceful societies) a precondition for achieving SDG 3 (health and well-being in all societies, including conflict-affected countries)? Do health system investments in conflict-affected countries waste resources or benefit the public’s health? To answer these questions, we examine the maternal, newborn, child and reproductive health (MNCRH) service provision during protracted conflicts and economic shocks in the Republic of South Sudan between 2011 (at independence) and 2015.

Methods We conducted two national cross-sectional probability surveys in 10 states (2011) and nine states (2015). Trained state-level health workers collected data from households randomly selected using probability proportional to size sampling of villages in each county. County data were weighted by their population sizes to measure state and national MNCRH services coverage. A two-sample, two-sided Z-test of proportions tested for changes in national health service coverage between 2011 (n=11 800) and 2015 (n=10 792).

Results Twenty-two of 27 national indicator estimates (81.5%) of MNCRH service coverage improved significantly. Examples: malaria prophylaxis in pregnancy increased by 8.6% (p<0.001) to 33.1% (397/1199 mothers, 95% CI ±2.9%), institutional deliveries by 10.5% (p<0.001) to 20% (230/1199 mothers, ±2.6%) and measles vaccination coverage in children aged 12–23 months by 11.2% (p<0.001) to 49.7% (529/1064 children, ±2.3%). The largest increase (17.7%, p<0.001) occurred for mothers treating diarrhoea in children aged 0–59 months with oral rehydration salts to 51.4% (635/1235 children, ±2.9%). Antenatal and postnatal care, and contraceptive prevalence did not change significantly. Child vitamin A supplementation decreased. Despite significant increases, coverage remained low (median of all indicators = 31.3%, SD = 19.7) . Coverage varied considerably by state (mean SD for all indicators and states=11.1%).

Conclusion Health system strengthening is not a uniform process and not necessarily deterred by conflict. Despite the conflict, health system investments were not wasted; health service coverage increased.

  • health policies and all other topics
  • child health
  • health policy
  • health systems evaluation
  • maternal health
http://creativecommons.org/licenses/by-nc/4.0/

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.

https://doi.org/10.1136/bmjgh-2019-002093

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    Footnotes

    • Handling editor Valery Ridde

    • Twitter @BerendesSima, @BerendesSima

    • Contributors JJV, RL: conception of the research. JJV, RL, WV, BD: acquisition of data. JJV, CJ, SB: analysis. JJV, SB, BD, JO, RL: interpretation of data. JJV, SB, JO: drafting the paper. All authors were involved in critical revision of the content, approval of the final manuscript and were accountable for all aspects of the work.

    • Funding This study was funded by the Ministry of Health of the government of South Sudan through the financial support of The World Bank.

    • Competing interests None declared.

    • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

    • Patient consent for publication Not required.

    • Ethics approval The ethical committees of the MOH for the Republic of South Sudan and the authors’ home institution approved the protocol, study instruments and consent procedures. We obtained oral rather than written informed consent from all respondents, because of the high illiteracy rate.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Data availability statement Data are available upon request. With permission from the Ministry of Health of the Republic of South Sudan, LSTM will then make an anonymised version of the two data sets available on the LSTM’s Online Research Archives available at https://archive.lstmed.ac.uk/ under a creative commons licence.