Reaching The “Last Mile” In South Sudan With Community Health Workers

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<p><em>Mother and baby watch as other community members water their vegetable gardens in Kuajok, Warrup State, South Sudan.</em></p>

Mother and baby watch as other community members water their vegetable gardens in Kuajok, Warrup State, South Sudan.

Jon Warren/World Vision

For the first time in her life, Freedom Santo – a traditional healer in South Sudan – recently felt positive recognition from both her government and her community. She is part of a group of traditional healers incorporated into a new cadre of community health workers (CHWs) blessed by the new government in South Sudan.

She underwent a one-week training on identification of danger signs in children for three diseases with which she’s been familiar all her life. She was acquainted with the signs and symptoms mentioned during the training, and learned more about how to react when she encounters a child with a danger sign.

This new level of frontline health workers will extend essential health services coverage to fulfill the new global agenda of universal health coverage. And on a personal level, the opportunity to serve her community has made Freedom feel proud and useful.

To achieve universal health care, the World Health Organization (WHO) recommends an average of 4.1 essential health workers (e.g., doctors, nurses/midwives, pharmacists) per 1,000 people. However, in Africa, there are 1.6 health workers per 1,000 people on average, with South Sudan one of 36 countries that do not meet this WHO criterion.

Moreover, only 20% of the health workforce in South Sudan is located at the sub-district level, meaning an average 80% of health staff do not render preventive or basic level services to people in their communities. To fill this gap, World Vision employs a community human resources task-shifting strategy in a program known as community case management.

CHWs like Freedom are key to accelerating progress in achieving universal coverage, but these efforts are not cheap: millions of dollars have been invested in task-shifting activities and systems to ensure competencies and skills of CHWs are not neglected. Improving and maintaining their clinical skills is critical for strengthening health systems and providing adequate care to mothers, newborns, and children.

Moreover, supervision is widely recognized as key to improving health worker performance. Among other goals, we hope that functioning supervision systems to support community case management activities will contribute to the appropriate use of antibiotics.

In Warrap State, South Sudan, a 13-month study funded by USAID through World Vision’s Child Survival grant was undertaken to assess a supervision model for illiterate CHWs. They were trained, supervised and studied to assess their correct use of newborn and child health record forms, identification, classification, treatment and referral of disease.

After the supervision period, 87 percent of CHWs were accredited as competent to deliver integrated community case management and essential newborn care services. A total of 2,552 children under age five were seen by CHWs, with a mean of 196 child visits per month.

Results indicate that a supervision process to monitor, improve and maintain clinical skill performance by CHWs within a community case management strategy is an important element of program design and implementation to obtain health outcomes. This is especially true in fragile state contexts and among community-based approaches where treatment with drugs is included.

Freedom was part of this group and even though she did not benefit financially from this activity, the sense of support and recognition of the value of her work was enough incentive to continue her efforts. She knows that her work is an investment in the development of her community and her country. Hopefully, she says, the support will continue over time.

Dr. Alfonso Rosales, MD, MPH-TM, World Vision

This blog is part of the Institutionalizing Community Health Conference blog series. We encourage those unable to join the conference to stay virtually connected and to add your voice to the conversation at #HealthForAll. As part of this series, we are posting blogs from our staff and partners around the world highlighting the necessity of community health in reaching those not currently accessing key health services.