7 April marks World Health Day, a day to share successes and raise awareness of challenges in global health. This year’s theme is Universal Health Coverage, which aims to ensure that everyone can obtain the care they need, when they need it, without financial hardship. Despite significant progress, millions of people around the world are forced to choose between health care and other daily expenses such as food, clothing and shelter. This is most notable for hard to reach populations who often cannot access healthcare because of migration patterns, security, cultural barriers and environmental circumstances. To mark World Health Day, the International Coalition for Trachoma Control highlights efforts by the government of South Sudan towards universal health coverage through its focus on indigenous and nomadic communities.
Migration presents many unique challenges to the achievement of universal health coverage in South Sudan. Indigenous and nomadic communities that travel according to seasons often do not live in a typical village based structure, and often have limited access to essential health services. This makes it difficult to identify disease burdens and provide interventions to people in need.
This is particularly true for trachoma, the world’s leading infectious cause of blindness. Although many counties require further baseline mapping, prevalence surveys conducted at the county level suggest that indigenous and nomadic communities who live and travel with livestock and have limited access to clean water and sanitation, have high levels of trachoma.
Delivering trachoma interventions to these populations is further complicated because of the nature of travel each group takes. It is common that a small group will remain behind at a base area, while others will break away into smaller groups as they search for water and grazing for their animals. At times smaller groups will join and travel together for a short period before breaking away again. This fluid movement of groups across the geographical and social landscape means “distribution sites” also need to be fluid.
This dedicated approach to reach mobile populations resulted in 6,650 people receiving treatment who would have otherwise missed treatment at the village level.
In a new strategy to track the movement of mobile communities and increase coverage levels for trachoma and Guinea worm, the Ministry of Health has employed full time field officers to monitor cattle camps, temporary settlements comprised of cows and their handlers that shift based on water and feeding accessibility, in order to know where populations are located at any given time.
Cattle camp field officers are trained about different public health diseases such as trachoma and Guinea worm and work closely with at risk communities so that the Ministry of Health can develop programs appropriately to ensure these mobile communities are not left behind. By engaging directly with communities at risk of trachoma and other diseases, information can be shared between government health workers and the communities about trachoma interventions being planned and the location of people who require essential services.
The program has shown considerable success in treating at risk mobile populations and in 2017, South Sudan reached 23 cattle camps spread over two counties. This dedicated approach to reach mobile populations resulted in 6,650 people receiving treatment who would have otherwise missed treatment at the village level.
Flexibility in healthcare programming and being able to adapt and react to changing circumstances is essential to end the epidemic of neglected tropical diseases (NTDs) and achieve targets that the Ministry of Health has set in its NTD Master Plan.
Trachoma, like many other NTDs, affects the poorest and most marginalized people in South Sudan. In order to help these people and fulfil our commitment, it is critical that we understand the different communities and populations we are serving and develop strategies that will be appropriate to their needs and sensitive to their cultures. We must be willing to go where they are, which, in the context of many places in South Sudan, often means going outside the traditional “village” setting.
Despite the high burden of trachoma and shortage of partners working in the country, the Ministry of Health has managed to achieve high coverage in targeted counties in difficult settings. Although more could be achieved with further support from the international community, South Sudan’s Trachoma Action Plan and NTD Master Plan has provided a framework that ensures accountability and government ownership over trachoma elimination activities, including the sustainability of the work through facial cleanliness and environmental improvements at the county level.
South Sudan is committed to taking any opportunity to make significant gains towards the elimination of trachoma as a public health problem, but increased attention to the challenges of implementing in low resource and hard to reach environments as well as new partnerships will be crucial to succeed.