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Research shows that creative solutions can overcome barriers to access to health services in fragile contexts. Innovation is also key to identify sustainable ways of improving maternal and child care, even in difficult contexts such as South Sudan, Uganda, and northern Nigeria.

On foot and pregnant, 14-year-old Angurese trekked for four days through the bush to flee ethnic violence in her home southwest of Juba, South Sudan. Now living with her son in the relative safety of the enormous Bidi Bidi refugee camp in Uganda, she tells media how Dinka fighters attacked Nuer villagers, indiscriminately killing women and children.

Thousands of women fleeing South Sudan tell a similar story, but most of their accounts are never reported and their voices are rarely heard. Unlike Angurese and her baby, many do not survive.

South Sudan is one of dozens of fragile zones around the world where child and maternal health services do not meet even the most basic needs. While weak health systems increase the risks women face in most developing countries, conflict and instability place them in even greater jeopardy, particularly during pregnancy and childbirth.

Alison Wright
Community health worker in South Sudan.

The availability and quality of human resources in the healthcare sector represent a major gap in meeting the needs of these women and children. This is why projects in South Sudan, Uganda, and northern Nigeria — funded through the Innovating for Maternal and Child Health in Africa (IMCHA) initiative — are finding innovative ways to effectively provide essential maternal and child care in fragile settings.

Meeting healthcare demands in South Sudan and Uganda

In South Sudan and northern Uganda, ongoing and past conflicts have devastated the healthcare infrastructure, leading to a chronic shortage of trained medical personnel. In South Sudan, fewer than 200 doctors and 2,000 nurses serve more than 10 million people. In Uganda, one doctor serves 24,000 residents, including some of the 1.2 million refugees Uganda hosts from 13 countries, many of them women and children from South Sudan.

South Sudan and Uganda rely on community health workers to help address this critical staff shortage. Recruited from their communities, these volunteer workers provide basic health education and services. The role they play in raising awareness about the importance of pre-natal and post-natal care and skilled assistance during delivery is vital. These workers also provide important links between communities and health facilities.

With funding from IMCHA, researchers from the non-governmental organization BRAC-Uganda and from Cape Breton University in Canada, in collaboration with South Sudan’s Ministry of Health, are exploring ways to increase access to health services by strengthening the role and expanding the activities of community health workers. They are testing various social enterprise models to motivate community health workers and improve their performance.

“We’re trying to understand what model works. Then we will recommend it to the health ministry,” says Jenipher Twebaze Musoke, director of research for BRAC-Uganda and leader of the IMCHA project. “The goal is to entice more South Sudanese to enter the program.”

This research is particularly timely as both countries seek to implement new strategies to enhance the role of community health extension workers.

Involving communities in their healthcare

In another IMCHA project in South Sudan and Uganda, a team of researchers from St. Mary’s Lacor Hospital in Uganda, Torit Hospital in South Sudan, and the Université de Montréal in Canada, seek to educate and enable communities to identify high-risk cases and refer them to health facilities. They are working to remove the barriers between hospitals and communities through training and close collaboration with community health workers.

The team is engaging communities to identify the challenges they face in accessing maternal services and to determine ways in which they can be addressed. They are also exploring strategies to improve maternal care, child nutrition services, and the growing need for cervical cancer screening.

Outreach efforts by the two hospitals will actively support women’s leadership and empowerment, leading to more community-focused health interventions, says project leader Dr Emmanuel Ochola. Work is also under way in health facilities to improve service quality and to meet needs identified by the communities.

Bringing education and care to doorsteps in Nigeria

Women in northern Nigeria are dying in childbirth at a much higher rate than elsewhere in the country due to the high levels of insecurity in the region. Access to healthcare is a major challenge for most women in remote communities. Domestic violence, continued heavy work during pregnancy, and lack of spousal communication about pregnancy increase the risks they face.

The Federation of Muslim Women’s Associations in Bauchi State is collaborating with Nigeria’s Ministry of Health and National Primary Health Care Development Agency, and with McGill University in Canada, to find innovative ways to address local challenges and stimulate access to healthcare. They are carrying out universal home visits to pregnant women and their spouses and they are using innovative digital technology and real time data to identify women who need urgent referral.

Equipped with mobile tablets to track responses and geolocate homes, teams of male and female health workers are each visiting some 400 households every two months. By the end of September 2017, they had registered more than 7,000 new pregnant women in need of healthcare.

Video edutainment — entertainment with an educational aspect — is also helping to inform men and women and it is changing attitudes toward risk factors such as heavy work and domestic violence.

Hadiza Mudi / Federation of Muslim Women's Associations in Nigeria
Providing health education at home with mobile tablets in Bauchi, Nigeria.

The impact of creative thinking

Northern Nigeria, South Sudan, and Uganda are three fragile contexts where traditional health systems are failing to meet needs, particularly for women and children. The research carried out under IMCHA in these regions shows that any scalable solution requires thinking creatively about the problem. Furthermore, effective partnerships with governments and local stakeholders creates a bridge between research and implementation and fosters local ownership.

The innovations being explored — social enterprises, community identified and driven health interventions, and universal home visits with video edutainment — could effectively fill gaps in existing health systems. In doing so, they would show that strengthening provision of care in and with communities can sustainably improve health services for women and children, even those living in fragile settings.

Learn more about the three projects:

Find out more in a Huffpost blog post about social enterprise models to improve health and women's livelihoods in South Sudan.

Read the Cape Breton University news article on the health workers’ incentives project in South Sudan.

Top image: Trocaire / Flickr