Access to maternal healthcare in post-conflict South Sudan. Is the health system designed for the context?

Abstract

Background: The importance of understanding the cultural, social, economic, political and historical contexts when working in post conflict fragile states is well documented. Many health and development projects in post conflict South Sudan are significantly hampered by (i) the mismatch between the views of service providers and those of the community, and (ii) because of the misunderstanding of the context. It is not clear in the literature if the health systems in post conflict situations are designed for or adapted to the context, and if they are, to what extent has understanding of the context and demand side barriers been useful in planning for accessible maternal health care services that can reduce the maternal mortality in such settings. Aim: The aim of this research is to gain an in depth understanding of the determinants of, and delays to access to, the maternal health services in a post conflict setting in South Sudan, and to investigate the extent to which health system actors take account of the context in designing a system that incorporates the health care needs of their clients in order to provide accessible maternal health care. Methods: This research applied a qualitative participatory action research approach in two phases. Phase one was to understand the issues around access and utilization of maternal health services using qualitative methods: Participatory Ethnographic Evaluation Research (PEER), and Critical Incident Technique (CIT), and stakeholder interviews. Phase two was interventions to improve the situation through Innovative Participatory Health Education (IPHE) and Participatory Reproductive Health Project Management (PRHPM). Findings: Access to maternal healthcare in the aftermath of conflict is complex. Maternal health is not always a priority, services do not usually match the needs of the people, most of the facilities are not functioning and many healthcare providers are not competent. Voices of hard to reach populations are usually excluded or not heard. Social determinants hugely influence access. Women often do not take decisions that prioritise their health, and even if they take healthy decisions, they do not act on them or act very late. There is a mismatch between stakeholders and service users' perspectives on access to maternal healthcare. Conclusion: Maternal healthcare in South Sudan will not be optimised unless women are cared for in their communities, and are empowered to take decisions about their care at the right time, without waiting for others to make decisions for them. Participatory Health Systems Research approaches strengthen capacity at multiple levels, ensure integrated knowledge translation, engage marginalized communities, and enhance their contribution to identify health needs, plan and design future health services.