Hospital vandalised by gunmen in South Sudan. |Credit: MSF|
By Kor Chop Leek, a researcher based in South Sudan
Abstract
The dynamic of conflict affects health services delivery as conflict is known to result in looting and destruction of health facilities as well as increased attacks on health workers which can deprive the community of adequate access to healthcare.
It has been widely reported that after the 2013 conflict, humanitarian organizations in southern Unity State encountered multifaceted challenges in delivering healthcare services to the local communities. This study aimed to examine the impact of the South Sudan conflict on the provision of healthcare services during the post-conflict period by humanitarian organizations in Leer and Mayiandit.
Using a survey method to assess the level of impact from the community, health workers, and humanitarian agencies operating in the area, the study found evidence of deterioration of healthcare services, destruction of health infrastructures, looting of health supplies, and targeting killing of health personnel that occurred between the periods of 2014 to 2018.
However, the period from 2019 to 2020 showed minimum access to healthcare in the areas. Security stability, professionalization of the national army, and improvement of healthcare through financing are recommended as better solutions.
Keywords: Conflict; Healthcare services; Humanitarian agencies; South Sudan
Introduction
South Sudan seceded from Sudan in July 2011 after decades of civil war which resulted in vast displacement, fragility, and collapse of healthcare systems, (MSF press release; 2014). Two years later, the country was engulfed by conflict that erupted in December 2013. The fight that initially started in the capital city Juba between units of the presidential guards soon spiraled into a country-wide conflict (Joshua et al 2015).
It is widely agreed that although the conflict started as a disagreement in the guards’ unit, there was a tribal dimension embedded, and as a result, thousands of civilians were displaced due to widespread violence and deliberate killing and looting of property (Roan Pijnacker; 2017).
When rival forces attacked the strategic town of Leer in 2014, which was one of the regional hubs for humanitarian organizations, Medicine San Frontier which was delivering most of the health services in the area evacuated its team, and the hospital was later looted and partially destroyed (Crombe and Kuper 2014, Craze and Tubiana 2016).
According to Roan Pijnacker (2017), when MSF revisited Leer in May 2015, it discovered that Leer Hospital was largely destroyed, leaving the local population of more than 250,000 without a single operational hospital.
A retrospective mortality survey conducted from January to February 2017 in both Mayendit and Leer by MSF found that 93% of the fatalities in the area were a result of conflict-related gun violence (Roan Pijnacker, 2017). Mortality among children under 5 years from the same incidences of gun violence was reported at 47%.
After the conflict subsided between 2018 and 2020, civilians’ access to healthcare remained difficult as no operational health facilities were existing in the area. Leer Hospital which was previously serving the entire region shrined in capacity to only a maternity clinic.
In a report published in May 2020 by a health consortium, known as the Health Pooled Funds (HPF) Report, 98% of the healthcare workers providing healthcare services at HPF-supported health facilities in both Mayendit and Leer lack professional clinical skills and have not undergone formal health training.
Problem Statement
The 2013 conflict in South Sudan created devastating human suffering which directly affected the provision of basic healthcare services across the country. The war not only affected the local population but also destroyed and crippled the entire healthcare system (MSF report; 2015) as well as people’s food and nutrition security.
For instance, the Famine that was declared in February 2017 in Unity State was directly linked to the outbreak of the conflict in December 2013. Repeated forced displacement of the civilians by the warring parties led to hunger, even in places where food used to be plenty.
In Leer and Mayendit counties, access to healthcare is difficult because the health facilities that existed before the 2013 conflict were either looted and destroyed or deserted as a result of deliberate attacks on healthcare providers. This study, therefore, assessed the impact of the South Sudan conflict between 20214 and 2021 on healthcare delivery in Leer and Mayiandit counties of Unity State to understand its consequences, coping strategies, and challenges.
Research Questions
What are the impacts of the South Sudan conflict on healthcare in Mayendit and Leer?
How have the humanitarian agencies delivering healthcare services in Mayendit and Leer been coping with the crisis?
Which challenges are faced by suppliers of health care services in Mayendit and Leer?
Methodology
This study used a qualitative research approach to understand the impact of the South Sudan conflict on healthcare delivery in the counties of Mayendit and Leer. This approach was chosen to generate data for deciphering the research questions because the approach has the potential to provide an in-depth understanding of the situation from a local perspective. Primary data was collected from the residents, healthcare workers, local authorities, stakeholders and humanitarian aid workers through questionnaire forms.
Research Design
The design adopted for this study employed a mixture of descriptions, exploratory, and analytical techniques. The purpose of choosing Mayendit and Leer for the survey was to assess the level of healthcare delivery the impact of the conflict and the legacy the conflict left behind in these war-torn counties.
It was also aimed to document the challenges faced by the humanitarian agencies in delivering health services during and after the conflict as well as the impact of flooding were analyzed.
The study population consisted of healthcare workers, County Health Department officials, and local people in the villages. These participants were selected due to their firsthand experience of the healthcare services in the areas and the impact of the conflict on the delivery of those services.
Thirty (30) respondents, 15 per each county participated in this study and they include, 5 government officials, 5 humanitarian workers, 10 health workers, and 10 local health services beneficiaries of both Leer and Mayendit Counties. Data was collected using a close and open-end questionnaire.
Ethical consideration
Ethical considerations are critical for any research study involving people (Neil and David, 2009). In this study, permission was obtained from the respondents in certain areas, and to respect their rights, participation was voluntary.
Results and Discussion
Results: Demographics
Table 1: Shows the respondents according to the county
In Table (1): Out of 30 respondents, 15 respondents were in Mayendit. 3 respondents’ equivalent to 10% were females, and 12, or equivalent to 40% of respondents were males representing the highest number while 15 respondents were in Leer. 8 or equivalent 27% respondents were females, 7 or equivalent 23% of the respondents were males.
| Counties | Females | Percentage | Males | percentage |
| Mayendit | 3 | 10% | 12 | 40% |
| Leer | 8 | 27% | 7 | 23% |
| Total | 11 | 37% | 19 | 63% |
Source: Field Research data December 2021
.
Table 2: Age of the respondents
In Table (2): the statistics showed that, out of 30 respondents, 16, or equivalent to 53.3% of respondents were between the ages of 18 to 35 years which represented the highest number while 14, or equivalent to 46.6% were in the range of 36 and above years which represent the smallest number. The age category statistics showed the respondents were drawn from different age sets. Therefore, this provided chances for balanced opinions about the healthcare crises.
| Age category | Frequency | Percentage |
| 18 years to 35 years | 16 | 53% |
| 36 years and above | 14 | 47% |
| Total | 30 | 100% |
Source: Field research data for Mayiandit and Leer Counties, Dec 2021
Table 3: Occupation of the respondents
In Table (3), out of 30 respondents, 7, or equivalent to 23.3% of respondents were farmers. 15 or equivalent to 50% of respondents were salaried employed which represents the highest number, while 8, or equivalent to 26.6% of respondents were unemployed.
| Occupation | Frequency | Percentage |
| Farmers | 7 | 23% |
| Employed | 15 | 50% |
| Unemployed | 8 | 27% |
| Total | 30 | 100% |
Impact of conflict on healthcare
Table 4: Respondents views on period of impact of conflict on healthcare
In Table (4): Out of 30 respondents, 26 or equivalent 86.6% said, the deterioration of the healthcare services in both counties of Mayendit and Leer was in the period between 2014 to 2018, while 4 or equivalent to 13.3% of the respondents said, the deterioration of the healthcare services in Mayiandit and Leer was in the period between 2019 to 2020.
| Period | Frequency | Percentage |
| 2014-2018 conflict period | 26 | 87% |
| 2019-2020 post conflict period | 4 | 13% |
| Total | 30 | 100% |
Source: Field data December 2021
Research Objective 1: To examine whether the South Sudan conflict is the cause of the healthcare crisis in Mayendit and Leer. This objective is set to examine how the community accessed healthcare services during and after the conflict in both Mayendit and Leer Counties.
Objective Question: What are the impacts of South Sudan Conflict on healthcare in Mayendit and Leer?
In the findings, all 30 respondents from both counties pointed out that, “Looting of health facilities (of their supplies)” was the major cause of the healthcare crisis.
They said that because they had witnessed rampant looting in health faculties during the conflict and after the conflict period. Healthcare facilities are being targeted by civilians and the fighting forces for looting because of their supplies (most importantly nutrition supplies) since there was no food and people were starving. Some respondents said, “Destruction of the health care facilities and related infrastructure” was another cause of the negative impact on healthcare.
Many respondents explained that most facilities were destroyed by the government forces to not offer any services to the community. Most of the static healthcare infrastructures are partially damaged.
In Leer County, for example, they described sadly how MSF-run Hospital was partially destroyed. 12 respondents said, another cause of the healthcare crisis was because “abduction and intimidation of staff and patients by armed forces”. They said patients were being targeted during the war. Respondents said that the healthcare workers and patients evacuated the health facilities to avoid being killed.
They said they received treatment from some of the healthcare workers who escaped with the community.
Such practices occurred in Bentiu Hospital, the Capital of Unity State when the fighting occurred in the town between the fighting forces. The hospital was evacuated by MSF, leaving the admitted patients and co-patients in the hospital with the understanding that, they would escape the fighting.
Figure. Remains of MSF Hospital in Leer. Photo taken on 23rd December 2020
The respondents confirmed it was exactly what has happened in health facilities in Leer and Mayiandit. 19 respondents said that “rape and other forms of violence perpetrated on civilians”, was another cause of the healthcare crisis.
Respondents pointed out that, females (both women and girls) were raped by the government army during the tense fighting. They said the survivors cannot access health services. The respondents said some survivors who seek medical care find it difficult to access health services due to a lack of medicines for rape victims as well as no psychosocial support for trauma healing.
Research Objective 2: To analyze the coping strategies employed by the humanitarian agencies in response to gaps in healthcare in both Leer and Mayendit Counties in the pre and post-conflict period.
The idea behind this survey objective is to learn the coping strategic measures employed by the humanitarian actors delivering healthcare services in the face of the conflict where all healthcare providers were in disarray and where all healthcare infrastructures were partially or destroyed and some remained empty.
Objective Question:
How have the humanitarian agencies delivering healthcare services in Mayendit and Leer been coping with the crisis? Out of 30, 22 respondents said that one of the coping strategies used by the humanitarian actors was continuously “Supply the minimum levels of health care services whenever or wherever possible”.
They said this because since the conflict broke out in Leer and Mayendit Counties, Humanitarian aid agencies have found it difficult to operate in areas of two fighting forces but never stop delivering emergency healthcare services to the communities of Leer and Mayendit. 14 respondents said, “Providing support to healthcare givers”. 27 respondents said that the International and local agencies were “enlisting the participation by the government and other political forces to enable access to health care services.”
This was because agencies have been engaging both authorities of either party in each county for easy access to the local community with health services. National humanitarian aid workers confirmed such effort when reached out for an interview.
Challenges facing Healthcare Delivery
Research Objective 3: To investigate the challenges facing healthcare delivery to the local community in Mayendit and Leer. This objective aims to map out the challenges hindering the delivery of healthcare services during and after the country witnessed political stability. The finding has two aspects. (1), challenges facing the suppliers of healthcare services, and (2), and the challenges facing the local community to access healthcare services.
Objective Question: Which challenges are faced by suppliers of health care services in Mayendit and Leer? Out of 30 respondents, 21 respondents ruled out that, “insecurity due to pervasive violence” is one of the major challenges. They related this to the intense serious fighting at the time which occurred on several occasions.
Some 20 respondents said that the “lack of funding to pay attractive wages to the qualified healthcare workers” which was attributed to low payment ranks was another challenge. The respondents referred this to the low incentive structure harmonized by the National Ministry of Health in early 2018 which has affected the delivery of healthcare services. 25 respondents said that “lack of qualified staff” related to the above.
They said this because most of the qualified healthcare professionals such as doctors, clinical officers, registered nurses, registered midwives, and laboratory technicians quit their jobs right after the execution of the harmonization.
Some 15 respondents said that there is a “Lack of essential equipment and supplies” in the respective County Health Departments (CHD), supported by donor partners (Health Pooled Funds-HPF). This refers to the diagnostics medical equipment such as thermometers, blood pressure machines, adults and pediatrics weighing scales, weight for heights, microscopes, glucose test machines, ambu bags, and delivery sets among others. 11 respondents described the challenges to “Deficient or non-existent health care infrastructure due to conflict and other causes”.
They said, most of the health facilities were burned down to ashes by the government troops when they attacked and occupied the area. 20 respondents said that “inaccessibility due to flooding” is one of the challenges hindering the delivery of healthcare services to both counties.
They said this because most parts of Mayendit and Leer are submerged by flooding, making it difficult for the community to access healthcare. Agencies and county health departments are cut off by the flooding to access health care units.
Research Objective 4: To investigate what legacy the South Sudan conflict left behind in Mayendit and Leer. The philosophical meaning behind this objective is to investigate the legacy the conflict has left behind on healthcare services in Mayendit and Leer. The objectives will gather the bad memoirs both communities have witnessed and recalled.
Objective Question: What impact has the conflict in South Sudan had upon Leer and Mayendit, and their providers of health care? Out of 30 respondents, 19 respondents said, there was an “increase of incidents of diseases and ailments.”
They referred to such because they have experienced the rise of prevalence health conditions. The participants pointed out that the level of healthcare services in Leer and Mayendit is badly deteriorated by the conflict with no improvement in access to healthcare. 20 respondents ruled that the “high rate of infants and maternal mortality and other health problems” is another bad legacy that would not be forgotten by many communities.
They said because many children died because of malnutrition, women died in labor without clinical attention. Some also died of Malaria and anemia.
One of the county health department officers in Mayendit County said, that during the time of the conflict, many children and pregnant mothers lost their lives because there was too much hunger. The food was taken by the enemy and nothing was left for children to eat.
He was referring to the government forces. These causes of death are all related to the lack of food. 25 respondents said the legacy to be remembered is the “destruction of health facilities”. All respondents said, the legacy left behind is “hunger and malnutrition”, and 15 respondents said, the legacy is the “pervasive and widespread insecurity”
Discussions
This research was conducted in Leer and Mayiandit Counties with four objectives: the impacts of war on healthcare, the copying strategies employed by the humanitarian aid workers in saving lives in the face of conflict, the challenges hindering healthcare delivery, and the legacy of the conflict of South Sudan upon healthcare.
The findings of the first objective showed that four major factors were responsible for the crisis. Some respondents blamed the healthcare crisis on the looting of the health facilities supplies by some people. Looting is a common practice used as a means of survival in times of conflict as hunger, and poverty increase due to anarchy and chaos. Conflicts bring destruction, displacement, and breakdown of systems and the rule of law to maintain order.
In Leer and Mayiandit Counties, there was no functional government in place to protect public installations, which made health facilities vulnerable and exposed to looting. As the conflict intensified, health facilities and healthcare workers became the target. Violence against health workers in fragile systems takes place within a wider social, cultural, and economic context, influenced by external forces (Ludvig and Rachel, 2014).
In the study areas, the communities were displaced and the government and opposition fighters occupied the deserted villages making it hard to provide healthcare services in such a situation.
According to some respondents, the destruction of health facilities and infrastructures has jeopardized access to healthcare. Given that the 2013 conflict took an ethnic dimension, the destruction of permanent infrastructures was common. This practice by the warring parties was not only limited to the destruction of healthcare infrastructures in Mayiandit and Leer but also civilians’ homes in the fighting areas were burned down.
For instance, Crombe and Kuper (2019) reported the destruction of MSF Hospital in Leer and Mayiandit Countiesby the government troops alongside several buildings. The motive behind the destruction of the health structures was assumed to limit the community and the wounded casualties from accessing healthcare.
This was evident in Mayiandit where a Primary Healthcare Center in Bhor Payam was destroyed when government forces took control of the area. One respondent expressed sadness about how MSF Hospital in Leer which was donated by the government of Holland to the community decades ago was destroyed. According to this respondent, the hospital building roofs, windows, and doors were removed and taken away, leaving only the building foundation as shown in the figure
Figure. Remains of MSF Hospital in Leer. Photo taken on 23rd December 2020
This explained the scale of health facilities destruction by the South Sudanese conflict. Although such destructions are common in any conflict involving armed forces, some community members in the study areas lamented that the violence was deliberately used as tools not only for displacement or killing of civilians but also to destroy important infrastructures such as healthcare facilities in the area.
Resilience and adoption of copying strategies in conflict zones have been common practices. Leer and Mayiandit, this study found that despite the challenging situation characterized by insecurity, intimidation, and killing, humanitarian organizations have not ceased delivering services to needy communities.
One of the copying strategies was ensuring that healthcare workers with no formal clinical training were being put on job training to save civilians in need of health services in various displaced sites despite insecurity in the face of the conflict with limited available resources.
In May 2014, MSF returned to Leer to resume the delivery of healthcare services. However, it found that the hospital was largely destroyed, leaving a population of more than 250,000 without a single operative hospital (Roan, 2017). Some respondents reported that it was difficult for humanitarian agencies to continue delivering the required healthcare services in that fragile region as aid workers faced intimidation, harassment, torture, and deliberate killing.
Such mistreatment of aid workers who lead the delivery of healthcare services to the communities continues even in the post-conflict situation involving local government senior officials. These Interferences by the local authorities are not only putting the security of the aid workers at risk but also jeopardizing the smooth delivery of healthcare services and other humanitarian assistance to the community.
Violence in healthcare occurs in many places worldwide including developed nations. According to Long (2016), several episodes of workplace violence against medical providers happen daily. In Mayendit County, for example, a community health worker at Jauguar PHCU was attacked in his home by unknown gunmen and sustained non-fatal gunshot injuries that took a year to heal.
Conclusion
This work found that the deterioration of healthcare services in Mayendit and Leer is aggravated by violent conflict in those areas. As many health infrastructures were destroyed including the only MSF-operational hospital in Leer Town, essential supplies of medical importance were looted by the local communities, and the armed fighters of both the government and rebels.
Pervasive gender-based sexual violence and extrajudicial killings were committed in the areas as a result of the conflict that left a worse legacy in those areas which is expected to live for generations to come.
Despite the return of calm and stability as a result of the 2018 peace deal, humanitarian partners are still facing multiple challenges, such as insecurity, intimidation, harassment, abduction, killings, destruction, and looting of their assets. In addition to the impact of the conflict, floods have added another layer to the already catastrophic health situation in both Leer and Mayiandit Counties.
Recommendations
As the country is in the paradigm shift to a peace era, this study recommends the government transform the army and ensure professionalism in protecting civilians and public institutions during times of combat. It also recommends finding amicable solutions to restore stability and generate resources to improve the health systems with a special focus on areas affected by conflict. The study further recommends the government take immediate steps to improve security so that the private sector can play a pivotal role in contributing to social development and young employment to reduce future violent conflicts.
About the writer
Kor Chop Leek is a Researcher. He once worked for Children Aid South Sudan (CASS) as a County Health Coordinator in Mayiandit. Mr. Leek is a founder and Head of Sudd Environment Agency (SEA). He supports Children Aid South Sudan as a Monitoring and Evaluation Officer under the UNICEF World Bank Project in Unity State.
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