South Sudan health crisis worsens as more partners pull out and number of displaced rises

August 2016

The recent escalation of the conflict in South Sudan has forced many people to flee, including those that were supporting the health response. Preventable and curable diseases, such as malaria and acute watery diarrhoea, are major causes of death among the growing number of internally displaced persons in the country. Many people do not have access to adequate shelter, which may increase rates of malaria and upper respiratory infections, while the ongoing rainy season is increasing the risk of water-borne diseases, such as cholera.

WHO/G. Novelo

WHO is working with the Ministry of Health in South Sudan to respond to people’s critical health needs as the conflict persists, and related political and security discussions continue. With more than 1.6 million people displaced internally, together with a decreased availability of health workers and aid workers, the work on the ground is becoming ever more challenging.

"Coupled with the conflict, the country is battling threats to health security due to disease outbreaks," says Dr Abdulmumini Usman, WHO’s Representative for South Sudan.

One of the key health areas affected by the current situation is the tracking of disease, which is essential to enable an efficient response to outbreaks such as cholera and measles. Before July, WHO led 67 partner organizations in the country, as the head of the Global Health Cluster. By mid-August, about one-third of these partners remain and, of those, many have retained only a skeleton staff. WHO has had to significantly reduce its number of international staff.

“The conflict has exacerbated existing challenges with the health system and disease surveillance,” Dr Usman says. “With so many health workers and partners moving to safety, data is more difficult to collect and challenges have emerged as humanitarian access remains limited.”

Disease surveillance and early warning reporting information has dropped by about half since the conflict began.

WHO expands mobile disease surveillance

In response, WHO is working with the Ministry of Health and the few health partners on the ground to enhance disease surveillance to rapidly detect and respond to disease outbreaks in high risk areas.

To cover the growing number of internally displaced persons near Juba and Wau, while availability of health workers decreases, WHO and the Ministry of Health supported 15 new Early Warning and Response System (EWARS) sites capable of monitoring diseases for up to 50 000 more people. This brings the total number of EWARS sites to 71 in South Sudan, which provides the capability of monitoring 300 000 people for disease outbreaks.

WHO’s EWARS initiative is committed to supporting disease surveillance, alert and response even in the most difficult operating environments. EWARS tries to catch disease outbreaks early on to help contain them in emergencies by providing technical support, training and field-based tools to Ministries of Health and other partners.

In 2015, WHO initiated a pilot deployment of its “EWARS in a box”, which is a kit of durable, field-ready equipment needed to establish and manage surveillance or response activities in field settings. A single kit costs approximately US$ 15 000 and can support surveillance for 50 fixed or mobile clinics, or roughly 500 000 people. Deployed to a settlement in Mingkaman with about 80 000 IDPs, WHO trained health workers to use the system.

Thus far in 2016, 45 disease alerts have been detected by the system. Immediate feedback is provided to WHO and Ministry of Health staff, and helps to ensure that alerts can be promptly verified and investigated.

“Before EWARS, the process of data collection was very slow and time consuming,” says Dr Joseph Wamala, WHO epidemiologist in Juba. “WHO colleagues and our partners worked manually with data that was collected in Word documents, which led to slower analysis and response planning. EWARS allows data to be collected and reported using mobile phones in health clinics. It is adapted specifically for use in emergency settings and has the flexibility to gather different kinds of data as a situation evolves.”

For example, South Sudan’s Ministry of Health officially confirmed a cholera outbreak on 21 July 2016. As of 15 August, a total of 1160 cholera cases including 23 deaths have been reported nationwide. The majority of these have been recorded in Juba County, where an average of 35 new admissions are being recorded daily.

WHO and the Ministry of Health added a component to EWARS to help track cholera cases, which has led to a more targeted response to cholera outbreaks. This includes plans to preposition oral cholera vaccines in community centres where cholera outbreaks are expected to rise, based on data collected by EWARS.

Temporary fix to a grave situation

“These additional resources for disease surveillance can help us to more quickly analyse and plan our response accordingly in real time,” says Dr Usman.

Prior to the recent escalation of the conflict, some 1.6 million people in South Sudan had already been displaced and 4.7 million were already in need of humanitarian health services. The recent conflicts will only add to health care needs.

Urgent funding is needed to respond to rising needs. The South Sudan Humanitarian Response Plan, launched earlier this year, requested a total of US$ 110 million, of which US$ 31.3 million has been received so far. WHO requires US$ 17.5 million of this total amount for 2016, of which US$ 4.3 million has so far been received. More funding will be required to respond to additional needs arising from the recent hostilities. Without urgent funding, WHO and partners will not be able to implement most of the planned interventions.

“WHO urges parties to the conflict to ensure that everything possible is done to protect health workers and facilities and facilitate humanitarian access to provide health care to the populations in need,” says Dr Usman.

EWARS has also been used in WHO’s recent responses to emergencies in Ethiopia and Fiji, and will eventually be introduced into all countries where WHO has emergency operations.