Voices from the Field: Southern Sudan Poses Unique Challenges To Improving Health Care

“People are a great strength. If you have people on your side, then things move,” says Carol Karutu, IntraHealth International program manager in Juba, Southern Sudan.

Change is occurring rapidly in Southern Sudan, which became an autonomous region in 2005 after decades of conflict. The country’s growing population is estimated between 6.5 and 11 million as many Southern Sudanese are returning from years of dislocation. While the country has had a relatively low prevalence of HIV, the increased migration and trade across its borders present a high risk for the spread of disease. With funding from the US Centers for Disease Control and Prevention (CDC), IntraHealth has teamed up with the Sudan People’s Liberation Army (SPLA) and local organizations to reduce the impact of HIV/AIDS and support the country’s need to rebuild its decimated health care system.

The SPLA—once a rebel force but now the recognized military of Southern Sudan—has established its own HIV/AIDS Secretariat to manage HIV prevention and treatment programs. In collaboration with the Southern Sudanese Ministry of Health and other NGOs, IntraHealth is working to strengthen the HIV/AIDS Secretariat, raise awareness about HIV/AIDS within the SPLA, and increase access to HIV/AIDS services within and outside of the SPLA.

“I think the [SPLA is] really going to churn out the numbers of people who get tested [for HIV],” emphasizes Jim McMahan, IntraHealth senior program manager. Getting started, however, is “like two steps forward, one step back,” he says.

One must understand the realities of Southern Sudan to understand its challenges. Karutu cites four factors as the ones that make the project’s goals hardest to accomplish:

  • Lack of infrastructure—including roads—which limits travel and often delays the initiation of health care services
  • Difficulty in hiring highly skilled personnel
  • High illiteracy levels in the population
  • Lack of policies and guidelines in all health areas.

“It takes longer and five times the level of effort to accomplish a task in Southern Sudan than it would elsewhere . . .” explains Karutu. “[R]esults are measured at the same level with others working in less difficult environments. This is rather challenging because one has to deliver at an international or organizational expected standard while in reality the environment does permit for this.”

To illustrate the slow pace of progess, McMahan describes the process of getting money to a small health facility—St. Bakhita’s Health Center—that the project supports to provide HIV prevention services. “We wire money for St Bakhita’s. The wire goes to a bank in Arua, Uganda, which is about a day’s drive from St. Bakhita’s in Southern Sudan,” he says. “So they have to leave Sudan, they have to get two [signatures] on the withdrawal slip—from the parish priest or the bishop plus the administrator of the health center—and then they have to drive to Arua, get the money and then drive all the way back.”

Transportation is really a challenge, McMahan adds. He points to a photo of a main road from Nimule to Juba with wooden slats all the way across it. “You have these huge trucks driving it every day. . . . It’s a long hard road—you see so many cars and vehicles broken down on the road, and it takes a long time for short distances. A hundred and twenty miles can take five hours.”

Despite such obstacles, the project has trained new staff and established or improved counseling and testing sites at three army bases—in Juba, Nimule and Lainya—and created mobile counseling and testing services. The project is also supporting and integrating HIV/AIDS services—including HIV/AIDS counseling, testing, education, and prevention of mother-to-child transmission of HIV—in clinical settings outside the military. Thus far, the project has trained 352 individuals to promote HIV/AIDS prevention, and 10,520 people have received counseling and testing. The project also distributed more than 400,000 male condoms during its first year.

Karutu says the results she is seeing give her great satisfaction. “I celebrate little achievements. I am excited when I meet a soldier and he or she tells me anything about HIV/AIDS. Even more excited when they request condoms from me.”

“We are known for results,” adds Karutu, which is why she thinks IntraHealth’s reputation within Southern Sudan and the SPLA is very good. “The SPLA respects us a great deal for having been bold enough to work with them from within.”

Over time, Karutu is learning to adapt to the unique challenges of Southern Sudan. “I don’t take anything for granted,” she says. “Every single day is a learning experience for me.”