In South Sudan, people live with infectious diseases. In February 2024, over 10,000 cases of cholera, 5,000 of measles, 8,000 of dengue, and a staggering 1.2 million cases of malaria were reported. 

Since 2017, the Health Pooled Fund Programme, led by Crown Agents in collaboration with Montrose and IPA and funded by FCDO, USAID, the EU, Canada, the Swedish International Development Cooperation Agency (SIDA) and GAVI, has worked towards increasing routine immunisation across seven states in collaboration with the South Sudanese Government. Its specific focus is to expand immunisation services to reach zero-dose, under-immunised children. It does this by offering routine immunisations alongside COVID-19 vaccinations, routine health services in hospitals and medical treatments in communities delivered by the Boma Health Workers (Community Health Workers). In the South Sudan context, the team is presented with extremely difficult circumstances.

Imagine a context in which the next health facility is a day away by foot. Imagine that if you embark on this journey, your travel may be affected by floods, or you may run into armed groups. Image after hours of walking, you arrive at the clinic, and it has been flooded. If you were a woman in South Sudan, would you risk going on such a journey with your baby, especially if you are unsure about the benefits of vaccination? 

Yet, this is the reality for many women in South Sudan. Around 83% of the population in South Sudan lives in rural cattle camps or villages. Approximately 56% live more than 5 km from the nearest health facility. South Sudan’s rainy season starts lasts for six months, making healthcare facilities inaccessible to a majority of the population. During the big floods of 2020, for example, more than 36 counties were under water, directly affecting approximately 1,000,000 people across South Sudan, destroying crops, critical infrastructure and housing. 

Given these challenges, it is not only important to communicate the benefits of vaccination, but also help people access it. To ensure the right amount of medicines is delivered to health facilities, reducing wastage, the HPF programme needs to know the number of defaulters and under-immunized children. In a country with limited physical infrastructure and mobile coverage, where populations move frequently due to adverse weather and internal conflict, this is challenging. So is monitoring vaccine supply, ensuring that every clinic has what it needs, when it needs it. 

To tackle this issue, HPF is working closely with healthcare staff at clinics as well as community chiefs and the Boma Health Workers. Where mobile coverage is patchy, clinic staff submit regular reports on medicine stocks and patient attendance, either in writing or electronically, walking to the closest area that has network. The chiefs come together regularly at health facilities to communicate information about the population residing within their chiefdoms, and those populations which have recently arrived, or left. The Boma Health Workers support this data gathering by sharing the information they obtain through their role in informing communities about health seeking behaviours and the health services available to them. They form part in HPF outreach activities into remote communities, alongside mobile outreaches by clinical staff.  

Once the defaulters and under-immunised children are identified, parents are encouraged to visit the nearest clinic or outreach activity to ensure their child is vaccinated against illnesses such as diphtheria, tetanus and measles. They receive a vaccination card which indicates the vaccinations administered, and the clinics record it through the Ticker filing system, an invention spearheaded by HPF. Given that populations frequently move, however, it is important for parents to hold on to their vaccination cards. HPF encourages this by linking other medical services such as nutrition to the possession of the card. Should the card get lost, medical personnel can assess the relevant vaccines the child has received by the location of their entry point into the body. 

The lack of access to information on health advice and medical care in South Sudan poses an additional challenge. Many families disregard vaccines as dangerous and are fearful about side effects. Beliefs stated were that vaccines were ‘harmful’, ‘expired’ and could cause ‘physical disability’ and/or ‘death’ among their children. Some parents also believe that the immunity induced by vaccines is less effective than that developed through catching the natural disease. 

To shift attitudes, HPF works with amenable chiefs and Boma health workers to spread the relevant messaging. Those who do not subscribe to vaccinations often see their population affected by infectious diseases such as measles, and at that point, they are approached by the HPF team or other chiefs to explain to them why other communities have remained immune. Whilst progress does take time, obtaining understanding and consensus ensures that the knowledge of the importance of vaccinating children stays with communities even after the programme ends. 

Although many health facilities are frequently affected by flooding, vaccine delivery continues with healthcare workers moving services to higher ground. Whilst air transportation can in some cases make up for bad or flooded road networks, many parts of the country lack airstrips, which means that healthcare workers and vaccinators have to wade through flood waters or use canoes to provide outreach services to displaced populations.  

It is commendable that despite these challenges, the programme has vaccinated over 2,400,000 children under one year with the third pentavalent/DPT vaccine, and increased coverage by over 23% across the 7 states the programme is active in. It is our hope that in future, community links can further be strengthened, and outreach services intensified, so that no child in South Sudan is left behind. We know this will only be possible through the dedication of the teams on the ground and their willingness to go above and beyond. They are the true heroes of HPF.