In April and May 2022, Dr Githinji Gitahi gave evidence to the House of Commons International Development Committee’s (IDC) enquiry into Extreme Poverty and the Sustainable Development Goals (SDGs).
He said there is “a conglomerate of intersecting issues" facing people living in poverty, including family planning, nutrition, and health costs that leave them out of pocket.
The IDC has just published the report with recommendations to the UK Government, which it must respond to by 13th February 2023. They include prioritising funding for health “as one of the most effective interventions in extreme poverty reduction,” and championing investment in Universal Health Coverage (UHC)
“already urgently needed due to the effects of climate change and food insecurity and…likely to become even more important in the future,” in line with Amref’s submitted recommendations where Dr Gitahi called UHC “a shock absorber for families” and a “creator of wealth for communities.”
The evidence Dr Gitahi provided also included a focus on the cuts to the UK’s Official Development Assistance budget and their direct impact on Amref Health Africa and the communities we serve. This includes family planning, health worker training, support for people living with disabilities, efforts to end Female Genital Mutilation / Cutting (FGM/C) – all of which saw reduced or completely cut funding. Where the cuts perhaps had the most immediate visible impact was in South Sudan.
South Sudan: fragile health systems, deep cuts impact
In rural South Sudan, health facilities are strategically positioned to serve scattered populations. Primary health facilities particularly are small-scale centres — Primary Health Care Units (PHCUs) and Primary Health Care Centres (PHCCs). The smaller PHCUs, which tend to have around five members of staff, provide basic consultation, immunise children, and can dress wounds and dispense drugs. Some have delivery beds that are intended for emergencies only. PHCCs, which have closer to ten members of staff, build on PHCU services with in-patient capacity, as well as lab technicians and midwives trained to deal with complicated cases and emergencies. Both PHCCs and PHCUs save and improve lives every day, often in extremely difficult circumstances.
In February 2022, Amref South Sudan was informed of a dramatic reduction in its programmes budget sourced through multilateral initiatives where the UK Government was a main donor. They were told that a total of 20 of the 34 facilities Amref had been supporting - all PHCUs embedded within remote communities - would no longer receive any support. The cuts would come into effect as early as April. With no time to seek alternative sources of funding, these facilities would be forced to close.
“There was no time to prepare”
says Amref South Sudan’s Peter Claver. Once the news broke, Peter and his team focused on organising the protection of essential medicines and equipment in affected facilities and on preparing health workers and the communities they serve for the impending changes.
“We feared there would be riots; people rely on these facilities. We spent many weeks talking to the communities who would be affected, trying to calm their fears. We tried to explain what was happening - but we couldn’t tell them why, because we ourselves did not understand beyond the ‘budget cut’. We engaged with the community members who form the management committee of the health facilities and the local community leaders; their core concern was how they can continue to access essential healthcare—what is going to fill that gap to continue to save lives?”
“For the health workers posted to PHCUs and PHCCs in remote communities, the cuts meant that not only would they stop receiving the vital ‘incentives’ that supplement their base-level government salary, it meant they would no longer receive supplies of essential drugs. They are far from their families, without secure income or the tools which they need to do their jobs, and so for many these cuts meant losing their livelihoods. On hearing the news of cuts, many returned back home to their families.”
The scale of the cuts threatens not just livelihoods, but lives:
If one day this programme closes, the health system in these areas will close, too. Without external funding, the system will collapse
Monica Ernesto, mother, Maridi, South Sudan
Monica Ernesto, 35 years old, is a farmer and mother of six: three boys and three girls. When Amref visited the Longbua Primary Health Care Unit (PCHU) and in August 2022, she was just a few weeks away from delivering her seventh baby, and the fourth of her children to be born in the facility’s single labour room.
But the Longbua PCHU in Maridi county, where women have lined up for service, has no medicines, no maternal health service, and the only available health care worker, Lika Gibson, was working without payment. This is because it was among those facilities whose funding was withdrawn, after the UK government made further cuts to its aid budget in early 2022. The cuts have affected service provision, which has profoundly impacted the community, especially mothers and children who depend on the facility for treatment.
“Women are the ones giving birth; women here are suffering and need to be cared for,”
The Longbua PCHU is a critical facility for the lives of the community in Longbua. It has a catchment area of 7,640 people and typically receives 300-350 outpatients a month. It offered a range of outpatient services including antenatal care, which is vital in a country where complications during pregnancy are common, and the health workers trained to deal with them are few and far between.
“Women are the ones giving birth; women here are suffering and need to be cared for,” Monica says.
“The rest of the women and I are scared because there are no services at this facility."
Many pregnant women in South Sudan have lost their lives during pregnancy or childbirth due to a lack of access to healthcare services. Due to a lack of antenatal care, complications are often discovered too late. Most villages are remote, and it takes time for pregnant mothers to receive services when they experience complications. Monica is fearful of what will happen when the time comes for her to give birth.
“The rest of the women and I are scared because there are no services at this facility. If a woman wants to deliver and develops complications, what do you think will happen since there are no services in this facility?“ she asks.
Increased maternal deaths
Lika Gibson, the facility’s in-charge, fears an increase in cases of obstructed labour, leading to more maternal and neo-natal deaths because women living in remote areas will not be able to access ante-natal care, meaning that any complications will go undetected until it is too late.
Gibson now provides pro-bono services because he no longer receives a salary. He works as a farmer to make ends meet. “It’s so sad, that the health volunteer is working without any support, no incentive and sometimes they may be called that there is a woman in labour,” Monica says. When that happens, the volunteers often working on their farms leave the work they are doing and rush to the facility to deliver babies.
But if women cannot deliver at Longbua, they are now faced with the prospect of travelling 12km to the nearest functioning facility. That might not seem a long way, but in South Sudan it is a lengthy and costly journey on roads that become unnavigable during the rainy season.
In Maridi County, which is home to 122,764 people, 15 of 22 primary health facilities had their funding cut.
Many more women and those seeking basic healthcare now have no choice: healthcare is impossible to access.
Images: Monica Ernesto stands at Longbua clinic (banner); midwives Hellen, Suzan and Margarete at Maridi Health Sciences Institute; Rosal and baby Charles at Longbua clinic; Monica Ernesto and her son Lika at Longbua clinic; in-charge Lika Gibson checks baby Charles as he’s held by his mother Rosal; all (c) Kennedy Musyoka for Amref Health Africa.