COUNTRY PROFILE photo Nicola Berti SNAP- A 69-YEARS DOCTORS SHOT HISTORY WITH AFRICA Doctors with Africa CUAMM is 1,800 currently People have left CUAMM operating in Italy and other Angola, Central countries to work African Republic, on projects: Ethiopia, of these, Mozambique, 515 returned Sierra Leone, on one or more South Sudan, occasions Tanzania and Uganda through: 227 Hospitals have 23 been served Hospitals

01 42 08 02 03 64 Countries Districts of intervention 04 (for public health activities, mother-child 05 care, fight against AIDS, 06 tuberculosis 07 and malaria, 01 SIERRA LEONE training) 02 SOUTH SUDAN 03 ETHIOPIA 04 UGANDA 3 05 TANZANIA Nursing 06 ANGOLA schools 07 MOZAMBIQUE 08 CENTRAL AFRICAN REPUBLIC 1 University Doctors with Africa CUAMM (Mozambique) has been the first NGO working VALUES in the international health field – «With Africa»: to be recognized in Italy and the organization works 605 is the largest Italian organization exclusively with African International for the promotion and protection populations, engaging Professionals of health in Africa. It works with local human resources a long-term developmental at all levels. perspective. To this end, in Italy – Experience: CUAMM and Africa, it is engaged in training, draws on over almost research, dissemination of scientific seventy years of work to knowledge, and ensuring support developing the universal fulfilment of the countries. fundamental human right to health. – Specific, exclusive expertise in medicine Doctors with Africa is for everyone and health. who believes in values like dialogue, cooperation, volunteerism, exchange between cultures, friendship between PRIORITY people, the defense of human rights, respect for life, the choice to help ISSUES the poor, the spirit of service, and – Reproductive, maternal, those who support the organization’s newborn, child and action criteria. adolescent health. – Nutrition. – Infectious diseases. – Non communicable diseases (NCDs) and traumas. – Universal Health Coverage (UHC).

Doctors with Africa South Sudan p. 2 CUAMM OUR WORK IN SOUTH SUDAN

Doctors with Africa CUAMM (CUAMM) has been working in South Sudan since 2006 with SUDAN the aim of increasing access, quality and utilization of health care services.

South CUAMM maintains aCENTRAL long-term Liech development perspectiveAFRICAN focusing State REPUBLIC NYAL ETHIOPIA on Health System Strengthening, promoting integration of primary CUEIBET and secondary care, community- YIROL Western Eastern based initiatives, capacity building State Lakes State Amadi Maridi State and empowerment of local State stakeholders. MARIDI LUI CUAMM has remained on ground also during the most acute crisis, KENYA gaining communities and DEM. REP. OF CONGO UGANDA counterparts trust.

2006-2012 2013-2015 2015-2017 2017-2018 AT PRESENT YIROL RUMBEK FORMER EMERGENCY CUAMM is supporting 5 State AND LUI NORTH, LAKES STATE RESPONSE Hospitals (Yirol, Cuibet, Lui, HOSPITAL CUIBET (New Western AND FORMER Rumbek, Maridi) and 164 primary In 2006, CUAMM started its health care (PHC) intervention in South Sudan, HOSPITAL Lakes, Eastern WESTERN reactivating Yirol Hospital facilities distributed and gradually expanding its AND LUI Lakes, Gok over 12 Counties. action to the surrounding In Former emergency Yirol West County (Former setting, CUAMM is Lakes State). Two years HEALTH States) STATE operating through 4 Aid after, it launched its Posts and 1 mobile health program in support of Lui CUAMM expanded its action team. Static services are Hospital (Mundri East SCIENCE to all remaining Counties (New Amadi complemented by County, Former Western constituting Former Lakes outreaches activities, Equatoria State). INSTITUTE States, working in a total of and Maridi bringing primary care up to 8 and started supporting the most remote areas. In In Former Lakes State, Rumbek Hospital as well. each County, referrals are CUAMM reached one of the Nutrition component was States) ensured by free of charge most isolate Counties, integrated to the permanent ambulance Rumbek North, for a interventions already After Famine Declaration in services. The beneficiary comprehensive Primary provided. Former Unity State, CUAMM population is about Health Care Program, while emergency intervention in 1.384.000 million people. upgrading Cuibet Health Nyal (Panyjiar County) The number of local health Center to County Hospital. started. CUAMM reinforced workers that CUAMM is In Former Western the presence in Former supporting is about 1500. Equatoria State, in 2014, a Western Equatoria State, training course for midwives sustaining County Health began at Lui Health Science System in Mundri East, Institute. Mundri West, Mvolo and in Maridi, where it started supporting the Hospital as well. In 2017, Lui Health Science Institute graduation ceremony was held in Juba. p. 3 “CONTINUUM OF CARE” MODEL

CUAMM INTERVENTION IS FOCUSED ON TWO MAIN COMPONENTS:

1) Service delivery at community, 24/24h free of charge ambulance hospital to communities. Activities primary health care facilities referral system. are specifically designed to tackle the and hospital level. This includes: three types of delays that pregnant prevention, diagnosis and 2) Health system strengthening, women experience everyday: delay treatment of malaria, diarrhoea working aside local health in deciding to seek care, delay in and respiratory infections in authorities and creating their reaching care and delay in receiving children and adults; ante-natal capacities in planning, managing and adequate care (Figure 1). CUAMM’s and post-natal care; delivery monitoring services. Amongst the intervention has been implemented attendance; nutrition screening for key performed activities: peripheral starting from ensuring comprehensive children U-5 and pregnant women; health centres supervision; health health care provision and then going acute malnutrition diagnosis and staff training on the job; regular down incentivizing demand, in this way treatment; vaccinations; health coordination meetings among guaranteeing quality and responsive education; admission of paediatric, stakeholders; distribution and offer to ground needs. Institutional obstetric, medical, surgical cases; monitoring of drugs; health data deliveries in Yirol West County emergency obstetric complication gathering, analysis and reporting. (Figure 2) is a concrete example of management, including caesarean the effective method implemented by section and blood transfusion; Doctors with Africa CUAMM strategy CUAMM; indeed, results from 2009 screening and treatment of HIV/ follows the «Continuum of care» to 2018 show a significant increase in AIDS; management of complicated model, working towards the provision institutional deliveries both at hospital severe acute malnutrition; surgeries; of adequate care at all levels, from and health centres.

24/7 FREE OF CHARGE County Wide • Qualitative Study AMBULANCE SERVICE, Referral System AND THEN direct call • Demand Side 2 Incentives • Outreaches Delay in • Health Promotion reaching care • TBAs involvement • Community Meetings

Hospital INFRASTRUCTURE 1 STAFF (recruitment, training, supervision) Delay EQUIPMENT & in decision SUPPLIES MANAGEMENT to seek care Technical Assistance 3 PHC Health Facilities Delay in receiving adequate health care Figure 1: Doctors with Africa CUAMM intervention Rational

1.800

1.600 Demand Side Incentives in PHC HF 1.400 PHC program 1.200 Demand Side Incentives 1.000

800 Ambulance

600

400

200

0 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 Figure 2: Institutional Deliveries in Yirol West Hospital Deliveries PHC Facility Deliveries County (2009-2018)

Doctors with Africa South Sudan p. 4 CUAMM , DATA 2018 COUNTIES AND YIROL HOSPITAL MATERNITY 3,241 Total institutional deliveries 1,537 at hospital 1,704 at PHC facilities ANC VISITS 7,819 Total ANC First Visit 4,687 at hospital 3,132 at PHC facilities MATERNAL AND CHILDREN HEALTH 62,955 photo Nicola Berti Out Patients consultations (OP) in U5 children CUAMM started its intervention in Yirol infrastructures (repair, upgrade, Hospital in 2006 answering a request equipment and supplies provision) have 28,354 of support from the local Church produced remarkable results in terms at hospital Authorities. In 2011, CUAMM began to of access increase: work also at community level, in the +7% ANC1 34,601 surrounding Yirol West County and, at PHC facilities in 2014, it was selected to take over +145% institutional deliveries the Primary Health Care program, consisting in supporting 10 facilities, +229% OPD U5. 6,358 working as County Health Department DPT3 vaccine in U1 children technical partner. In 2017, CUAMM expanded the same intervention to Awerial and Yirol East Investments done in these few 1,977 Counties, constituting, together with at hospital years on health staff (recruitment, Yirol West, the recently established retention, training, supervision) and Eastern Lakes State. 4,381 at PHC facilities

p. 5 AMADI STATE, DATA 2018 COUNTIES AND LUI HOSPITAL MATERNITY 1,130 Total institutional deliveries 633 at hospital 497 at PHC facilities ANC VISITS 2,849 Total ANC First Visit 1,091 at hospital 1,758 at PHC facilities MATERNAL AND CHILDREN HEALTH 36,137 Out Patients consultations (OP) in U5 children Lui Hospital is the only referral In 2018, CUAMM took over the PHC Hospital of the recently established program in Mundri East County, 9,997 Amadi State, which counts a total managing to gradually reactivate at hospital population of about 175.000. Property almost all PHC facilities, restoring of the Episcopal Church of Sudan and the key preventive and curative 26,140 South Sudan, Lui Hospital is supported services. Similar intervention was at PHC facilities by CUAMM since 2009 and since 2016 conducted in the two other Counties CUAMM has been given full mandate on constituting Lui Hospital catchment Hospital management. This decision was area, namely Mundri West and Mvolo. 1,623 taken by the Diocese of Lui to further DPT3 vaccine in U1 children strengthen Lui Hospital resilience Remarkable results registered in and responsiveness in an increasingly terms of Hospital access increase, in 463 instable context. spite of the drop experienced during at hospital insecurity peak moments: Since 2015, due to internal fighting +24% ANC, 1,160 for territory control, health services at PHC facilities provision and accessibility have been +47% Hospital based deliveries, compromised. Lui Hospital has been the only health facility remaining full +30% OPD visits in U5. time operational along this period, while primary health care units and Concerning PHC services in Mundri centres were on and off because of East County, 2018 has marked a looting episodes and staff migration to significant improvement compared safer places. The Hospital has served to previous year, confirming the also as shelter for several displaced successful reactivation of services: families, being its neutral status +118% OPD U5, respected by both fighting parties. Lui Hospital continuous quality services +109% ANC1, provision has been a key retention +112% Institutional deliveries. factors for local population and the ground for growing trust towards the formal health system.

Doctors with Africa South Sudan p. 6 CUAMM LUI HEALTH SCIENCE INSTITUTE photo Nicola Berti

In 2012, CUAMM proposed Ministry when the First graduation ceremony Being annexed to a functional hospital, of Heath to activate a school near Lui was held in Juba at the presence of the students have been supervised by Hospital as Health Training Institutes Minister of Health. highly qualified medical and nursing belonging to South Sudan Health staff and could experience the reality of System. In line with MoH priorities, it Students were ensured full board rural health services, developing the was decided to start with Registered accommodation within School motivation needed to serve as health Midwifery course. compound, benefiting of constant personnel also out of urban setting, where tutoring and mentorship during at present very few are accepting to work. In 2012 and 2013, CUAMM focused lessons, clinical placement at Lui Putting together 20 people belonging to on renovating and expanding school Hospital and individual study by the different groups transmitted a successful infrastructures and on procuring the principal and two tutors. Besides that, peace and reconciliation message. needed didactic materials, creating they could attend special training the conditions for both students and sessions held by teachers coming from Lui Health Training Institute offered tutors being safely and adequately other schools, Lui Hospital staff and students and its staff a way to participate accommodated and for teaching and CUAMM’s medical and nursing team. in the Country’s future alternative to the studying activities to take place. involvement into the conflict. Lui School has demonstrated to be In 2014, the first cohort of 20 students an enabling environment for learning. All this considered, MoH and CUAMM started the 3 years Registered Indeed, all 20 students succesfully agreed to enroll a new cohort of 20 Midwifery course, terminating it in 20 17, completed the course in the due time. students at the beginning of 2019.

p. 7 GOK STATE, DATA 2018 COUNTY AND CUIBET HOSPITAL MATERNITY 2,686 Total institutional deliveries 1,058 at hospital 1,628 at PHC facilities ANC VISITS 7,638 Total ANC First Visit 2,911 at hospital 4,727 at PHC facilities MATERNAL AND CHILDREN HEALTH 60,678 photo Nicola Berti Out Patients consultations (OP) in U5 children Former Cuibet County is coinciding County Health Department technical with the recently established Gok State, partner. 19,391 counting 185.870 inhabitants. CUAMM at hospital started its intervention in former Cuibet Over these years, remarkable results County in 2014, when it was chosen to have been registred in terms of 41,287 join the Ministry of Health in upgrading access increase: at PHC facilities the main Primary Health Care Centre to County Hospital level. +145% ANC, In 2017, CUAMM took over the Primary +327% institutional deliveries, 3,774 Health Care program, consisting in DPT3 vaccine in U1 children supporting 13 facilities, working as +67% OPD paediatric consultations 422 at hospital 1,352 at PHC facilities

Doctors with Africa South Sudan p. 8 CUAMM , DATA 2018 COUNTIES AND RUMBEK HOSPITAL MATERNITY 3,166 Total institutional deliveries 1,467 at hospital 1,699 at PHC facilities ANC VISITS 10,850 Total ANC First Visit 5,089 at hospital 5,761 at PHC facilities MATERNAL AND CHILDREN HEALTH 64,831 photo Nicola Berti Out Patients consultations (OP) in U5 children Former Rumbek Center County is part Counties constituting the new Western of the recently established Western Lake Lakes State (Rumbek North, Rumbek 17,617 States and it counts a total population of East, Wulu) are all supported by CUAMM at hospital 243.061. CUAMM started its intervention for PHC and Nutrition component in Rumbek Center County in 2014, when 47,214 it was chosen as technical advisor by the Investments done in these few years at PHC facilities State Ministry of Health for improving on health staff and infrastructures its management capacities . In 2015, have produced remarkable results in CUAMM took over the Primary Health terms of access increase: 4,177 Care program, consisting in supporting DPT3 vaccine in U1 children 14 facilities, working as County Health +210% ANC1, Department technical partner. In 2016 +1796% institutional deliveries, 539 CUAMM started supporting Rumbek at hospital Hospital, for mothers and children +352% OPD U5. health related services. The other 3,638 at PHC facilities

p. 9 MARIDI COUNTY DATA 2018 AND MARIDI HOSPITAL MATERNITY 1,512 Total institutional deliveries 744 at hospital 768 at PHC facilities ANC VISITS 4,823 Total ANC First Visit 1,464 at hospital 3,359 at PHC facilities MATERNAL AND CHILDREN HEALTH 53,093 photo Luigi Baldelli Out Patients consultations (OP) in U5 children Maridi Hospital, located in Maridi In 2018, Doctors with Africa CUAMM County, is the only referral Hospital of supported 22 PHC facilities in the same 7,190 the recently established Maridi State, County. at hospital which counts a total population of about 166.000. Maridi Hospital is supported Investments done on health staff 45,903 by CUAMM since 2018, when CUAMM and infrastructures have produced at PHC facilities started its intervention in the area, remarkable results in terms of targeting both primary and secondary Hospital access increase, compared care services. In Maridi Hospital, to previous year, especially in 2,319 CUAMM is sustaining mainly the Maternal Health sector, with DPT3 vaccine in U1 children services for mothers and children, 44% increment of institutional investing on safe pregnancy and deliveries. Concerning PHC services, 367 delivery and on new-borns and U5 2018 has marked a significant at hospital health. improvement compared to previous In Maridi County, CUAMM managed to year, confirming the successful 1,952 gradually reactivate almost all PHC reactivation of services: at PHC facilities facilities, previously closed or abounded because of the instability in the area, +26% ANC1 restoring the key preventive and +39% Institutional deliveries curative services. +64% OPD U5

Doctors with Africa South Sudan p. 10 CUAMM OCTOBER 2017 - NYAL PAYAM, PANYIJAR JULY 2018 COUNTY, EX UNITY STATE OUTPATIENTS 17,759 Total patients consulted (out of which 4159 U5 children). Diarrhea , leading morbidity cause for U5, followed by respiratory infections and malaria. ANC 542 Pregnant Women, at least one ANC visit

Since March 2018, the mobile team has guaranteed routine immunization: 197 U2 Children BCG vaccine 116 for the first dose Polio 128 for the first dose DPT photo Nicola Berti 106 On May 1st 2017, due to the high cases attendance, in order to improve Measles instability of the country, CUAMM local population resilience towards started its intervention in Panyijiar recurrent crises. CUAMM built an County, in the area of Nyal, where operating room in Nyal health center thousands of internally displaced and 4 Aid Posts and activated a mobile persons (IDPs) were fleeing from the health team adequately equipped conflict zones. CUAMM decided to and staffed to reach the most remote respond to people health care needs areas with a package of basic services, with a long-term perspective and preventive care and the means to with the aim of benefiting the entire identify and refer the most complicated population, both resident and displaced, cases. through health system strengthening In spite of logistic constraints and the and resilience enhancement. CUAMM hostile environment, some results has focused on setting up a referral in terms of access and utilization pathway, passing through community of primary care services have been based primary health care to emergency achieved, as show in the right column.

p. 11 Contacts Juba - CUAMM Doctors with Africa CUAMM Coordination Office Headquarter Italy, Padua c/o TM Lion Hotel Browker via San Francesco, 126 Blvd, Juba100 Meters from 35121 Padova, Italy the US Embassy JUBA 0039 049 8751279 [email protected] [email protected]

www.doctorswithafrica.org

Cover photo Our doctors and beneficiaries photo Nicola Berti

Back IDPs in Nyal Payam photo Nicola Berti photo Nicola Berti

Thanks to the support of

Diocese of Lund

the Italian Episcopal Conference through the Diocese of Padua