Community Participation in Primary Healthcare in the South Sudan Boma Health Initiative: A Document Analysis

Document Type : Original Article

Authors

1 CIET-PRAM (Participatory Research at McGill), Department of Family Medicine, McGill University, Montreal, QC, Canada

2 Grupo de Estudios en Sistemas Tradicionales de Salud, Universidad del Rosario, Bogotá, Colombia

3 Department of Reproductive Health, Ministry of Health, Juba, South Sudan

4 Centro de Investigación de Enfermedades Tropicales, Universidad Autónoma de Guerrero, Acapulco, Mexico

Abstract

Background 
Community participation is central to primary healthcare, yet there is little evidence of how this works in conflict settings. In 2016, South Sudan’s Ministry of Health launched the Boma Health Initiative (BHI) to improve primary care services through community participation.

Methods 
We conducted a document analysis to examine how well the BHI policy addressed community participation in its policy formulation. We reviewed other policy documents and published literature to provide background context and supplementary data. We used a deductive thematic analysis that followed Rifkin and colleagues’ community participation framework to assess the BHI policy.

Results 
The BHI planners included inputs from communities without details on how the needs assessment was conducted at the community level, what needs were considered, and from which community. The intended role of communities was to implement the policy under local leadership. There was no information on how the Initiative might strengthen or expand local women’s leadership. Official documents did not contemplate local power relations or address gender imbalance. The policy approached households as consumers of health services.

Conclusion 
Although the BHI advocated community participation to generate awareness, increase acceptability, access to services and ownership, the policy document did not include community participation during policy cycle.

Keywords


  1.  WHO. Declaration of Alma-Ata. https://cdn.who.int/media/docs/default-source/documents/almaata-declaration-en.pdf?sfvrsn=7b3c2167_2.
  2. The United Nations. Goal 17. Revitalize the global partnership for sustainable development. https://www.un.org/sustainabledevelopment/globalpartnerships/. Accessed April 5, 2022.
  3. Marston C, Hinton R, Kean S, et al. Community participation for transformative action on women's, children's and adolescents' health. Bull World Health Organ. 2016;94(5):376-382. doi:2471/blt.15.168492
  4. George AS, Mehra V, Scott K, Sriram V. Community participation in health systems research: a systematic review assessing the state of research, the nature of interventions involved and the features of engagement with communities. PLoS One. 2015;10(10):e0141091. doi:1371/journal.pone.0141091
  5. Rifkin SB. Lessons from community participation in health programmes: a review of the post Alma-Ata experience. Int Health. 2009;1(1):31-36. doi:1016/j.inhe.2009.02.001
  6. Rifkin SB. Examining the links between community participation and health outcomes: a review of the literature. Health Policy Plan. 2014;29(Suppl 2):ii98-106. doi:1093/heapol/czu076
  7. Rosato M, Laverack G, Grabman LH, et al. Community participation: lessons for maternal, newborn, and child health. Lancet. 2008;372(9642):962-971. doi:1016/s0140-6736(08)61406-3
  8. Rifkin SB. Paradigms lost: toward a new understanding of community participation in health programmes. Acta Trop. 1996;61(2):79-92. doi:1016/0001-706x(95)00105-n
  9. Haldane V, Chuah FLH, Srivastava A, et al. Community participation in health services development, implementation, and evaluation: a systematic review of empowerment, health, community, and process outcomes. PLoS One. 2019;14(5):e0216112. doi:1371/journal.pone.0216112
  10. WHO Regional Office for Europe. Community Participation in Local Health and Sustainable Development: Approaches and Techniques. Copenhagen: WHO Regional Office for Europe; 2002.
  11. Hoon Chuah FL, Srivastava A, Singh SR, et al. Community participation in general health initiatives in high and upper-middle income countries: a systematic review exploring the nature of participation, use of theories, contextual drivers and power relations in community participation. Soc Sci Med. 2018;213:106-122. doi:1016/j.socscimed.2018.07.019
  12. Eyre R, Gauld R. Community participation in a rural community health trust: the case of Lawrence, New Zealand. Health Promot Int. 2003;18(3):189-197. doi:1093/heapro/dag014
  13. Schmidt DH, Rifkin SB. Measuring participation: its use as a managerial tool for district health planners based on a case study in Tanzania. Int J Health Plann Manage. 1996;11(4):345-358. doi:1002/(sici)1099-1751(199610)11:4<345::aid-hpm445>3.0.co;2-f
  14. Rass E, Lokot M, Brown FL, et al. Participation by conflict-affected and forcibly displaced communities in humanitarian healthcare responses: a systematic review. J Migr Health. 2020;1-2:100026. doi:1016/j.jmh.2020.100026
  15. Ministry of Health. The Community Health System in South Sudan: The Boma Health Initiative. Juba, South Sudan: Ministry of Health; 2016.
  16. The Boma Health Initiative. Costing and investment case analysis. April 2019. The the Ministry of health of South Sudan, Management Science for Health, UNICEF, The Government of Canada. https://www.unicef.org/southsudan/media/2031/file/South-Sudan-2019-BHI-Costing-Investment-Case-Analysis.pdf.
  17. Mugo N, Zwi AB, Botfield JR, Steiner C. Maternal and child health in South Sudan: priorities for the post-2015 agenda. SAGE Open. 2015;5(2):2158244015581190. doi:1177/2158244015581190
  18. Asala BT. Indigenous knowledge system of conflict resolution in Africa: sudanese peace processes, 1970-2011. In: Yacob-Haliso O, Nwogwugwu N, Ntiwunka G, eds. African Indigenous Knowledges in a Postcolonial World: Essays in Honour of Toyin Falola. London: Routledge; 2020:306.
  19. South Sudan: World Bank Data. https://data.worldbank.org/country/SS. Accessed July 11, 2020.
  20. Education and literacy in South Sudan 2020. http://uis.unesco.org/en/country/ss. Accessed July 11, 2020.
  21. Belaid L, Bayo P, Kamau L, et al. Health policy mapping and system gaps impeding the implementation of reproductive, maternal, neonatal, child, and adolescent health programs in South Sudan: a scoping review. Confl Health. 2020;14:20. doi:1186/s13031-020-00258-0
  22. Justin PH, De Vries L. Governing unclear lines: local boundaries as a (re)source of conflict in South Sudan. J Borderl Stud. 2019;34(1):31-46. doi:1080/08865655.2017.1294497
  23. Evaluation of the South Sudan Health Pooled Fund. London: Integrity; 2018.
  24. Walt G, Shiffman J, Schneider H, Murray SF, Brugha R, Gilson L. 'Doing' health policy analysis: methodological and conceptual reflections and challenges. Health Policy Plan. 2008;23(5):308-317. doi:1093/heapol/czn024
  25. Kayesa NK, Shung-King M. The role of document analysis in health policy analysis studies in low and middle-income countries: lessons for HPA researchers from a qualitative systematic review. Health Policy OPEN. 2021;2:100024. doi:1016/j.hpopen.2020.100024
  26. Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol. 2006;3(2):77-101. doi:1191/1478088706qp063oa
  27. Rifkin SB, Muller F, Bichmann W. Primary health care: on measuring participation. Soc Sci Med. 1988;26(9):931-940. doi:1016/0277-9536(88)90413-3
  28. Baatiema L, Skovdal M, Rifkin S, Campbell C. Assessing participation in a community-based health planning and services programme in Ghana. BMC Health Serv Res. 2013;13:233. doi:1186/1472-6963-13-233
  29. Carlisle K, Farmer J, Taylor J, Larkins S, Evans R. Evaluating community participation: a comparison of participatory approaches in the planning and implementation of new primary health-care services in northern Australia. Int J Health Plann Manage. 2018;33(3):704-722. doi:1002/hpm.2523
  30. Ankomah SE, Fusheini A, Ballard C, Kumah E, Gurung G, Derrett S. Patient-public engagement strategies for health system improvement in sub-Saharan Africa: a systematic scoping review. BMC Health Serv Res. 2021;21(1):1047. doi:1186/s12913-021-07085-w
  31. Murphy K, Branje K, White T, et al. Are we walking the talk of participatory Indigenous health research? a scoping review of the literature in Atlantic Canada. PLoS One. 2021;16(7):e0255265. doi:1371/journal.pone.0255265
  32. Brear M, Hammarberg K, Fisher J. Community participation in research from resource-constrained countries: a scoping review. Health Promot Int. 2018;33(4):723-733. doi:1093/heapro/dax010
  33. DeFeo M. The effects of institutional and political instability on civil war in South Sudan. Inquiries Journal. 2017;9(11).
  34. Pendle N. Interrupting the balance: reconsidering the complexities of conflict in South Sudan. Disasters. 2014;38(2):227-248. doi:1111/disa.12055
  35. Pendle N. Elite Bargains and Political Deals Project: South Sudan Case Study. London: Stabilisation Unit, UK Government; 2018.
  36. Singh NS, Ataullahjan A, Ndiaye K, et al. Delivering health interventions to women, children, and adolescents in conflict settings: what have we learned from ten country case studies? Lancet. 2021;397(10273):533-542. doi:1016/s0140-6736(21)00132-x
  37. Anderson K, Rivera R. The disintegration of South Sudan: political violence from 2011 to 2016. Sudan Studies Association Bulletin (Spring Issue). 2018;35(1):15-27.
  38. Nyadera IN. South Sudan conflict from 2013 to 2018: rethinking the causes, situation and solutions. Afr J Confl Resolut. 2018;18(2):59-86. doi:10520/EJC-14066df969
  39. Lutwama GW, Kok M, Jacobs E. An exploratory study of the barriers and facilitators to the implementation of community health worker programmes in conflict-affected South Sudan. Confl Health. 2021;15(1):82. doi:1186/s13031-021-00422-0
  40. Lawn JE, Rohde J, Rifkin S, Were M, Paul VK, Chopra M. Alma-Ata 30 years on: revolutionary, relevant, and time to revitalise. Lancet. 2008;372(9642):917-927. doi:1016/s0140-6736(08)61402-6
  41. Walley J, Lawn JE, Tinker A, et al. Primary health care: making Alma-Ata a reality. Lancet. 2008;372(9642):1001-1007. doi:1016/s0140-6736(08)61409-9
  42. Hone T, Macinko J, Millett C. Revisiting Alma-Ata: what is the role of primary health care in achieving the Sustainable Development Goals? Lancet. 2018;392(10156):1461-1472. doi:1016/s0140-6736(18)31829-4
  43. Martini J, Tijou Traoré A, Mahieu C. Chronic patient as intermittent partner for policy-makers: the case of patient participation in the fight against diabetes and HIV/AIDS in Mali. BMC Public Health. 2019;19(1):1179. doi:1186/s12889-019-7453-2
  44. Kloos H. Primary health care in Ethiopia under three political systems: community participation in a war-torn society. Soc Sci Med. 1998;46(4-5):505-522. doi:1016/s0277-9536(97)00194-9
  45. von Roenne A, von Roenne F, Kollie S, Swaray Y, Sondorp E, Borchert M. Reproductive health services for refugees by refugees: an example from Guinea. Disasters. 2010;34(1):16-29. doi:1111/j.1467-7717.2009.01112.x
  46. Ho LS, Labrecque G, Batonon I, Salsi V, Ratnayake R. Effects of a community scorecard on improving the local health system in Eastern Democratic Republic of Congo: qualitative evidence using the most significant change technique. Confl Health. 2015;9:27. doi:1186/s13031-015-0055-4
  47. Masumbuko Claude K, Hawkes MT. Ebola crisis in Eastern Democratic Republic of Congo: student-led community engagement. Pathog Glob Health. 2020;114(4):218-223. doi:1080/20477724.2020.1754654
  48. McMahon SA, Ho LS, Scott K, et al. "We and the nurses are now working with one voice": how community leaders and health committee members describe their role in Sierra Leone's Ebola response. BMC Health Serv Res. 2017;17(1):495. doi:1186/s12913-017-2414-x
  49. Mbaku JM, Smith JE. Efficient and Equitable Natural Resource Management: Using Transparency to Avoid the Resource Curse. The Brookings Institution, Africa growth initiative; 2012.
  50. Pedersen A, Bazilian M. Considering the impact of oil politics on nation building in the Republic of South Sudan. Extr Ind Soc. 2014;1(2):163-175. doi:1016/j.exis.2014.07.007
  51. Downie R. The State of Public Health in South Sudan. Washington, DC: Center for Strategic and International Studies (CSIS); 2012.
  52. Cometto G, Fritsche G, Sondorp E. Health sector recovery in early post-conflict environments: experience from southern Sudan. Disasters. 2010;34(4):885-909. doi:1111/j.1467-7717.2010.01174.x
  53. Widdig H, Tromp N, Lutwama GW, Jacobs E. The Political Economy of Priority-Setting for Health in South Sudan: A Case Study of The Health Pooled Fund. Research Square; 2021. doi:21203/rs.3.rs-970768/v1
  54. Sami S, Mayai A, Sheehy G, et al. Maternal and child health service delivery in conflict-affected settings: a case study example from Upper Nile and Unity states, South Sudan. Confl Health. 2020;14:34. doi:1186/s13031-020-00272-2

 


Articles in Press, Corrected Proof
Available Online from 28 March 2022
  • Receive Date: 21 July 2021
  • Revise Date: 09 January 2022
  • Accept Date: 27 March 2022
  • First Publish Date: 28 March 2022