How Do You Get to Equity when Inequity is Everywhere?

Source: DHIS2. Key and interpretation as in Figure 30. State aggregated data errors for WAR and WEQ.

Throughout my career I’ve been grateful to be able to experience global public health across its many complex layers. In early October, I flew to South Sudan as part of a Gavi mission to help the Ministry of Health (MoH) with finalizing its submission for their next round of immunization system funding. Gavi’s funding is critical for many countries in the effort to scale an effective immunization system – and in a fragile country like South Sudan, it is the foundation of their entire system.

Health services in South Sudan are provided to their mostly nomadic population through a network of local and international partners, rather than the local government. While these partners are doing good and impactful work, this model has led to a fragmented ecosystem where the MoH’s voice is often underrepresented in resourcing and planning.

It felt most important to design a process for the funding meetings where the MoH’s voice would be the leading voice in the room. South Sudan is made up of 10 states, six of which were flooded during the week we were there. The nomadic nature of many of South Sudan’s tribes, years of conflict, and increasing flooding due to climate change have all contributed to an increasing number of internally displaced people and a severe lack of access to basic health services, including immunization.

As I listened and facilitated during these meetings, I found myself wondering “How do we approach equity in a place where inequity is so equally distributed?” In South Sudan, the inequities are so widespread that Gavi’s equity analysis was not particularly useful. Most of the population is more than five kilometers away from a health facility and the numbers of internally displaced people (IDPs) continue to grow thanks to flooding and conflict. Considering these issues in a fragile setting requires an entirely different way of thinking and problem solving.

Our approach during the week was to break into groups, with the MoH being their own group. As we worked through the greatest challenges that needed to be addressed and the actions required to address them, by separating out the MoH, we were able to constantly benchmark the other groups’ work against what the MoH was saying they wanted.  

Some of the challenges that were repeatedly articulated included alignment and coordination of partner activities, access issues related to flooding and conflict, an acute shortage of qualified vaccinators and healthcare workers, low demand for services due to cultural norms, and lack of targeted information and difficulty identifying and targeting zero dose children (defined by Gavi as children who don’t receive a single dose of diphtheria, tetanus, and pertussis-containing vaccine) due to lack of coordinated, timely, and accurate data.   

We found a surprising amount of synergy across the content generated in terms of what the key issues are and activities required to address them, and worked to ensure the MoH’s views were prioritized when considering how to address their core immunization system challenges. They well know their own country and the needs of their people; what they need from the global community is support to solidify and resource their plans. How to approach the work of strengthening their fragile systems is something our MoH colleagues are uniquely positioned to do.  

The answers aren’t easy, but the process undertaken by the MoH and their partners was a big step forward in developing a truly MoH-led plan for addressing the vast inequities that have led to large numbers of un- and under-vaccinated children across the country.  The number of unvaccinated (no Penta1/DTP1) and under-vaccinated (no Penta3/DTP3) children is high; it is estimated that 178,000 children remain unreached (i.e. no Penta1/DTP1) in the country with some counties reporting a less than 50% coverage rate with rates declining. 

We look forward to continuing working with the MoH and their partners as we move through the process of submitting an effective, focused plan for global funding and coordination with the aim of increasing access to basic childhood immunizations in a place where inequity is so widespread.