Eight days by foot to deliver healthcare to the world’s most underserved communities

BMJ 2012; 345 doi: (Published 27 December 2012) Cite this as: BMJ 2012;345:e8685
  1. Peter Moszynski
  1. 1Boma, Jonglei, South Sudan

One of the key hurdles to achieving the millennium development goals is the need to provide healthcare to those hardest to reach populations who have traditionally been unable to access even basic services.

South Sudan, the world’s newest country, also has some of the world’s worst socioeconomic indicators because decades of war and lack of development have left most of the population without access to education or healthcare, and consequently with the world’s highest rates of maternal and infant mortality and lowest levels of female literacy.

In a country where only one in four people have access to medical facilities, virtually everyone qualifies as “hard to reach” and those attempting to rectify the situation face many challenges. One of the most isolated areas is the mountainous Boma district on the Ethiopian border, where the UK based health agency Merlin ( is the only healthcare provider and village health workers trek for up to eight days by foot to reach outlying communities.

Ugandan doctor Sarah Kasoga, who has been in South Sudan for nine months, prefers this difficult environment to other posts she has held across East Africa. She said working in Boma “gives me the feeling that I am providing services to those who need them the most. I am the only doctor in a 150 km radius and I get immense satisfaction by delivering quality healthcare to the most vulnerable and marginalised groups in such an underserved area.”

She said that in addition to the lack of transport infrastructure there are particular problems stemming from the “almost total lack of women’s education and empowerment,” which allows the continuation of harmful traditional practices, including early marriage, widespread pre-teen pregnancy, and the requirement for women to obtain permission from their husbands and, often their traditional healers, before travelling to seek healthcare.

This means most patients “only come to the hospital very late, after complications have set in, so we are generally dealing with more complicated cases that would have been easier to treat in their early stages,” said Kasoga.

In addition to widespread malnutrition and complications arising from pregnancy she said that the commonest causes of ill health were malaria, acute respiratory tract infections, acute watery diarrhoea, sexually transmitted infections, skin diseases, and intestinal parasites.

Primary health care supervisor Collins Kyererezi, who runs a team of outreach workers, explains: “We are working in one of the most difficult environments in one of the most challenging countries in the world. Instead of expecting people to come to us, we reach out to them to give vaccinations, health education, primary health care, and referrals.”

He has also recruited teams of “home based hygiene promoters” who in addition to basic health education and first aid, screen under-fives for malnutrition and refer complex pregnancies to Boma’s basic hospital.

This approach is already showing dividends, with house to house mobilisations resulting in three quarters of children under 5 years being reached in the cyclic Extended Programme of Immunisation campaigns, well above the national average of 37%. Similarly, one quarter of births now take place in hospital, as the village health workers are now able to screen for complicated pregnancies and have managed to convince many expectant mothers of the benefits of modern healthcare.


Cite this as: BMJ 2012;345:e8685