Returning to South Sudan after the civil war: “How are we again going to survive?”

In the early morning in Kajo Keji, Central Equatoria, what used to be a very busy market slowly opens. A few people set up their stands, while small groups of children in uniforms are walking to school. From the main road, one can still see the scars of the civil war – destroyed buildings, abandoned houses, bullet impacts.

From 2016 to 2018, Kajo Keji was badly affected by violence, forcing most of the population to abandon their home and seek safety in Uganda. A few people remained behind – James Mirye, executive chief of Kangai village in Kajo Keji county, was one of them.

“This is the third war I experienced so I figured I would survive this one as well. I didn’t want to leave my place; I could not abandon my community.” However, people could not access healthcare and faced unlawful killings, lootings, robbery. “When you went to bed at night, you did not know if you would wake up the next day.”

For the people who fled to Uganda, the living conditions in the camps were dire and refugees faced many challenges – no shelter, shortage of food, water, firewood and very bad access to healthcare. Some went back to South Sudan a short time after arriving, preferring to face insecurity than life in the camps. “Today, when you need medical care in the camps, you go to a health centre, and you will get referred to a private clinic. But the clinic is not free. Without money, you cannot survive”, says Mirye.

Yet six years after the peace agreement, families are not yet ready to completely settle back in their homeland. Instability, severe economic inflation and upcoming national elections – expected to be held in December 2024 – add fear and uncertainty among communities.

In a region beset by crises, Médecins Sans Frontières (MSF) and the Ministry of Health (MoH) resumed secondary level healthcare services in the Kajo Keji Civil Hospital last year, providing healthcare in maternity, pediatrics, neonates, emergency room, intensive care unit, surgery and internal medicine – encouraging people to come back to seek safe and free healthcare.

Jane Kiden had fled to Uganda and decided to come back when she was pregnant, hearing that MSF was supporting the Mundari County Hospital. “During and after the war, the biggest challenge was healthcare. There was no one. For us women, it was a big problem and there were many maternal deaths because of complications and heavy bleedings. The only option was to cross again to Uganda, but during Covid-19, it was impossible. So, I really thank MSF for providing care for women”, says Kiden, who safely delivered her baby girl at the hospital last year.

Today, MSF remains the only actor to provide pre-delivery care for pregnant women presenting with complications, delivery and obstetrical surgeries in case of complications, medical care for sick newborn babies, ante-natal and post-natal care.

Beatrice Cosmas is MSF midwife supervisor in Kajo Keji County Civil Hospital. Every day, she sees pregnant women like Jane Kiden reaching the facility after days of suffering, either because labour has started or because of complications, putting their lives and the lives of their babies at high risk.

“Most women are still living in the refugee camps, but they come all the way to Kajo Keji because they heard that MSF is here”, explains Cosmas.

After the operating theatre and the emergency room, the hospital's maternity will be entirely rehabilitated by June 2024, with a capacity of twelve beds for mothers and four beds in the Newborns Intensive Care Unit. From February 2023 to 2024, our teams provided life-saving care to 272 mothers and 281 babies. Yet, the community's needs are huge and remain insufficiently addressed.

“We used to have other organisations supporting Primary Health Care Centers in the county. Midwives would receive pregnant women and could identify the need for specialized medical care. They could call an ambulance and send the patients to us. Now, pregnant women fully rely on themselves, their relatives or their community to reach our facility”, says Cosmas.

Following the withdrawal of partners and humanitarian actors in the region, MSF is now supporting five Primary Health Care Centers (PHCC). Our teams provide medicines, training and incentives for healthcare workers, and ensure referrals by ambulance to the County hospital.

In Kajo Keji, women suffer stress, anxiety and depression among other mental health difficulties.

"Women have been facing a lot of abuse”, says Tom Friday, MSF mental health supervisor. “Fleeing South Sudan and living in refugee camps made them very vulnerable. Today they must deal with trauma from the conflict, the violence they saw or endured, and the struggle of having lost everything – and now having to rebuild their lives.”

With national elections coming up and the phasing out of partner organisations, a lot of uncertainty remains for people considering settling back in Kajo Keji. Even if the situation has slightly improved in recent years, communities still face many challenges, such as access to food, education and sustainable, quality healthcare.

“People in Kajo Keji are really surviving because of the support of MSF. But I am worried”, says Mirye. “If MSF leaves and the government has not stabilized the health system here, how are we again going to survive?”