In a region beset by crises, a once-bustling market opens for the day, with vendors setting up their stands as schoolchildren walk to school past buildings and abandoned houses marred by bullet holes. This is life in Kajo Keji, a county in South Sudan’s Central Equatoria state.
From 2016 to 2018, Kajo Keji was badly affected by violence that forced most of its residents to abandon their homes and seek safety in neighboring Uganda. The few who stayed behind faced unlawful killings, looting, robbery, and extremely limited access to health care.
“I didn’t want to leave my place—I could not abandon my community,” said James Mirye, executive chief of Kangai village. “This is the third war I experienced so I figured I would survive this one as well,” however, “when you went to bed at night, you did not know if you would wake up the next day.”
To encourage people who fled to return and access health care, Doctors Without Borders/Médecins Sans Frontières (MSF) has been working with Ministry of Health teams at Kajo Keji Civil Hospital, where we provide maternal, pediatric, and neonatal care, as well as support for the emergency room, intensive care unit, surgery, and internal medicine.
South Sudan 2024 © Manon Massiat/MSF
Those who fled to Uganda as refugees live in dire conditions in camps and lack access to basic needs including food, water, firewood, adequate shelter, and health care. The conditions were so poor that some returned to South Sudan despite the insecurity.
“When you need medical care in the camps, you go to a health center and you will get referred to a private clinic. But the clinic is not free. Without money, you cannot survive,” explained Mirye.
Despite a peace agreement being reached six years ago, many families are not ready to completely settle back into their homeland. The instability, severe economic inflation, and upcoming national elections—expected to be held in December 2024—add to their fears and uncertainty.
Maternal health care in Kajo Keji
Jane Kiden fled to Uganda and then decided to return when she was pregnant. She had heard that MSF was supporting the Mundari County Hospital.
“During and after the war, the biggest challenge was health care. There was no one. For us women, it was a big problem and there were many maternal deaths because of complications and heavy bleeding. The only option was to cross again to Uganda, but during COVID-19, it was impossible. I thank MSF for providing care for women,” Kiden said, after safely delivering her baby girl at the hospital last year.
Today, MSF remains the only organization providing care for pregnant women showing signs of complications, including deliveries and obstetrical surgeries, medical care for sick newborn babies, and prenatal and postnatal care.
Beatrice Cosmas is MSF's midwife supervisor in Kajo Keji County Civil Hospital. Every day, she sees pregnant women like Kiden reach the facility after days of suffering, either because labor has begun 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,” said Cosmas.
After the operating theater and the emergency room, the hospital's maternity unit will be entirely rehabilitated by June 2024, with a bed capacity of 12 for mothers and four beds in the newborn intensive care unit (NICU). From February 2023 to 2024, our teams provided lifesaving care to 272 mothers and 281 babies. Yet, the community's needs are huge and remain insufficiently addressed.
South Sudan 2024 © Manon Massiat/MSF
“We used to have other organizations that were supporting primary health care centers in the county,” said Cosmas. “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, relatives, or their community to reach our facility.”
Following the withdrawal of partners and humanitarian organizations in the region, MSF is now supporting five primary health care centers. Our teams provide medicines, training, and incentives for health care workers, and ensure referrals by ambulance to the county hospital.
Mental health needs after conflict
Women in Kajo Keji suffer stress, anxiety, and depression, among other mental health issues.
"Women have been facing a lot of abuse,” said 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.”
Ita Joice meets her baby girl after her cesarean section at Mundari County Hospital, the only secondary health care facility in Kajo Keji. South Sudan 2024 © Manon Massiat/MSF
With national elections coming up and partner organizations phasing out activities, there is still uncertainty among people considering returning to Kajo Keji. Even though the situation has slightly improved in recent years, communities still face many challenges, such as access to food, education, and sustainable, quality health care.
“People in Kajo Keji are surviving because of the support of MSF,” said Mirye. “But I am worried. If MSF leaves and the government has not stabilized the health system here, how are we going to survive?”
