Beads and barefoot nurses

South Sudan’s community health workers reach remotest lands

By Peter Martell
Healthcare worker Lokale Marko shows how beads are used to assess for pneumonia.
UNICEF South Sudan/2018/Martell
15 October 2018

NAKWA, South Sudan, 15 October 2018 – Slowly passing a string of large white beads through her fingers, healthcare worker Lokale Marko counts the breaths of the six-month old girl held in front of her.

At each breath, another bead slides through her fingers.

Focusing hard, the South Sudanese health worker stops only at the beeping of a timer countdown dangled on a string around her neck. 

“The baby does not have pneumonia,” said Marko happily, holding up the remaining beads, which show the baby was breathing normally. The final section of beads is coloured red. “If had reached the red beads in the time, then that means I would refer the baby to the health centre,” she said.

She wears the beads around her neck as through jewellery, always ready to hand, with different sized circles of beads depending on the age of the child.

The toughest of lands needs innovative solutions for help.

Here in Nakwa, in the far Eastern Equatoria region of South Sudan, access to formal healthcare is limited. Basic health clinics serve vast regions, and many mothers live too far away to bring their baby. So, in the remotest of places, sometimes one has to take the healthcare to the people.

Community-based distributors

Marko, a mother of five, is member of teams of trained barefoot health workers.

The women receive healthcare training, through the support of UNICEF implementing partner Save the Children. The trained women are called community-based distributors, or CBDs for short.

They focus on children aged under five, and work to combat the diseases and sicknesses that are the most common – and some of the deadliest. 

Lokale Marko demonstrates how a plastic arm band can assess a child for malnutrition.
UNICEF South Sudan/2018/Martell
Lokale Marko demonstrates how a plastic arm band can assess a child for malnutrition.

South Sudan, recovering after decades of war that led to its independence, and now struggling with a civil war, has some of the lowest indicators on healthcare in the world. So, the healthcare volunteers are crucial.

“It is too far for many mothers to come to the health centre if their child is sick,” said Marko, who began work as a CBD seven years ago. “They might not know exactly what is wrong, and leave it too late. We are nearby to ask for help.”

The women, who receive a basic incentive equivalent to US$25 every month, either volunteer themselves or are chosen by the community.

Lifesaving drugs and health training

“The women can get access to mothers who would not have come to the health centre,” said David Lokai, who helps train the women for Save the Children. “The mothers trust them too, because they are from the community. So, if they say, ‘there is a problem, and you must go,’ then they listen.”

They focus on the three key problems that prove deadly to children here; pneumonia, diarrhoea, and malaria.

“They are some of the most preventable deaths,” said Lokai. “So, the CBDs do their part to stop the children from dying.”

The barefoot nurses have only basic training, but they can carry with them lifesaving drugs; treatment for pneumonia, drugs for malaria, and oral rehydration salts for diarrhoea. They also give health training and tips to the mothers they meet.

In a community of around 8,000 people, some 30 of the volunteers are scattered throughout – and can always be reached.

“I do checks and follow up those I know are sick, or have heard are not well,” said Marko. “Then other times I am going to the fields to farm, and a woman will come to me and tell me her child needs help.”

It is helping some of the weakest children.

The project is funded by UNICEF through its implementing partner on the ground, Save the Children.

Saving lives

They also assess for malnutrition, carrying special sliding armbands that, when tightened around the upper arm of a baby, shows if the baby is too thin.

They are colour coded for simple identification. If the band can slide too far, the arm is too thin – and red shows. “Then we tell the mother to go to the health centre to get treatment for malnutrition,” she said.

The education is having a big impact. 

Longokoro Lachebe (centre)
UNICEF South Sudan/2018/Martell
Longokoro Lachebe (centre), a mother of three, said the community health workers saved the life of her one-year-old daughter from malaria.

“Before, with my older children, I would go to the local healer,” said mother of three, Longokoro Lachebe. “Sometimes the children got better, and sometimes they did not. Some children died.”

Earlier this year, when her one-year-old daughter had a severe fever, a CBD worker came. Caring for her other three children and a walk of several hours of the health centre meant she had delayed taking the baby until the fever was intense. But the CBD worker was able to help.

“They said it is malaria, and left some drugs,” Lachebe said. “Then they came back two days later with more – and my daughter got better. They have made a big change to our lives.”


(Funding for community-based health workers in Eastern Equatoria, South Sudan, is generously supported by the Government of Germany, the Government of Kuwait, the Swedish International Development Cooperation Agency (SIDA), UK Aid and the United States Funds for UNICEF.)