Delivering Seasonal Malaria Chemoprevention in Conflict-affected Settings Experiences from Northern Bahrel Ghazal, South Sudan

Delivering Seasonal Malaria Chemoprevention in Conflict-affected Settings Experiences from Northern Bahrel Ghazal, South Sudan | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Delivering Seasonal Malaria Chemoprevention in Conflict-affected Settings Experiences from Northern Bahrel Ghazal, South Sudan Abubaker Rom Ayuiel, Francis Okot, Jamshed Khan, Denis Mubiru, and 5 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7931566/v1 This work is licensed under a CC BY 4.0 License Status: Under Revision Version 1 posted 8 You are reading this latest preprint version Abstract South Sudan, a country with a high malaria burden, faces considerable health system challenges due to decades of civil war, which disrupts access to essential services. For three years, the Malaria Consortium has implemented Seasonal Malaria Chemoprevention (SMC) in Aweil South and Aweil West Counties; however, coverage remains below optimal at 79%, falling short of established targets. This study examines the barriers and enablers to accessing and distributing SMC during the 2024 round. Methods: A qualitative study design was used, involving 60 stakeholders involved in implementing SMC. Data were collected through 42 key informant interviews and 18 in-depth interviews with caregivers of eligible children who received all SMC doses or none, as well as those of ineligible children who received SMC. The data were analysed using deductive thematic analysis. Results: Factors that enabled SMC distribution and access included government support, community trust, efficient logistics, integrated activities, access to vital information, involvement of Boma health workers, supervisor transportation, and organized malaria management. The main challenges included shortages of healthcare workers, drug shortages, geographic and transportation difficulties, caregiver relocation, delayed referrals, and poor communication. Conclusion: These findings underscore the necessity for targeted interventions to address resource constraints, enhance workforce capacity, communication, and logistics infrastructure, thereby ensuring sustainable SMC delivery in conflict-affected areas. Strengthening these areas will be crucial for maximizing the impact of SMC as a malaria prevention strategy in such environments. Seasonal malaria chemoprevention Conflict-affected settings South Sudan enablers barriers Figures Figure 1 Introduction Seasonal malaria chemoprevention (SMC) is a highly effective intervention recommended by the World Health Organization (WHO) since 2012 for children aged 3–9 months in regions with highly seasonal malaria transmission, such as sub-Saharan Africa 1 . SMC has been implemented since 2022 in South Sudan, where malaria transmission peaks during a specific seasonal period 2 . As part of this intervention, children are treated monthly with sulfadoxine-pyrimethamine plus amodiaquine (SPAQ) to sustain therapeutic antimalarial levels during peak transmission seasons 3 . This approach has been shown to reduce clinical malaria and related mortality significantly 4 . Aweil South and Aweil West are two rural counties in Northern Bahrel-Ghazal, South Sudan, that heavily depend on farming and cattle raising 5 . The people in these areas have limited access to essential health services because most health facilities are either non-functional or damaged due to prolonged civil conflict, displacement caused by flooding, poor road conditions, the difficulty of accessing remote areas, or a lack of funding for these facilities 6 . They face major challenges, including inadequate infrastructure, frequent flooding, displacement, food insecurity, and limited access to essential services 7 . As a result, their populations are highly reliant on humanitarian aid and require targeted efforts to build resilience. Malaria is a huge concern in these counties, with seasonal epidemics exacerbated by flooding and limited access to healthcare. In 2024, malaria accounted for 30% of deaths and 52% of medical consultations, with a notable impact on children under five, who experienced a prevalence rate of 32.5% 8 . From June to October 2024, Malaria Consortium distributed SMC to children aged three to 59 months in two counties to prevent malaria. Despite its proven effectiveness, the 2024 End of Round Survey reported a substandard SMC coverage of 79%, which falls short of the standard target for successful implementation. This shortfall highlighted the need to identify and eliminate barriers to achieving optimal coverage in these conflict-affected areas. To explore the challenges and opportunities in delivering SMC, a qualitative study was conducted involving stakeholders in Aweil South and Aweil West Counties. Methodology Study location The study was conducted in November 2024 in the Aweil South and Aweil West counties of Northern Bahrel Ghazal State, South Sudan. These counties experience heavy seasonal rainfall, leading to flooding, and have seasonal malaria transmission patterns that peak between June and October each year 6 . Conflicts in Aweil South are mostly community-based in Aweil East and Gogrial West Payams, stemming from competition over land and water, as well as ongoing cycles of revenge among livestock owners and farmers. This includes cattle raids, abductions, and property damage, which increase tensions. The return of people from Sudan is adding to the social and economic stress. In Aweil West, disputes over land and clashes with Sudanese cattle keepers over grazing land and water, particularly in payams like Ayat West and Gomjuer West, often lead to conflict and crop damage. Refugees and those returning from Sudan face violence and harassment, further straining local communities. In addition, the ongoing tribal tensions in Sudan, which on some occasions have broken down into insurgencies, have also affected the organization of health services in the study area 9 . Study design This qualitative study employed focus group discussions and key informant interviews to explore the challenges and opportunities associated with implementing SMC in conflict-affected settings. Study population Eligible participants included those directly or indirectly involved in implementing SMC in 2024. The group consisted of caregivers of children who received SMC that year, local authority officials, officials from the State Ministry of Health, drug distributors (including health workers), County Health Department staff, healthcare facility staff, cultural and religious leaders, community elders, and Malaria Consortium personnel. Sample size and sampling procedure Previous research suggests that a relatively small sample size can be enough to reach data saturation, a crucial milestone in qualitative research. Research shows that anywhere from 9 to 50 interviews can be sufficient to reach saturation (where new themes or insights stop emerging), indicating that further data collection is no longer needed 10 . The goal of this evaluation was to achieve saturation, so 60 interviews were conducted, surpassing the minimum threshold recommended. This approach facilitated a detailed examination of the experiences, perceptions, and perspectives of caregivers and key stakeholders about the 2024 SMC round in the study area, yielding a deeper understanding of the program. Forty-one key informant interviews were conducted with respondents from various positions, providing a comprehensive overview of the program. The interviews included a diverse group of participants, such as an Aweil State Surveillance Officer, four Primary Health Care Unit (PHCU) In-charges (Clinical Officers), two County Public Health Department Officers, one State Public Health Officer, one State Pharmacist, and one State Data Manager. Other participants included two Malaria Consortium staff members, 15 Payam Leaders/Chiefs, three Religious Leaders, 10 Boma Healthcare Workers (BHWs) who had worked as Drug Distributors, supervisors, or both, a town crier (Social Mobilizer), and one Refugee Coordinator. Additionally, 18 in-depth interviews were conducted with caregivers of eligible children. These were split evenly among caregivers whose children had received all SPAQ doses across all five cycles, those whose children had not received any SPAQ doses in any cycle, and six interviews with caregivers of ineligible children who had received SPAQ. The characteristics of the study participants are shown in Table 1 . Table 1 Characteristics of participants in key informant and in-depth interviews KII category / Position Number State surveillance officer 1 Primary Health Care Units (PHCUs) in charge (clinical officers) 4 County Public Health Department Officers 2 State Public Health Officer 1 State Pharmacist 1 State Data Manager 1 Malaria Consortium staff one at the country office in Juba and the other at the Aeil field office. 2 Payam leaders/chiefs 15 Religious leaders 3 BHWs (drug distributors) 10 Town Cryer (social mobiliser) 1 Refugee coordinator 1 KII Total 42 IDIs Caregivers of eligible children received the SPAQ 6 Caregivers of eligible children did not receive the SPAQ 6 caregivers whose children, though ineligible, will have accessed SPAQ 6 IDI Total 18 Data collection Key informant interview guides were used to collect relevant data on stakeholders' perceptions of the enablers and challenges affecting SMC drug distribution during the 2024 round. Each county had one research assistant who conducted in-depth interviews with respondents selected by community-level enumerators, as well as key informant interviews. Interviews were conducted in English with key informants who spoke English fluently. In-depth interviews with caregivers of children and key informant interviews with local leaders who were not fluent in English were conducted in Dinka, the local language, and then translated back into English by trained, experienced research assistants. This approach ensured the collection of high-quality data throughout the interviews, thereby preventing language barriers from interfering with data collection. Each interview took between 35 and 60 minutes. In-depth interviews were conducted with caregivers of eligible children who completed all SMC doses and cycles, as well as with caregivers of children who did not complete all SMC doses or cycles or did not participate in the SMC campaign at all. These interviews were conducted in private settings to ensure participants felt comfortable and could share their thoughts openly. The interviews with caregivers provided a deeper understanding of their thoughts, experiences, and perspectives on SMC. Structured IDI guides specific to each group were used to collect the data. Before the interviews, participants provided verbal consent, and those who could read and write received a consent sheet to review before signing to confirm their consent. The researchers reached data saturation after 28 interviews, but conducted three additional interviews to ensure comprehensive coverage. Data Analysis All interviews were audio-recorded, transcribed, and analyzed using a deductive thematic analysis approach. Three authors analyzed the data. Predetermined themes were used to guide the analysis, including: (a) factors enabling access to SMC services, and (b) challenges to accessing SMC. These themes were based on prior knowledge of the program and evaluation experience. Two authors first familiarized themselves with the transcripts, independently analyzing one key informant and one in-depth interview using Microsoft Excel. They coded the data by attaching labels to text segments and linking them to relevant quotes, capturing both similar and differing perspectives. The codes were grouped under themes (e.g., “enablers to SMC” as “ESMC”). The data analysts first met to agree on a unified coding strategy and apply it consistently across all transcripts. They then compared notes on the codes every three days to ensure clarity, coherence, and an accurate representation of participant views. The emerging patterns, relationships, and inconsistencies were identified. The codes were then clustered into themes and subthemes, grouping related patterns. The third author then refined the codes and harmonized the themes by excluding or merging irrelevant or weak codes into broader categories. The analyzed data was finalized, and the theme names were finalized. The entire process took two weeks. Results The study involved 60 participants, including 18 caregivers and 42 other stakeholders, as previously mentioned. All caregivers were women aged 27 to 45 years. Except for four BHWs, the remaining key informants were all men, comprising 63.3% of the respondents. These key informants ranged in age from 25 to 60 years. The BHWs’ experience in community health work ranged from 3 to 5 years. Thematic summary Two major themes were deductively agreed upon, i.e., enablers to SMC implementation and access, and Challenges to SMC implementation and access. key challenges and enablers affecting SMC implementation during the 2024 SMC round. These factors include support from the government, community acceptance of the program, improved logistical planning and medicine availability, integration of activities, the role played by BHWs, and community engagement, among others. Enablers of the distribution of SMC Government Support One of the key factors recognized for the success of the SMC program is the support from the South Sudanese government, especially the Ministry of Health's Malaria Control Program. The SMC initiative has become so crucial to the ministry that it was included in South Sudan's 2020–2025 National Malaria Strategic Plan. According to a South Sudan Ministry of Health official, " SMC is one of our interventions and is mentioned in our strategic plan, the National Malaria Strategic Plan 2020–2025 ." Another narrative highlighted the strong political will and commitment supporting the SMC intervention through the partnership between the Malaria Control Programme Department of the Ministry of Health and the Malaria Consortium in implementing SMC. " We approve and collaborate well with the Malaria Consortium, which is implementing SMC. This is because SMC is also one of the WHO's recommended strategies ." (South Sudan MoH Official) The findings confirm that Seasonal Malaria Chemoprevention (SMC) in South Sudan is regarded as more than just a strategic measure, receiving clear policy backing and strong political commitment. Community Acceptance of and confidence in SMC effectiveness Implementing SMC in the 2024 round was also attributed to community members who, having had their children use SMC, came to recognize and appreciate the SMC drugs' effectiveness. After noting a decrease in malaria cases among children who took their SMC medication, caregivers valued the benefits of the drug. As a result, they ensured their children finished all the medicines in the subsequent distribution cycles. “Now caregivers realize that when the drug is used correctly, it protects children from contracting malaria and reduces the need for hospital visits. As a result, those who follow this ensure their children take all the medicines they are prescribed.” (BHW Supervisor, Aweil West). Caregivers’ confidence and trust in SMC are further demonstrated by one caregiver’s account of a child who did not complete the SMC cycles because they were taken for a cultural practice, resulting in missing all cycles. Despite this, she firmly believed in the treatment's effectiveness and planned to finish it, if possible, explained: “ These medications have been a huge relief. When my child took the first two doses, she stopped getting sick, which was a big relief for me. However, since I wasn't with her, I could not ensure she completed the full treatment. I would never deliberately prevent my child from taking these medicines, especially since they're free and effective in keeping her safe, healthy, and healthy ” (Female caregiver, FGD, Aweil West). The findings demonstrate that caregivers recognize the benefits of SMC, while also highlighting the need to address access and adherence issues to enhance the program’s effectiveness. Improved Logistics and Drug Availability The timely delivery of SPAQ, Coartem, and other supplies to the two counties and health facilities, in particular, in the 2024 cycle, compared to previous SMC cycles, was identified as a key factor enabling implementation. The drug distributors received the supplies early, overcoming a challenge that previously disrupted the program. The improvements in drug distribution introduced in the 2024 cycle resulted in no stockouts at health facilities. So far this year, the program has run smoothly in contrast to previous years, which has enhanced its effectiveness. There have been no reports of delayed consignments from Malaria Consortium. Additionally, BHWs effectively managed the distribution and storage of the drugs, ensuring they were readily available throughout the rounds. A health facility in charge noted, " When a new round starts, there are no delays or confusion about whether the drugs are available .” Integrated activities for efficiency Combining malaria prevention activities, such as SMC, surveillance, mosquito net distribution, and malaria case management, has helped improve efficiency and project implementation, leading to the desired outcomes. By streamlining efforts and eliminating duplication, this approach has also enhanced resource utilization, leading to improved malaria control, as noted by a malaria control official. Our approach combines all activities, including SMC distribution, surveillance, and case management. By adopting a coordinated strategy and providing multiple services simultaneously, we enhance SMC coverage, promoting trust and participation within the community. This efficiency enables us to reach a wider audience and have a greater impact in the fight against malaria . (KI, Malaria Consortium Official) The findings demonstrate how sharing resources, personnel, and logistics across different interventions enhances the distribution of SMC. Availability of critical information The SMC distribution program focused on giving caregivers all the essential information about SMC. Efforts were made to quickly share this information with beneficiaries so they could better understand the importance and correct use of SMC drugs. " When information is available and shared promptly with the caregivers, it supports better decision-making and implementation ." These findings indicate that sharing information promptly and thoroughly was another key component to the success of SMC distribution. This is because it enabled caregivers to get accurate information and make informed decisions about giving the medications. Role of Boma Health Workers (BHWs) Boma Health workers (BHWs) were identified as crucial and proactive players in distributing the SMC medication, which significantly contributed to the program's success. They played a significant role in administering SPAQs, conducting rapid diagnostic tests (RDTs), and providing timely referrals. Additionally, training BHWs to refer fever cases to the health facility simplified the malaria management process and reduced malaria-related complications. “These BHWs provide the first, second, third, and fifth rounds of SMC services. Additionally, if a child receives SPAQ and then tests positive for malaria, the BHWs refer them to the health center facility.” (Pastor, Aweil West). The community-focused approach, where BHWs come from within their own local areas of SMC distribution, reduces logistical issues like transportation. In places like Marial Bai, the BHWs are nominated from the local community and reside in the same locations they serve. Community Engagement and Support Local leaders, including chiefs and religious leaders, played a key role in making the SMC program a success. By getting involved, they helped the community accept SMC and made sure the organization ran smoothly. “Community leaders, including religious leaders and chiefs, were instrumental in this program. Malaria Consortium consulted with key stakeholders before launching the initiative.” (BHW, Aweil South). The provision of bicycles to mobilisers Transport and communication tools were considered essential for enhancing service delivery and motivating staff. The bicycles allowed supervisors and social mobilizers to cover more ground in their supervision and social mobilization roles. Referral and Treatment Processes Another approach that boosted SPAQ distribution was the SMC program's referral system. By equipping BHWs with Malaria rapid tests, they can quickly spot kids with malaria and send them to health facilities for proper care. With health facilities stocked with antimalarial medicines, caregivers were assured that their children would receive the appropriate treatment. “If the child’s condition seems serious, they immediately issue a referral card and send the child to the facility for further treatment. Once the referred children arrive at the facility, anti-malarial drugs are readily available, and they receive timely care.” (KI, BHI Supervisor). Additionally, the referral system significantly helped reduce the misdiagnosis of febrile illnesses, such as malaria, leading to improved care quality for children. One additional benefit of the referral system under the SMC program is that it can identify and refer children with fever who might otherwise be overlooked because their caregivers are unaware of malaria or other illnesses, such as pneumonia. This helps ensure timely diagnosis and treatment by connecting these cases with healthcare facilities (Clinician and In-charge, Aweil West County). Challenges to Effective SMC Program Implementation and Access Logistics, human resources, training, flooding, and access issues significantly affected the rollout of the 2024 Seasonal Malaria Chemotherapy (SMC) cycle, as thoroughly explained henceforth. Human Resources for Health Challenges Within the human resources for health sub-theme, the shortage of healthcare workers and the lack of training for BHWs were mentioned as key factors hindering the implementation of SMC. Inadequate Drug Distributors Respondents mentioned that some Payams didn't have enough BHWs to cover all villages in a Boma during the five days allocated for drug distribution. This was particularly evident in Bomas with many remote or distant villages, where supervisors and BHWs find it challenging to reach all households within the given time. “We only have one supervisor and one social mobiliser. This one social mobiliser cannot cover all those villages (BHW Supervisor, Aweil West). This impacted SMC access and distribution, as some BHWs were unable to reach all households within the planned 5-day distribution round, missing specific households, particularly those that are far away. Additionally, it was observed that having only one social mobilizer per Payam caused major challenges in community mobilization. This proved remarkably ineffective in Payams with large populations or villages spread over a wide area, where a single mobilizer could not sufficiently cover the entire region. Logistics and Drug Shortages It was observed that Primary Health Care Centres (PHCCs) frequently run out of antimalarial drugs. This left clinicians in a challenging situation, having to prescribe Coartem to children who were not SMC referrals. This went against the guidelines for using these medications, as the SMC program only provided Coartem for treating malaria in children referred by BHWs, as they distributed SMC drugs. However, most children seeking treatment were not referred from the SMC program. For example, one clinician noted that; In the facility, we face challenges when children come in suffering from malaria, but the BHWs' SMC program did not refer them. (Clinician Aweil West County) Inaccuracies in Population projection Some respondents noted that the population projections used for planning the 2024 SMC program likely contained inaccuracies, which could have impacted SMC targets. The issue arose from high population mobility, especially in areas along the border without SMC coverage, such as Warrap, Aweil Center, and Aweil East. These areas often experienced unexpected population surges due to cross-border migration, particularly from the influx of refugees from North Sudan, returnees, and internally displaced persons (IDPs), which negatively impacted SMC's drug supply, personnel deployment, and transportation needs. Refugees from Sudan, returnees from other countries, and people displaced within Sudan added to the growing populations. This resulted in a higher number of children eligible for SPAQ than initially anticipated. The inaccuracies resulted in the target populations being underestimated or overestimated. With the increased demand, particularly in areas such as Nyoc-Awany and Tarueng, resources were severely strained (SMC Project Personnel, Malaria Consortium). Additionally, this led to budgetary issues. Undercounts may have caused stockouts in certain areas because more children needed SPAQ treatment, while overcounts wasted resources. Geographic Coverage Challenges Some respondents mentioned significant difficulties in covering the large Payam area independently. The long distances made it tough for BHWs to reach every household, particularly in areas with sparse population and rough terrain. The region's vast size poses a major structural challenge that impacts how effectively the community can be mobilized for efforts. A social mobiliser explained, “ This Payam is huge, and I'm struggling to cover it on my own. If possible, I think it would be a good idea to add another town crier so we can collaborate to achieve better coverage. That way, we can split up, one person on the lowland side and one on the highland side . (KI, Town Crier, Aweil West). There was concern that the national guideline recommending a 5–25 kilometres between households and BHWs was too large and often exceeded in practice. Per national guidelines, households should be located within 5 to 25 kilometres of BHWs operational area. However, the maximum recommended 25-kilometer distance is too far and unrealistic for distributing SMC drugs. In fact, some BHWs are required to work even beyond that distance.” (KI, BHW Coordinator). Transport-related challenges Bicycle Maintenance Issues Although the BHW supervisors and social mobilizers received bicycles to help ease their movements, the lack of spare parts and limited repair funds made it difficult for them to use and maintain the bikes effectively. When they broke down, they often could not get fixed because the funding for repairs was too low, which affected how the program ran. As a result, many bicycles were returned in poor condition by the end of the SMC campaign. They gave us the bicycles without spare parts, which was not right. The incentives we receive for our work are relatively low, so I couldn't afford to repair the bike with what I have. As a result, many of the bicycles were returned in poor condition.” Relocation of caregivers from their known residences Relocation due to the challenge of floods The 2024 SMC program was severely disrupted by flooding in both counties, especially in September and October. The floods made it impossible to travel by road in remote, low-lying areas, and using makeshift canoes as a substitute for transportation proved unreliable. A BHW Supervisor underscored this challenge, noting, “During the flood season, vehicles could not access the flood-affected areas for supervision, nor were the roads passable on bicycles and motorcycles.” As a result, many BHWs were unable to reach specific communities across rivers and in areas affected by flooding. The flooding also forced people to leave their homes in affected areas for non-flooded regions, especially along major roads and highways. This complicated the drug distribution program and contributed to the low coverage rates seen in the third to fifth SMC cycles. The house-to-house approach typically used by the SMC program was ineffective during the flooding. A clinician from Aweil West explained, " It was hard to move from house to house because many households, often ten to twenty at a time, were displaced by flooding in the affected areas ." (KII, clinical officer, Aweil West) The floods also led to ponds with stagnant water that took a long time to be cleared. This extended close to 2 months. This led some to believe that SMC may need to be extended from five to six or seven rounds as the breeding sites for mosquitoes remain existent for a longer time. A clinician asserted that; Whenever floods become a breeding ground, resulting in more malaria cases, the 6th or 7th cycle can help counteract this in some areas (Clinical Officer, Aweil South). The floods also triggered mass migration as many families fled their homes to move to higher ground along roadsides. This made it challenging for BHWs to reach target households and deliver SMC drugs to everyone affected, resulting in lower coverage gaps. “When you move along this road going to Warrap, you will find a lot of people who have put up small temporary houses for them to stay after the heavy rains destroyed their original homes. In most cases, these people lose their retention cards, sometimes miss some rounds,” (BHWs in Aweil , South County). The flooding during the SMC program also blocked access to several areas because the roads became impassable. This causes logistical challenges, especially in delivering supplies to those areas. This led to delays or incomplete deliveries of medicines. Movements due to farming It was observed that during the planting season, several children only received the first two SMC cycles, missing out on the remaining three. As the rains intensified, caretakers often moved with their children to remote farming areas, resulting in missed cycles 3, 4, and 5. This migration disrupts the continuity of malaria prevention efforts, especially in areas prone to seasonal flooding, reducing the overall effectiveness of the program. During the rainy season, some people relocated from their usual homes to other places, mainly for farming. “ During the flood season, like two months ago, it was challenging. Vehicles could not access the flood-affected areas for supervision .” (KI, Local Chief, Awel West). As a result, reaching out to such people became difficult, particularly for those who moved to distant, unfamiliar areas beyond the reach of drug distributors. A chief, for example, explained that; “I have visited some of the caregivers twice but found no one at home, which complicated my work of making sure that every eligible child has the rightful dose” (BHW in Aweil South County). Another said that; When it rains, reaching the highland area becomes more difficult because the entire community often relocates to other places for farming tasks. However, the BHWs can't access these locations. As a result, many children on this side remain unreached for SMC distribution. (KII with Local Chief, Aweil South). Movements due to cultural practices There were also caregiver movements, sometimes influenced by traditional practices, that disrupted the completion of all SMC cycles as recommended. This issue is exacerbated by the lack of mechanisms to track these caregivers, resulting in missed opportunities to identify and reach out to SMC-eligible children. One caregiver shared her experience, emphasizing how cultural practices and a lack of follow-up contributed to missed opportunities for doses: “The main reason was that I was not at home when they came for the third, fourth, and fifth doses. My child had been staying with my family because she was in the weaning stage. By the time she came back, only two doses had been given, and I couldn’t make sure she got the rest. I also didn’t follow up as much as I should have, since I didn’t get a card to track the doses.” (Female caregiver of an eligible child who didn’t complete the SMC cycles) (Female Caregiver, Aweil South). This example highlighted the need for enhanced tracking mechanisms and follow-up strategies to ensure continuity in administering SMC doses, even when caregivers relocate or move out of their homes for other reasons. Delayed Referrals There was a challenge of delayed referrals for children with fever to receive appropriate malaria treatment. This problem is particularly prevalent in communities far from health facilities, where children referred to by BHWs often face delays in accessing care. A persistent issue is the delay in caregivers bringing referred children to healthcare facilities. As one respondent pointed out, " The challenges we have are in the community. When the child is referred, maybe the person cannot come on that very day ." (KI, Clinical Officer, Aweil West). This delay is made worse by caregivers juggling multiple responsibilities. Many caregivers also serve as household heads, taking care of other children or managing other household tasks. In these cases, caregivers face competing priorities and urgent responsibilities, which can put off their decision to act on a child's fever referral. As one clinician emphasized, " Maybe she is the one people are surviving [on]. Okay. Maybe she is a widow. Or they are not having a good job." When this happens, children with fever referred by the BHWs sometimes show up at the health facility late, after their condition has gotten worse, which can lead to a poor outcome. Communication Barriers One major communication challenge faced during the 2024 SMC distribution was related to the poor state of the phone networks. Lack of network in remote areas. The 2024 SMC program struggled with substantial communication issues, primarily due to inadequate phone network coverage. This matter was particularly severe in remote areas, where it hindered coordination of drug distribution and slowed down addressing problems that came up during the SMC distribution process. Additionally, limited network coverage often resulted in delays in data reporting, making it more difficult to respond quickly to emerging issues. A BHW supervisor emphasized this point, saying, “ There’s no network, no communication in some areas . You find you are going to do SMC for five days, but then you get to know a problem on the fifth day because of communication challenges .” (BHW Supervisor, Aweil South). Things become even more difficult when a supervisor tries to meet with a supervisee in person, since it is often hard to track them down. One BHW supervisor put it this way: " You'll go and spend the whole day, but you will not actually see that person ." Discussion The study findings show that several factors, including strong government support for the SMC program, effective community outreach, efficient logistics, and the key role of Boma Health Workers as drug distributors, contributed to the distribution and access to SMC in Aweil South and Aweil West counties in the 2024 SMC drug distribution program. Incorporating SMC into national malaria control strategies also played an essential role in its success. Other crucial factors include caregivers' trust in the SMC drugs to reduce malaria rates and deaths among children under five, timely drug distribution, provision of transportation such as bicycles for supervisors and mobilizers, and the integration of malaria control activities, including surveillance, confirmed case management, and mosquito net distribution. However, the program encountered several challenges, including staffing issues, logistical problems, operational difficulties, geographic barriers, extreme weather (primarily flooding), and inaccuracies in population target planning during the rollout and implementation. Staffing challenges, including a shortage of workers and inadequate training for BHWs, impacted SMC distribution. The importance of community trust in SMC effectiveness, which is crucial to the program's success, was emphasized in this study. This study's findings align with earlier research on the feasibility of SMC in Aweil South, South Sudan, which investigated the implementation of SMC in areas affected by conflict and humanitarian crises 6 . Trust is essential for making the program sustainable, and it can be strengthened through ongoing training and support. Investing in local health workers and integrating the program with other services is crucial for ensuring everyone has equal access to SMC in fragile contexts. The study findings, which show that involving community health workers in drug distribution enhances access to and distribution of SMC, align well with research in Nigeria and Ghana 11 – 13 . These studies demonstrate that engaging local community members in the distribution of medicine can help build trust. The study reported that when people trust the health workers in their community, caregivers are more likely to accept, follow, and participate in the SMC program, thereby reducing scepticism and misinformation, which in turn increases the distribution of SMC drugs. Their strong community links, cultural understanding, and door-to-door medication delivery help reach people in hard-to-reach, conflict-affected areas 6 . The BHWs also play a vital role in mobilizing, engaging, and educating people, as well as dispelling misconceptions to ensure they receive the necessary information 14 . Additionally, the BHWs facilitate networks between SMC and other healthcare providers and systems. 15 . Their flexibility helps ensure continuity even in unstable situations, making their role crucial when people are displaced or insecure. 11 . Therefore, strengthening BHWs’ capacity, offering incentives as was seen with the bicycles, and integrating BHWs more deeply into the health system will expand SMC coverage and promote equitable malaria prevention. The integration of Seasonal Malaria Chemoprevention (SMC) into South Sudan's national malaria control strategy was also highlighted as instrumental in the successful distribution and accessibility of medications during the 2024 SMC distribution program in Aweil South and Aweil West counties. This assertion has been corroborated in other contexts, including Nigeria, Burkina Faso, Ghana, and Chad, where the SMC program also operates under the premise that governmental support enhances legitimacy and community trust through the provision of essential funds, coordination, and the alignment of malaria interventions. 15,16 . The integration also facilitates resource pooling, training, and the development of partnerships. 17 . This emphasizes the necessity for the continued incorporation of SMC into national malaria control strategies and the adoption of best practices to support this integration, thereby ensuring the long-term sustainability of the SMC program as an integral component of the malaria control program. Another issue reported was that drugs intended for children with fever and malaria diagnoses under the SMC program, referred by drug distributors, were being diverted for malaria treatment of non-SMC program children at health facilities. These diverted drugs mainly included artemether and lumefantrine. Unlike countries like Mozambique, Nigeria, Burkina Faso, Ghana, Chad, and Mali, which have strong national systems in place to monitor and reduce the risk of drug diversion, South Sudan faces a unique challenge with the misuse or diversion of SMC program drugs 18 – 20 . Although it is not the SMC SPAQ, this diversion disrupts the program's operations, leading to unintended consequences, such as stockouts of these medicines and preventing referred children from getting proper treatment. The severe flooding in Aweil South and Aweil West significantly disrupted the 2024 SMC distribution. The floods were reported to have blocked transportation routes and displaced people, making it difficult to trace families to ensure their children complete the SMC cycle 9 . As observed in this study and elsewhere, flooding slows down the delivery of medicine. As a result, the risk of malaria increases due to increased mosquito breeding, even after the rains stop, because flooded plains remain wet for an extended period, thereby prolonging the breeding season for mosquitoes. Flooding also hinders efforts to track eligible children, especially those whose caregivers are displaced, thereby reducing the number of children covered by SMC 21 . While a plan was in place to address this challenge through strategies such as pre-positioning medicines, utilizing boats, and establishing fixed distribution points, these efforts were limited by weak infrastructure and a shortage of staff. Similar problems have been reported in some countries. For example, across the Sub-Saharan region, the SMC distribution period coincides with the rainy season, which can sometimes lead to flooding 19 . Flooding has often directly impacted implementation through logistical and transportation problems 22 . The 2024 floods in Mali, for instance, disrupted SMC distribution in the affected areas 23 . In Uganda and Mozambique, a complex distribution also exists in flood-prone regions following rainfall, increasing malaria cases. 24 . In Burkina Faso, flooding led to calls for expanding SMC beyond the distribution period to prevent outbreaks 25 . Thus, similar approaches, in addition to other climate-resilient strategies and customized delivery models, may be necessary in the study area to address distribution challenges caused by flooding and maintain the effectiveness of SMC. Another challenge expressed was the insufficiency of healthcare personnel (BHWs) necessary to cover extensive operational areas, thereby affecting drug distribution and community mobilization. This problem was exacerbated by poor maintenance of bicycles, which impacted supervisors' mobility and ability to perform their duties effectively, ultimately compromising the program's success. A study on implementing Seasonal Malaria Chemoprevention (SMC) across sub-Saharan Africa highlights that community health workers (CHWs) often face excessive workloads due to large coverage areas, which reduces efficiency in drug distribution and mobilization, issues like the BHW shortages reported in Aweil South and Aweil West, along with the transportation challenges mentioned earlier 18 . Microplanning strategies have been used to optimize CHW routes and cut walking distances by up to 25%, helping to fix transportation inefficiencies in Burkina Faso and Mali 26 . Related plans may be necessary to address unique issues observed in South Sudan, such as bicycle maintenance. These findings underscore the need for targeted investments in strong transportation solutions to enhance the capacity of Aweil’s SMC programs to adapt effectively to the counties’ unique geographical conditions. The study results also revealed that inaccurate population data may have affected the SMC distribution, resulting in the under-allocation of resources and waste. This was evident in the refugee settlements, which have experienced a sharp increase in demand for services, primarily due to unplanned influxes of refugees from Sudan. This matches previous research, which found that large refugee arrivals and displacement in Africa can disrupt supply chains, causing wrong population estimates and poor supply planning 24 . Consequently, resources are often not distributed where they are needed most, while other areas become overstocked, resulting in waste 9 . This can also lessen the effectiveness of interventions, with up to 10–20% of antimalarial stocks being wasted during emergencies 27 . The study further revealed that communication gaps remained a challenge, mainly due to poor network coverage in remote areas. Previous research has highlighted similar issues with inadequate mobile network coverage in these regions, which significantly disrupts the implementation of SMC by affecting coordination, problem-solving, and data reporting 28 . As noted in this study, community health workers face challenges in communicating stock levels and managing supervision, which result in delays and missed opportunities to address project issues 29 . Poor connectivity also delays responses to drug shortages or adverse events 29 . Gaps in data management weaken real-time monitoring, equity, and accountability. Evidence from Nigeria, The Gambia, Mali, and Burkina Faso indicate similar barriers, with coverage losses in hard-to-reach areas 11 , 12 , 19 . Studies recommend using offline-capable applications, community radio, and infrastructure investments to ensure equitable access and maintain the protective effects of SMC in high-risk zones 28 , 29 . Strengths and Limitations This study has two major strengths: its emphasis on real-world implementation in a high-malaria-burden, conflict-affected area, and its use of qualitative data to gather in-depth insights from stakeholders. This approach increases the reliability of the findings for policy purposes. However, the study has some limitations that call for interpretation and the use of the findings with caution. The results are based on data from only two counties, which may limit the applicability of the findings to other areas of South Sudan or similar contexts. The sample size and selection process could also introduce biases, such as overrepresenting communities that are easily accessible. Additionally, the study's cross-sectional design doesn't allow for conclusions about cause and effect. Another limitation is that the study relies on self-reported data, which can be affected by memory bias. Despite this, efforts were made to cross-check sources to minimize the potential issues. Conclusion This study investigated the factors that enabled and hindered the distribution of, and access to, seasonal malaria chemoprevention (SMC) in the conflict-affected Aweil South and Aweil West counties of South Sudan during the 2024 round. The study found that delivering SMC in rural, conflict-affected areas of South Sudan mainly relied on community trust, government support, efficient logistics, and the involvement of local health workers. However, shortages of drug distributors, disruptions to the drug supply, poor transportation, displacement due to flooding, and inadequate communication all limited coverage. To improve access in future SMC distribution and related areas, it is crucial to strengthen supply chains, increase healthcare workforce capacity, address challenges such as limited resources, flooding, and mobility constraints, and implement innovative approaches to reach remote areas, including the use of mobile clinics. Declarations Acknowledgements The authors wish to express their profound appreciation to all Seasonal Malaria Chemoprevention (SMC) Volunteers for their unwavering dedication and exemplary efforts in the implementation of this project. We are deeply grateful to the staff of Malaria Consortium, both at the Juba main office and the Aweil Field Office, for their steadfast support and invaluable contributions throughout the project’s duration. Our sincere thanks are also extended to Dev-com Consultants Juba for their pivotal role in conducting the end-of-round survey and qualitative data collection, which provided critical insights into this study. Furthermore, we acknowledge with gratitude the collaboration and support of the National and State Malaria Control Programme of the Ministry of Health, Republic of South Sudan, as well as the County Health Department officials in Aweil South and Aweil West Counties, Northern Bahrel Ghazal State. Author contributions AR: study conceptualization, writing original manuscript. SP: supervision of data collection, data analysis, manuscript editing. FO: supervision of data collection, study conceptualization, review of manuscript. DM: study conceptualization, review of manuscript. JK: study conceptualization, review of manuscript. AD: study conceptualization and review of manuscript, EW: study conceptualization and review of manuscript, NA: study conceptualization and review of manuscript. All authors have reviewed and approved the final version of the manuscript Ethics approval consent to participate This study received ethical approval from the Republic of South Sudan Ministry of Health’s Ethical Review Board in Juba, Reference No:( MOH/RERB/P/D.05/2025) All participants provided informed consent after being fully briefed on the study’s objectives, procedures, and ethical considerations. Additional authorization to conduct the research was obtained from the Aweil State Public Health Officer and the coordinators of each county. Participants were also provided with a contact point to report any concerns or issues related to their participation in the survey. Competing interests The authors declare they have no competing interests. Funding Declaration: This research, including its authorship and publication, did not receive any financial support from funding agencies, commercial entities, or non-profit organizations References World Health Organization. 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Introducing field digital data collection systems into seasonal malaria chemoprevention campaigns: Opportunities for robust evidence development and national e-health strategies. Vol. 7, BMJ Global Health. BMJ Publishing Group; 2022. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Revision Version 1 posted Editorial decision: Revision requested 17 May, 2026 Reviews received at journal 16 May, 2026 Reviewers agreed at journal 16 May, 2026 Reviewers agreed at journal 29 Nov, 2025 Reviewers invited by journal 26 Nov, 2025 Editor assigned by journal 14 Nov, 2025 Submission checks completed at journal 14 Nov, 2025 First submitted to journal 23 Oct, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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1","display":"","copyAsset":false,"role":"figure","size":97519,"visible":true,"origin":"","legend":"\u003cp\u003eUnnumbered image in the Methodology section.\u003c/p\u003e","description":"","filename":"1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7931566/v1/bd82b47374b891f4a309826b.jpg"},{"id":97664774,"identity":"fd3648fa-6e48-45f7-b4a5-933055a141f5","added_by":"auto","created_at":"2025-12-08 09:14:08","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1086942,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7931566/v1/9eed5d80-6f3c-40b3-8143-245f53ea50cd.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Delivering Seasonal Malaria Chemoprevention in Conflict-affected Settings Experiences from Northern Bahrel Ghazal, South Sudan","fulltext":[{"header":"Introduction","content":"\u003cp\u003eSeasonal malaria chemoprevention (SMC) is a highly effective intervention recommended by the World Health Organization (WHO) since 2012 for children aged 3\u0026ndash;9 months in regions with highly seasonal malaria transmission, such as sub-Saharan Africa \u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e. SMC has been implemented since 2022 in South Sudan, where malaria transmission peaks during a specific seasonal period \u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e. As part of this intervention, children are treated monthly with sulfadoxine-pyrimethamine plus amodiaquine (SPAQ) to sustain therapeutic antimalarial levels during peak transmission seasons \u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e. This approach has been shown to reduce clinical malaria and related mortality significantly \u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eAweil South and Aweil West are two rural counties in Northern Bahrel-Ghazal, South Sudan, that heavily depend on farming and cattle raising \u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e. The people in these areas have limited access to essential health services because most health facilities are either non-functional or damaged due to prolonged civil conflict, displacement caused by flooding, poor road conditions, the difficulty of accessing remote areas, or a lack of funding for these facilities \u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e. They face major challenges, including inadequate infrastructure, frequent flooding, displacement, food insecurity, and limited access to essential services \u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e. As a result, their populations are highly reliant on humanitarian aid and require targeted efforts to build resilience. Malaria is a huge concern in these counties, with seasonal epidemics exacerbated by flooding and limited access to healthcare. In 2024, malaria accounted for 30% of deaths and 52% of medical consultations, with a notable impact on children under five, who experienced a prevalence rate of 32.5% \u003csup\u003e8\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eFrom June to October 2024, Malaria Consortium distributed SMC to children aged three to 59 months in two counties to prevent malaria. Despite its proven effectiveness, the 2024 End of Round Survey reported a substandard SMC coverage of 79%, which falls short of the standard target for successful implementation. This shortfall highlighted the need to identify and eliminate barriers to achieving optimal coverage in these conflict-affected areas. To explore the challenges and opportunities in delivering SMC, a qualitative study was conducted involving stakeholders in Aweil South and Aweil West Counties.\u003c/p\u003e"},{"header":"Methodology","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eStudy location\u003c/h2\u003e\u003cp\u003eThe study was conducted in November 2024 in the Aweil South and Aweil West counties of Northern Bahrel Ghazal State, South Sudan. These counties experience heavy seasonal rainfall, leading to flooding, and have seasonal malaria transmission patterns that peak between June and October each year \u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e. Conflicts in Aweil South are mostly community-based in Aweil East and Gogrial West Payams, stemming from competition over land and water, as well as ongoing cycles of revenge among livestock owners and farmers. This includes cattle raids, abductions, and property damage, which increase tensions. The return of people from Sudan is adding to the social and economic stress. In Aweil West, disputes over land and clashes with Sudanese cattle keepers over grazing land and water, particularly in payams like Ayat West and Gomjuer West, often lead to conflict and crop damage. Refugees and those returning from Sudan face violence and harassment, further straining local communities. In addition, the ongoing tribal tensions in Sudan, which on some occasions have broken down into insurgencies, have also affected the organization of health services in the study area \u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eStudy design\u003c/h3\u003e\n\u003cp\u003eThis qualitative study employed focus group discussions and key informant interviews to explore the challenges and opportunities associated with implementing SMC in conflict-affected settings.\u003c/p\u003e\n\u003ch3\u003eStudy population\u003c/h3\u003e\n\u003cp\u003eEligible participants included those directly or indirectly involved in implementing SMC in 2024. The group consisted of caregivers of children who received SMC that year, local authority officials, officials from the State Ministry of Health, drug distributors (including health workers), County Health Department staff, healthcare facility staff, cultural and religious leaders, community elders, and Malaria Consortium personnel.\u003c/p\u003e\n\u003ch3\u003eSample size and sampling procedure\u003c/h3\u003e\n\u003cp\u003ePrevious research suggests that a relatively small sample size can be enough to reach data saturation, a crucial milestone in qualitative research. Research shows that anywhere from 9 to 50 interviews can be sufficient to reach saturation (where new themes or insights stop emerging), indicating that further data collection is no longer needed \u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e. The goal of this evaluation was to achieve saturation, so 60 interviews were conducted, surpassing the minimum threshold recommended. This approach facilitated a detailed examination of the experiences, perceptions, and perspectives of caregivers and key stakeholders about the 2024 SMC round in the study area, yielding a deeper understanding of the program.\u003c/p\u003e\u003cp\u003eForty-one key informant interviews were conducted with respondents from various positions, providing a comprehensive overview of the program. The interviews included a diverse group of participants, such as an Aweil State Surveillance Officer, four Primary Health Care Unit (PHCU) In-charges (Clinical Officers), two County Public Health Department Officers, one State Public Health Officer, one State Pharmacist, and one State Data Manager. Other participants included two Malaria Consortium staff members, 15 Payam Leaders/Chiefs, three Religious Leaders, 10 Boma Healthcare Workers (BHWs) who had worked as Drug Distributors, supervisors, or both, a town crier (Social Mobilizer), and one Refugee Coordinator. Additionally, 18 in-depth interviews were conducted with caregivers of eligible children. These were split evenly among caregivers whose children had received all SPAQ doses across all five cycles, those whose children had not received any SPAQ doses in any cycle, and six interviews with caregivers of ineligible children who had received SPAQ. The characteristics of the study participants are shown in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eCharacteristics of participants in key informant and in-depth interviews\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"2\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eKII category / Position\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNumber\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eState surveillance officer\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePrimary Health Care Units (PHCUs) in charge (clinical officers)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCounty Public Health Department Officers\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eState Public Health Officer\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eState Pharmacist\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eState Data Manager\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMalaria Consortium staff one at the country office in Juba and the other at the Aeil field office.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePayam leaders/chiefs\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e15\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eReligious leaders\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBHWs (drug distributors)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e10\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTown Cryer (social mobiliser)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRefugee coordinator\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eKII Total\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e42\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIDIs\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCaregivers of eligible children received the SPAQ\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCaregivers of eligible children did not receive the SPAQ\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ecaregivers whose children, though ineligible, will have accessed SPAQ\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIDI Total\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e18\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\n\u003ch3\u003eData collection\u003c/h3\u003e\n\u003cp\u003eKey informant interview guides were used to collect relevant data on stakeholders' perceptions of the enablers and challenges affecting SMC drug distribution during the 2024 round. Each county had one research assistant who conducted in-depth interviews with respondents selected by community-level enumerators, as well as key informant interviews. Interviews were conducted in English with key informants who spoke English fluently. In-depth interviews with caregivers of children and key informant interviews with local leaders who were not fluent in English were conducted in Dinka, the local language, and then translated back into English by trained, experienced research assistants. This approach ensured the collection of high-quality data throughout the interviews, thereby preventing language barriers from interfering with data collection. Each interview took between 35 and 60 minutes.\u003c/p\u003e\u003cp\u003eIn-depth interviews were conducted with caregivers of eligible children who completed all SMC doses and cycles, as well as with caregivers of children who did not complete all SMC doses or cycles or did not participate in the SMC campaign at all. These interviews were conducted in private settings to ensure participants felt comfortable and could share their thoughts openly. The interviews with caregivers provided a deeper understanding of their thoughts, experiences, and perspectives on SMC. Structured IDI guides specific to each group were used to collect the data. Before the interviews, participants provided verbal consent, and those who could read and write received a consent sheet to review before signing to confirm their consent. The researchers reached data saturation after 28 interviews, but conducted three additional interviews to ensure comprehensive coverage.\u003c/p\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003eData Analysis\u003c/h2\u003e\u003cp\u003eAll interviews were audio-recorded, transcribed, and analyzed using a deductive thematic analysis approach. Three authors analyzed the data. Predetermined themes were used to guide the analysis, including: (a) factors enabling access to SMC services, and (b) challenges to accessing SMC. These themes were based on prior knowledge of the program and evaluation experience. Two authors first familiarized themselves with the transcripts, independently analyzing one key informant and one in-depth interview using Microsoft Excel. They coded the data by attaching labels to text segments and linking them to relevant quotes, capturing both similar and differing perspectives. The codes were grouped under themes (e.g., \u0026ldquo;enablers to SMC\u0026rdquo; as \u0026ldquo;ESMC\u0026rdquo;). The data analysts first met to agree on a unified coding strategy and apply it consistently across all transcripts. They then compared notes on the codes every three days to ensure clarity, coherence, and an accurate representation of participant views. The emerging patterns, relationships, and inconsistencies were identified. The codes were then clustered into themes and subthemes, grouping related patterns. The third author then refined the codes and harmonized the themes by excluding or merging irrelevant or weak codes into broader categories. The analyzed data was finalized, and the theme names were finalized. The entire process took two weeks.\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eThe study involved 60 participants, including 18 caregivers and 42 other stakeholders, as previously mentioned. All caregivers were women aged 27 to 45 years. Except for four BHWs, the remaining key informants were all men, comprising 63.3% of the respondents. These key informants ranged in age from 25 to 60 years. The BHWs\u0026rsquo; experience in community health work ranged from 3 to 5 years.\u003c/p\u003e\n\u003ch3\u003eThematic summary\u003c/h3\u003e\n\u003cp\u003eTwo major themes were deductively agreed upon, i.e., enablers to SMC implementation and access, and Challenges to SMC implementation and access. key challenges and enablers affecting SMC implementation during the 2024 SMC round. These factors include support from the government, community acceptance of the program, improved logistical planning and medicine availability, integration of activities, the role played by BHWs, and community engagement, among others.\u003c/p\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003eEnablers of the distribution of SMC\u003c/h2\u003e\u003cdiv id=\"Sec12\" class=\"Section3\"\u003e\u003ch2\u003eGovernment Support\u003c/h2\u003e\u003cp\u003eOne of the key factors recognized for the success of the SMC program is the support from the South Sudanese government, especially the Ministry of Health's Malaria Control Program. The SMC initiative has become so crucial to the ministry that it was included in South Sudan's 2020\u0026ndash;2025 National Malaria Strategic Plan. According to a South Sudan Ministry of Health official,\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\"\u003cem\u003eSMC is one of our interventions and is mentioned in our strategic plan, the National Malaria Strategic Plan 2020\u0026ndash;2025\u003c/em\u003e.\"\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eAnother narrative highlighted the strong political will and commitment supporting the SMC intervention through the partnership between the Malaria Control Programme Department of the Ministry of Health and the Malaria Consortium in implementing SMC.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\"\u003cem\u003eWe approve and collaborate well with the Malaria Consortium, which is implementing SMC. This is because SMC is also one of the WHO's recommended strategies\u003c/em\u003e.\" (South Sudan MoH Official)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eThe findings confirm that Seasonal Malaria Chemoprevention (SMC) in South Sudan is regarded as more than just a strategic measure, receiving clear policy backing and strong political commitment.\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\u003ch2\u003eCommunity Acceptance of and confidence in SMC effectiveness\u003c/h2\u003e\u003cp\u003eImplementing SMC in the 2024 round was also attributed to community members who, having had their children use SMC, came to recognize and appreciate the SMC drugs' effectiveness. After noting a decrease in malaria cases among children who took their SMC medication, caregivers valued the benefits of the drug. As a result, they ensured their children finished all the medicines in the subsequent distribution cycles.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Now caregivers realize that when the drug is used correctly, it protects children from contracting malaria and reduces the need for hospital visits. As a result, those who follow this ensure their children take all the medicines they are prescribed.\u0026rdquo;\u003c/em\u003e (BHW Supervisor, Aweil West).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eCaregivers\u0026rsquo; confidence and trust in SMC are further demonstrated by one caregiver\u0026rsquo;s account of a child who did not complete the SMC cycles because they were taken for a cultural practice, resulting in missing all cycles. Despite this, she firmly believed in the treatment's effectiveness and planned to finish it, if possible, explained:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;\u003cem\u003eThese medications have been a huge relief. When my child took the first two doses, she stopped getting sick, which was a big relief for me. However, since I wasn't with her, I could not ensure she completed the full treatment. I would never deliberately prevent my child from taking these medicines, especially since they're free and effective in keeping her safe, healthy, and healthy\u003c/em\u003e\u0026rdquo; (Female caregiver, FGD, Aweil West).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eThe findings demonstrate that caregivers recognize the benefits of SMC, while also highlighting the need to address access and adherence issues to enhance the program\u0026rsquo;s effectiveness.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\u003ch2\u003eImproved Logistics and Drug Availability\u003c/h2\u003e\u003cp\u003eThe timely delivery of SPAQ, Coartem, and other supplies to the two counties and health facilities, in particular, in the 2024 cycle, compared to previous SMC cycles, was identified as a key factor enabling implementation. The drug distributors received the supplies early, overcoming a challenge that previously disrupted the program. The improvements in drug distribution introduced in the 2024 cycle resulted in no stockouts at health facilities.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eSo far this year, the program has run smoothly in contrast to previous years, which has enhanced its effectiveness. There have been no reports of delayed consignments from Malaria Consortium.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eAdditionally, BHWs effectively managed the distribution and storage of the drugs, ensuring they were readily available throughout the rounds. A health facility in charge noted, \"\u003cem\u003eWhen a new round starts, there are no delays or confusion about whether the drugs are available\u003c/em\u003e.\u0026rdquo;\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e\u003ch2\u003eIntegrated activities for efficiency\u003c/h2\u003e\u003cp\u003eCombining malaria prevention activities, such as SMC, surveillance, mosquito net distribution, and malaria case management, has helped improve efficiency and project implementation, leading to the desired outcomes. By streamlining efforts and eliminating duplication, this approach has also enhanced resource utilization, leading to improved malaria control, as noted by a malaria control official.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003eOur approach combines all activities, including SMC distribution, surveillance, and case management. By adopting a coordinated strategy and providing multiple services simultaneously, we enhance SMC coverage, promoting trust and participation within the community. This efficiency enables us to reach a wider audience and have a greater impact in the fight against malaria\u003c/em\u003e. (KI, Malaria Consortium Official)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eThe findings demonstrate how sharing resources, personnel, and logistics across different interventions enhances the distribution of SMC.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec16\" class=\"Section2\"\u003e\u003ch2\u003eAvailability of critical information\u003c/h2\u003e\u003cp\u003eThe SMC distribution program focused on giving caregivers all the essential information about SMC. Efforts were made to quickly share this information with beneficiaries so they could better understand the importance and correct use of SMC drugs.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\"\u003cem\u003eWhen information is available and shared promptly with the caregivers, it supports better decision-making and implementation\u003c/em\u003e.\"\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eThese findings indicate that sharing information promptly and thoroughly was another key component to the success of SMC distribution. This is because it enabled caregivers to get accurate information and make informed decisions about giving the medications.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec17\" class=\"Section2\"\u003e\u003ch2\u003eRole of Boma Health Workers (BHWs)\u003c/h2\u003e\u003cp\u003eBoma Health workers (BHWs) were identified as crucial and proactive players in distributing the SMC medication, which significantly contributed to the program's success. They played a significant role in administering SPAQs, conducting rapid diagnostic tests (RDTs), and providing timely referrals. Additionally, training BHWs to refer fever cases to the health facility simplified the malaria management process and reduced malaria-related complications.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;These BHWs provide the first, second, third, and fifth rounds of SMC services. Additionally, if a child receives SPAQ and then tests positive for malaria, the BHWs refer them to the health center facility.\u0026rdquo; (Pastor, Aweil West).\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eThe community-focused approach, where BHWs come from within their own local areas of SMC distribution, reduces logistical issues like transportation.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eIn places like Marial Bai, the BHWs are nominated from the local community and reside in the same locations they serve.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec18\" class=\"Section2\"\u003e\u003ch2\u003eCommunity Engagement and Support\u003c/h2\u003e\u003cp\u003eLocal leaders, including chiefs and religious leaders, played a key role in making the SMC program a success. By getting involved, they helped the community accept SMC and made sure the organization ran smoothly.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Community leaders, including religious leaders and chiefs, were instrumental in this program. Malaria Consortium consulted with key stakeholders before launching the initiative.\u0026rdquo; (BHW, Aweil South).\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec19\" class=\"Section2\"\u003e\u003ch2\u003eThe provision of bicycles to mobilisers\u003c/h2\u003e\u003cp\u003eTransport and communication tools were considered essential for enhancing service delivery and motivating staff. The bicycles allowed supervisors and social mobilizers to cover more ground in their supervision and social mobilization roles.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec20\" class=\"Section2\"\u003e\u003ch2\u003eReferral and Treatment Processes\u003c/h2\u003e\u003cp\u003eAnother approach that boosted SPAQ distribution was the SMC program's referral system. By equipping BHWs with Malaria rapid tests, they can quickly spot kids with malaria and send them to health facilities for proper care. With health facilities stocked with antimalarial medicines, caregivers were assured that their children would receive the appropriate treatment.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;If the child\u0026rsquo;s condition seems serious, they immediately issue a referral card and send the child to the facility for further treatment. Once the referred children arrive at the facility, anti-malarial drugs are readily available, and they receive timely care.\u0026rdquo; (KI, BHI Supervisor).\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eAdditionally, the referral system significantly helped reduce the misdiagnosis of febrile illnesses, such as malaria, leading to improved care quality for children.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003eOne additional benefit of the referral system under the SMC program is that it can identify and refer children with fever who might otherwise be overlooked because their caregivers are unaware of malaria or other illnesses, such as pneumonia. This helps ensure timely diagnosis and treatment by connecting these cases with healthcare facilities (Clinician and In-charge, Aweil West County).\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec21\" class=\"Section2\"\u003e\u003ch2\u003eChallenges to Effective SMC Program Implementation and Access\u003c/h2\u003e\u003cp\u003eLogistics, human resources, training, flooding, and access issues significantly affected the rollout of the 2024 Seasonal Malaria Chemotherapy (SMC) cycle, as thoroughly explained henceforth.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec22\" class=\"Section2\"\u003e\u003ch2\u003eHuman Resources for Health Challenges\u003c/h2\u003e\u003cp\u003eWithin the human resources for health sub-theme, the shortage of healthcare workers and the lack of training for BHWs were mentioned as key factors hindering the implementation of SMC.\u003c/p\u003e\u003cdiv id=\"Sec23\" class=\"Section3\"\u003e\u003ch2\u003eInadequate Drug Distributors\u003c/h2\u003e\u003cp\u003eRespondents mentioned that some Payams didn't have enough BHWs to cover all villages in a Boma during the five days allocated for drug distribution. This was particularly evident in Bomas with many remote or distant villages, where supervisors and BHWs find it challenging to reach all households within the given time.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;We only have one supervisor and one social mobiliser. This one social mobiliser cannot cover all those villages\u003c/em\u003e (BHW Supervisor, Aweil West).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eThis impacted SMC access and distribution, as some BHWs were unable to reach all households within the planned 5-day distribution round, missing specific households, particularly those that are far away.\u003c/p\u003e\u003cp\u003eAdditionally, it was observed that having only one social mobilizer per Payam caused major challenges in community mobilization. This proved remarkably ineffective in Payams with large populations or villages spread over a wide area, where a single mobilizer could not sufficiently cover the entire region.\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Sec24\" class=\"Section2\"\u003e\u003ch2\u003eLogistics and Drug Shortages\u003c/h2\u003e\u003cp\u003eIt was observed that Primary Health Care Centres (PHCCs) frequently run out of antimalarial drugs. This left clinicians in a challenging situation, having to prescribe Coartem to children who were not SMC referrals. This went against the guidelines for using these medications, as the SMC program only provided Coartem for treating malaria in children referred by BHWs, as they distributed SMC drugs. However, most children seeking treatment were not referred from the SMC program. For example, one clinician noted that;\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003eIn the facility, we face challenges when children come in suffering from malaria, but the BHWs' SMC program did not refer them. (Clinician Aweil West County)\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cdiv id=\"Sec25\" class=\"Section3\"\u003e\u003ch2\u003eInaccuracies in Population projection\u003c/h2\u003e\u003cp\u003eSome respondents noted that the population projections used for planning the 2024 SMC program likely contained inaccuracies, which could have impacted SMC targets. The issue arose from high population mobility, especially in areas along the border without SMC coverage, such as Warrap, Aweil Center, and Aweil East. These areas often experienced unexpected population surges due to cross-border migration, particularly from the influx of refugees from North Sudan, returnees, and internally displaced persons (IDPs), which negatively impacted SMC's drug supply, personnel deployment, and transportation needs.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003eRefugees from Sudan, returnees from other countries, and people displaced within Sudan added to the growing populations. This resulted in a higher number of children eligible for SPAQ than initially anticipated. The inaccuracies resulted in the target populations being underestimated or overestimated. With the increased demand, particularly in areas such as Nyoc-Awany and Tarueng, resources were severely strained\u003c/em\u003e (SMC Project Personnel, Malaria Consortium).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eAdditionally, this led to budgetary issues. Undercounts may have caused stockouts in certain areas because more children needed SPAQ treatment, while overcounts wasted resources.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec26\" class=\"Section3\"\u003e\u003ch2\u003eGeographic Coverage Challenges\u003c/h2\u003e\u003cp\u003eSome respondents mentioned significant difficulties in covering the large Payam area independently. The long distances made it tough for BHWs to reach every household, particularly in areas with sparse population and rough terrain. The region's vast size poses a major structural challenge that impacts how effectively the community can be mobilized for efforts.\u003c/p\u003e\u003cp\u003eA social mobiliser explained,\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;\u003cem\u003eThis Payam is huge, and I'm struggling to cover it on my own. If possible, I think it would be a good idea to add another town crier so we can collaborate to achieve better coverage. That way, we can split up, one person on the lowland side and one on the highland side\u003c/em\u003e. (KI, Town Crier, Aweil West).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e There was concern that the national guideline recommending a 5\u0026ndash;25 kilometres between households and BHWs was too large and often exceeded in practice.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e Per national guidelines, households should be located within 5 to 25 kilometres of BHWs operational area. However, the maximum recommended 25-kilometer distance is too far and unrealistic for distributing SMC drugs. In fact, some BHWs are required to work even beyond that distance.\u0026rdquo;\u003c/em\u003e (KI, BHW Coordinator).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec27\" class=\"Section3\"\u003e\u003ch2\u003eTransport-related challenges\u003c/h2\u003e\u003cdiv id=\"Sec28\" class=\"Section4\"\u003e\u003ch2\u003eBicycle Maintenance Issues\u003c/h2\u003e\u003cp\u003eAlthough the BHW supervisors and social mobilizers received bicycles to help ease their movements, the lack of spare parts and limited repair funds made it difficult for them to use and maintain the bikes effectively. When they broke down, they often could not get fixed because the funding for repairs was too low, which affected how the program ran. As a result, many bicycles were returned in poor condition by the end of the SMC campaign.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003eThey gave us the bicycles without spare parts, which was not right. The incentives we receive for our work are relatively low, so I couldn't afford to repair the bike with what I have. As a result, many of the bicycles were returned in poor condition.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Sec29\" class=\"Section2\"\u003e\u003ch2\u003eRelocation of caregivers from their known residences\u003c/h2\u003e\u003cdiv id=\"Sec30\" class=\"Section3\"\u003e\u003ch2\u003eRelocation due to the challenge of floods\u003c/h2\u003e\u003cp\u003eThe 2024 SMC program was severely disrupted by flooding in both counties, especially in September and October. The floods made it impossible to travel by road in remote, low-lying areas, and using makeshift canoes as a substitute for transportation proved unreliable. A BHW Supervisor underscored this challenge, noting, \u0026ldquo;During the flood season, vehicles could not access the flood-affected areas for supervision, nor were \u003cem\u003ethe roads passable on bicycles and motorcycles.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\u003cp\u003eAs a result, many BHWs were unable to reach specific communities across rivers and in areas affected by flooding. The flooding also forced people to leave their homes in affected areas for non-flooded regions, especially along major roads and highways. This complicated the drug distribution program and contributed to the low coverage rates seen in the third to fifth SMC cycles. The house-to-house approach typically used by the SMC program was ineffective during the flooding. A clinician from Aweil West explained,\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\"\u003cem\u003eIt was hard to move from house to house because many households, often ten to twenty at a time, were displaced by flooding in the affected areas\u003c/em\u003e.\" (KII, clinical officer, Aweil West)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eThe floods also led to ponds with stagnant water that took a long time to be cleared. This extended close to 2 months. This led some to believe that SMC may need to be extended from five to six or seven rounds as the breeding sites for mosquitoes remain existent for a longer time. A clinician asserted that;\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003eWhenever floods become a breeding ground, resulting in more malaria cases, the 6th or 7th cycle can help counteract this in some areas\u003c/em\u003e (Clinical Officer, Aweil South).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eThe floods also triggered mass migration as many families fled their homes to move to higher ground along roadsides. This made it challenging for BHWs to reach target households and deliver SMC drugs to everyone affected, resulting in lower coverage gaps.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;When you move along this road going to Warrap, you will find a lot of people who have put up small temporary houses for them to stay after the heavy rains destroyed their original homes. In most cases, these people lose their retention cards, sometimes miss some rounds,\u0026rdquo; (BHWs in Aweil\u003c/em\u003e, South County).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eThe flooding during the SMC program also blocked access to several areas because the roads became impassable. This causes logistical challenges, especially in delivering supplies to those areas. This led to delays or incomplete deliveries of medicines.\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Sec31\" class=\"Section2\"\u003e\u003ch2\u003eMovements due to farming\u003c/h2\u003e\u003cp\u003eIt was observed that during the planting season, several children only received the first two SMC cycles, missing out on the remaining three. As the rains intensified, caretakers often moved with their children to remote farming areas, resulting in missed cycles 3, 4, and 5. This migration disrupts the continuity of malaria prevention efforts, especially in areas prone to seasonal flooding, reducing the overall effectiveness of the program. During the rainy season, some people relocated from their usual homes to other places, mainly for farming.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;\u003cem\u003eDuring the flood season, like two months ago, it was challenging. Vehicles could not access the flood-affected areas for supervision\u003c/em\u003e.\u0026rdquo; (KI, Local Chief, Awel West).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eAs a result, reaching out to such people became difficult, particularly for those who moved to distant, unfamiliar areas beyond the reach of drug distributors. A chief, for example, explained that;\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I have visited some of the caregivers twice but found no one at home, which complicated my work of making sure that every eligible child has the rightful dose\u0026rdquo;\u003c/em\u003e (BHW in Aweil South County).\u003c/p\u003e\u003cp\u003eAnother said that;\u003c/p\u003e\u003cp\u003e\u003cem\u003eWhen it rains, reaching the highland area becomes more difficult because the entire community often relocates to other places for farming tasks. However, the BHWs can't access these locations. As a result, many children on this side remain unreached for SMC distribution. (KII with Local Chief, Aweil South).\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec32\" class=\"Section2\"\u003e\u003ch2\u003eMovements due to cultural practices\u003c/h2\u003e\u003cp\u003eThere were also caregiver movements, sometimes influenced by traditional practices, that disrupted the completion of all SMC cycles as recommended. This issue is exacerbated by the lack of mechanisms to track these caregivers, resulting in missed opportunities to identify and reach out to SMC-eligible children. One caregiver shared her experience, emphasizing how cultural practices and a lack of follow-up contributed to missed opportunities for doses:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;The main reason was that I was not at home when they came for the third, fourth, and fifth doses. My child had been staying with my family because she was in the weaning stage. By the time she came back, only two doses had been given, and I couldn\u0026rsquo;t make sure she got the rest. I also didn\u0026rsquo;t follow up as much as I should have, since I didn\u0026rsquo;t get a card to track the doses.\u0026rdquo; (Female caregiver of an eligible child who didn\u0026rsquo;t complete the SMC cycles)\u003c/em\u003e (Female Caregiver, Aweil South).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eThis example highlighted the need for enhanced tracking mechanisms and follow-up strategies to ensure continuity in administering SMC doses, even when caregivers relocate or move out of their homes for other reasons.\u003c/p\u003e\u003cdiv id=\"Sec33\" class=\"Section3\"\u003e\u003ch2\u003eDelayed Referrals\u003c/h2\u003e\u003cp\u003eThere was a challenge of delayed referrals for children with fever to receive appropriate malaria treatment. This problem is particularly prevalent in communities far from health facilities, where children referred to by BHWs often face delays in accessing care. A persistent issue is the delay in caregivers bringing referred children to healthcare facilities. As one respondent pointed out,\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\"\u003cem\u003eThe challenges we have are in the community. When the child is referred, maybe the person cannot come on that very day\u003c/em\u003e.\" (KI, Clinical Officer, Aweil West).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eThis delay is made worse by caregivers juggling multiple responsibilities. Many caregivers also serve as household heads, taking care of other children or managing other household tasks. In these cases, caregivers face competing priorities and urgent responsibilities, which can put off their decision to act on a child's fever referral. As one clinician emphasized,\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\"\u003cem\u003eMaybe she is the one people are surviving [on]. Okay. Maybe she is a widow. Or they are not having a good job.\"\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eWhen this happens, children with fever referred by the BHWs sometimes show up at the health facility late, after their condition has gotten worse, which can lead to a poor outcome.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec34\" class=\"Section3\"\u003e\u003ch2\u003eCommunication Barriers\u003c/h2\u003e\u003cp\u003eOne major communication challenge faced during the 2024 SMC distribution was related to the poor state of the phone networks.\u003c/p\u003e\u003cp\u003e\u003cb\u003eLack of network in remote areas.\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe 2024 SMC program struggled with substantial communication issues, primarily due to inadequate phone network coverage. This matter was particularly severe in remote areas, where it hindered coordination of drug distribution and slowed down addressing problems that came up during the SMC distribution process. Additionally, limited network coverage often resulted in delays in data reporting, making it more difficult to respond quickly to emerging issues. A BHW supervisor emphasized this point, saying,\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;\u003cem\u003eThere\u0026rsquo;s no network, no communication in some areas\u003c/em\u003e. \u003cem\u003eYou find you are going to do SMC for five days, but then you get to know a problem on the fifth day because of communication challenges\u003c/em\u003e.\u0026rdquo; (BHW Supervisor, Aweil South).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eThings become even more difficult when a supervisor tries to meet with a supervisee in person, since it is often hard to track them down. One BHW supervisor put it this way: \"\u003cem\u003eYou'll go and spend the whole day, but you will not actually see that person\u003c/em\u003e.\"\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe study findings show that several factors, including strong government support for the SMC program, effective community outreach, efficient logistics, and the key role of Boma Health Workers as drug distributors, contributed to the distribution and access to SMC in Aweil South and Aweil West counties in the 2024 SMC drug distribution program. Incorporating SMC into national malaria control strategies also played an essential role in its success. Other crucial factors include caregivers' trust in the SMC drugs to reduce malaria rates and deaths among children under five, timely drug distribution, provision of transportation such as bicycles for supervisors and mobilizers, and the integration of malaria control activities, including surveillance, confirmed case management, and mosquito net distribution. However, the program encountered several challenges, including staffing issues, logistical problems, operational difficulties, geographic barriers, extreme weather (primarily flooding), and inaccuracies in population target planning during the rollout and implementation. Staffing challenges, including a shortage of workers and inadequate training for BHWs, impacted SMC distribution.\u003c/p\u003e\u003cp\u003eThe importance of community trust in SMC effectiveness, which is crucial to the program's success, was emphasized in this study. This study's findings align with earlier research on the feasibility of SMC in Aweil South, South Sudan, which investigated the implementation of SMC in areas affected by conflict and humanitarian crises \u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e. Trust is essential for making the program sustainable, and it can be strengthened through ongoing training and support. Investing in local health workers and integrating the program with other services is crucial for ensuring everyone has equal access to SMC in fragile contexts.\u003c/p\u003e\u003cp\u003eThe study findings, which show that involving community health workers in drug distribution enhances access to and distribution of SMC, align well with research in Nigeria and Ghana \u003csup\u003e\u003cspan additionalcitationids=\"CR12\" citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e. These studies demonstrate that engaging local community members in the distribution of medicine can help build trust. The study reported that when people trust the health workers in their community, caregivers are more likely to accept, follow, and participate in the SMC program, thereby reducing scepticism and misinformation, which in turn increases the distribution of SMC drugs. Their strong community links, cultural understanding, and door-to-door medication delivery help reach people in hard-to-reach, conflict-affected areas \u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e. The BHWs also play a vital role in mobilizing, engaging, and educating people, as well as dispelling misconceptions to ensure they receive the necessary information \u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e. Additionally, the BHWs facilitate networks between SMC and other healthcare providers and systems. \u003csup\u003e15\u003c/sup\u003e. Their flexibility helps ensure continuity even in unstable situations, making their role crucial when people are displaced or insecure. \u003csup\u003e11\u003c/sup\u003e. Therefore, strengthening BHWs\u0026rsquo; capacity, offering incentives as was seen with the bicycles, and integrating BHWs more deeply into the health system will expand SMC coverage and promote equitable malaria prevention.\u003c/p\u003e\u003cp\u003eThe integration of Seasonal Malaria Chemoprevention (SMC) into South Sudan's national malaria control strategy was also highlighted as instrumental in the successful distribution and accessibility of medications during the 2024 SMC distribution program in Aweil South and Aweil West counties. This assertion has been corroborated in other contexts, including Nigeria, Burkina Faso, Ghana, and Chad, where the SMC program also operates under the premise that governmental support enhances legitimacy and community trust through the provision of essential funds, coordination, and the alignment of malaria interventions. \u003csup\u003e15,16\u003c/sup\u003e. The integration also facilitates resource pooling, training, and the development of partnerships. \u003csup\u003e17\u003c/sup\u003e. This emphasizes the necessity for the continued incorporation of SMC into national malaria control strategies and the adoption of best practices to support this integration, thereby ensuring the long-term sustainability of the SMC program as an integral component of the malaria control program.\u003c/p\u003e\u003cp\u003eAnother issue reported was that drugs intended for children with fever and malaria diagnoses under the SMC program, referred by drug distributors, were being diverted for malaria treatment of non-SMC program children at health facilities. These diverted drugs mainly included artemether and lumefantrine. Unlike countries like Mozambique, Nigeria, Burkina Faso, Ghana, Chad, and Mali, which have strong national systems in place to monitor and reduce the risk of drug diversion, South Sudan faces a unique challenge with the misuse or diversion of SMC program drugs \u003csup\u003e\u003cspan additionalcitationids=\"CR19\" citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e. Although it is not the SMC SPAQ, this diversion disrupts the program's operations, leading to unintended consequences, such as stockouts of these medicines and preventing referred children from getting proper treatment.\u003c/p\u003e\u003cp\u003eThe severe flooding in Aweil South and Aweil West significantly disrupted the 2024 SMC distribution. The floods were reported to have blocked transportation routes and displaced people, making it difficult to trace families to ensure their children complete the SMC cycle \u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e. As observed in this study and elsewhere, flooding slows down the delivery of medicine. As a result, the risk of malaria increases due to increased mosquito breeding, even after the rains stop, because flooded plains remain wet for an extended period, thereby prolonging the breeding season for mosquitoes. Flooding also hinders efforts to track eligible children, especially those whose caregivers are displaced, thereby reducing the number of children covered by SMC \u003csup\u003e\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e. While a plan was in place to address this challenge through strategies such as pre-positioning medicines, utilizing boats, and establishing fixed distribution points, these efforts were limited by weak infrastructure and a shortage of staff. Similar problems have been reported in some countries. For example, across the Sub-Saharan region, the SMC distribution period coincides with the rainy season, which can sometimes lead to flooding \u003csup\u003e\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e. Flooding has often directly impacted implementation through logistical and transportation problems \u003csup\u003e\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e. The 2024 floods in Mali, for instance, disrupted SMC distribution in the affected areas \u003csup\u003e\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e. In Uganda and Mozambique, a complex distribution also exists in flood-prone regions following rainfall, increasing malaria cases. \u003csup\u003e24\u003c/sup\u003e. In Burkina Faso, flooding led to calls for expanding SMC beyond the distribution period to prevent outbreaks \u003csup\u003e\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u003c/sup\u003e. Thus, similar approaches, in addition to other climate-resilient strategies and customized delivery models, may be necessary in the study area to address distribution challenges caused by flooding and maintain the effectiveness of SMC.\u003c/p\u003e\u003cp\u003eAnother challenge expressed was the insufficiency of healthcare personnel (BHWs) necessary to cover extensive operational areas, thereby affecting drug distribution and community mobilization. This problem was exacerbated by poor maintenance of bicycles, which impacted supervisors' mobility and ability to perform their duties effectively, ultimately compromising the program's success. A study on implementing Seasonal Malaria Chemoprevention (SMC) across sub-Saharan Africa highlights that community health workers (CHWs) often face excessive workloads due to large coverage areas, which reduces efficiency in drug distribution and mobilization, issues like the BHW shortages reported in Aweil South and Aweil West, along with the transportation challenges mentioned earlier \u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e. Microplanning strategies have been used to optimize CHW routes and cut walking distances by up to 25%, helping to fix transportation inefficiencies in Burkina Faso and Mali \u003csup\u003e\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u003c/sup\u003e. Related plans may be necessary to address unique issues observed in South Sudan, such as bicycle maintenance. These findings underscore the need for targeted investments in strong transportation solutions to enhance the capacity of Aweil\u0026rsquo;s SMC programs to adapt effectively to the counties\u0026rsquo; unique geographical conditions.\u003c/p\u003e\u003cp\u003eThe study results also revealed that inaccurate population data may have affected the SMC distribution, resulting in the under-allocation of resources and waste. This was evident in the refugee settlements, which have experienced a sharp increase in demand for services, primarily due to unplanned influxes of refugees from Sudan. This matches previous research, which found that large refugee arrivals and displacement in Africa can disrupt supply chains, causing wrong population estimates and poor supply planning \u003csup\u003e\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u003c/sup\u003e. Consequently, resources are often not distributed where they are needed most, while other areas become overstocked, resulting in waste \u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e. This can also lessen the effectiveness of interventions, with up to 10\u0026ndash;20% of antimalarial stocks being wasted during emergencies \u003csup\u003e\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eThe study further revealed that communication gaps remained a challenge, mainly due to poor network coverage in remote areas. Previous research has highlighted similar issues with inadequate mobile network coverage in these regions, which significantly disrupts the implementation of SMC by affecting coordination, problem-solving, and data reporting \u003csup\u003e\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u003c/sup\u003e. As noted in this study, community health workers face challenges in communicating stock levels and managing supervision, which result in delays and missed opportunities to address project issues \u003csup\u003e\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u003c/sup\u003e. Poor connectivity also delays responses to drug shortages or adverse events \u003csup\u003e\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u003c/sup\u003e. Gaps in data management weaken real-time monitoring, equity, and accountability. Evidence from Nigeria, The Gambia, Mali, and Burkina Faso indicate similar barriers, with coverage losses in hard-to-reach areas \u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e,\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e,\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e. Studies recommend using offline-capable applications, community radio, and infrastructure investments to ensure equitable access and maintain the protective effects of SMC in high-risk zones \u003csup\u003e\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e,\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\n\u003ch3\u003eStrengths and Limitations\u003c/h3\u003e\n\u003cp\u003eThis study has two major strengths: its emphasis on real-world implementation in a high-malaria-burden, conflict-affected area, and its use of qualitative data to gather in-depth insights from stakeholders. This approach increases the reliability of the findings for policy purposes. However, the study has some limitations that call for interpretation and the use of the findings with caution. The results are based on data from only two counties, which may limit the applicability of the findings to other areas of South Sudan or similar contexts. The sample size and selection process could also introduce biases, such as overrepresenting communities that are easily accessible. Additionally, the study's cross-sectional design doesn't allow for conclusions about cause and effect. Another limitation is that the study relies on self-reported data, which can be affected by memory bias. Despite this, efforts were made to cross-check sources to minimize the potential issues.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study investigated the factors that enabled and hindered the distribution of, and access to, seasonal malaria chemoprevention (SMC) in the conflict-affected Aweil South and Aweil West counties of South Sudan during the 2024 round. The study found that delivering SMC in rural, conflict-affected areas of South Sudan mainly relied on community trust, government support, efficient logistics, and the involvement of local health workers. However, shortages of drug distributors, disruptions to the drug supply, poor transportation, displacement due to flooding, and inadequate communication all limited coverage. To improve access in future SMC distribution and related areas, it is crucial to strengthen supply chains, increase healthcare workforce capacity, address challenges such as limited resources, flooding, and mobility constraints, and implement innovative approaches to reach remote areas, including the use of mobile clinics.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors wish to express their profound appreciation to all Seasonal Malaria Chemoprevention (SMC) Volunteers for their unwavering dedication and exemplary efforts in the implementation of this project. We are deeply grateful to the staff of Malaria Consortium, both at the Juba main office and the Aweil Field Office, for their steadfast support and invaluable contributions throughout the project\u0026rsquo;s duration. Our sincere thanks are also extended to Dev-com Consultants Juba for their pivotal role in conducting the end-of-round survey and qualitative data collection, which provided critical insights into this study. Furthermore, we acknowledge with gratitude the collaboration and support of the National and State Malaria Control Programme of the Ministry of Health, Republic of South Sudan, as well as the County Health Department officials in Aweil South and Aweil West Counties, Northern Bahrel Ghazal State.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAR: study conceptualization, writing original manuscript. SP: supervision of data collection, data analysis, manuscript editing. FO: supervision of data collection, study conceptualization, review of manuscript. DM: study conceptualization, review of manuscript. JK: study conceptualization, review of manuscript. AD: study conceptualization and review of manuscript, EW: \u0026nbsp;study conceptualization and review of manuscript, NA: \u0026nbsp; study conceptualization and review of manuscript. \u0026nbsp;All authors have reviewed and approved the final version of the manuscript\u003c/p\u003e\n\u003cp\u003eEthics approval consent to participate\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis study received ethical approval from the\u0026nbsp;Republic of South Sudan Ministry of Health\u0026rsquo;s Ethical Review Board in Juba, Reference No:( MOH/RERB/P/D.05/2025) All participants provided informed consent after being fully briefed on the study\u0026rsquo;s objectives, procedures, and ethical considerations. Additional authorization to conduct the research was obtained from the Aweil State Public Health Officer and the coordinators of each county. Participants were also provided with a contact point to report any concerns or issues related to their participation in the survey.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding Declaration:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research, including its authorship and publication, did not receive any financial support from funding agencies, commercial entities, or non-profit organizations\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eWorld Health Organization. WHO policy recommendation: seasonal malaria chemoprevention (\u0026lrm;SMC)\u0026lrm; for Plasmodium falciparum malaria control in highly seasonal transmission areas of the Sahel sub-region in Africa [Internet]. 2012. Available from: http://www.who.int/malaria/publications/atoz/smc_report_teg_meetingmay2011.pdf\u003c/li\u003e\n\u003cli\u003eMolina-de la Fuente I, Sagrado Benito MJ, Lasry E, Ousley J, Garc\u0026iacute;a L, Gonz\u0026aacute;lez V, et al. Seasonal malaria chemoprevention in a context of high presumed sulfadoxine-pyrimethamine resistance: malaria morbidity and molecular drug resistance profiles in South Sudan. Malar J. 2023 Dec;22(1). \u003c/li\u003e\n\u003cli\u003eYam\u0026eacute;ogo KB, Yerbanga RS, Ouattara SB, Yao FA, Lef\u0026egrave;vre T, Zongo I, et al. Effect of Seasonal Malaria Chemoprevention Plus Azithromycin on Plasmodium falciparum Transmission: Gametocyte Infectivity and Mosquito Fitness Malar J. 2021 Dec 1;20(1). \u003c/li\u003e\n\u003cli\u003eNuwa A, Baker K, Bonnington C, Odongo M, Kyagulanyi T, Bwanika JB, et al. A non-randomized controlled trial to assess the protective effect of SMC in the context of high parasite resistance in Uganda. Malar J. 2023 Dec 1;22(1). \u003c/li\u003e\n\u003cli\u003eOkot F, Sans MS, Vigan\u0026ograve; E, Rom A, Mubiru D, Baker K, et al. \u0026ldquo;We witnessed medicines help our children, then we became proud\u0026rdquo;: experiences and acceptability of seasonal malaria chemoprevention in Aweil, South Sudan. Malaria Journal. 2025 Dec 1;24(1). \u003c/li\u003e\n\u003cli\u003eKhan J, Suau Sans M, Okot F, Rom Ayuiel A, Magoola J, Rassi C, et al. A quasi-experimental study to estimate the effectiveness of seasonal malaria chemoprevention in Aweil South County in Northern Bahr El Ghazal, South Sudan. Malar J. 2024 Dec 1;23(1). \u003c/li\u003e\n\u003cli\u003eMadut NA, Muwonge A, Nasinyama GW, Muma JB, Godfroid J, Jubara AS, et al. The sero-prevalence of brucellosis in cattle and their herders in the Bahr el Ghazal region, South Sudan. PLoS Negl Trop Dis. 2018 Jun 1;12(6). \u003c/li\u003e\n\u003cli\u003eMbishi JV, Chombo S, Luoga P, Omary HJ, Paulo HA, Andrew J, et al. Malaria in under-five children: prevalence and multi-factor analysis of high-risk African countries. BMC Public Health. 2024 Dec 1;24(1). \u003c/li\u003e\n\u003cli\u003eMajok Joseph. War and the Borderland: Northern Bahr El-Ghazal During the Sudan Conflict [Internet]. 2024. Available from: https://riftvalley.net/publication/war-migration-and-work-agricultural-labour-and-cross-border-\u003c/li\u003e\n\u003cli\u003eKorstjens I, Moser A. Series: Practical guidance to qualitative research. Part 2: Context, research questions, and designs. European Journal of General Practice [Internet]. 2017;23(1):274\u0026ndash;9. Available from: https://doi.org/10.1080/13814788.2017.1375090\u003c/li\u003e\n\u003cli\u003eSunguya BF, Mlunde LB, Ayer R, Jimba M. Towards eliminating malaria in high endemic countries: the roles of community health workers and related cadres and their challenges in integrated community case management for malaria: a systematic review. Vol. 16, Malaria Journal. BioMed Central; 2017. p. 1\u0026ndash;14. \u003c/li\u003e\n\u003cli\u003eOgbulafor N, Uhomoibhi P, Shekarau E, Nikau J, Okoronkwo C, Fanou NML, et al. Facilitators and Barriers to Seasonal Malaria Chemoprevention (SMC) Uptake in Nigeria: A Qualitative Approach. Malar J. 2023 Dec 1;22(1). \u003c/li\u003e\n\u003cli\u003eChatio S, Ansah NA, Awuni DA, Oduro A, Ansah PO. Community acceptability of Seasonal Malaria Chemoprevention of morbidity and mortality in young children: A qualitative study in the Upper West Region of Ghana. PLoS One. 2019 May 1;14(5). \u003c/li\u003e\n\u003cli\u003eLutwama GW, Kok M, Jacobs E. An exploratory study of the barriers and facilitators to the implementation of community health worker programmes in conflict-affected South Sudan. Confl Health. 2021 Dec 1;15(1). \u003c/li\u003e\n\u003cli\u003eMallari E, Lasco G, Sayman DJ, Amit AML, Balabanova D, McKee M, et al. Connecting communities to primary care: A qualitative study on the roles, motivations and lived experiences of community health workers in the Philippines. BMC Health Serv Res. 2020 Sep 11;20(1). \u003c/li\u003e\n\u003cli\u003eLasmi K, Elimian K, Donovan L, Tounaikok N, Traor\u0026eacute; A, Gils T, et al. Barriers to the quality delivery of seasonal malaria chemoprevention in Chad and Burkina Faso: a qualitative exploration of caregivers and community distributors\u0026rsquo; perspectives. Malar J. 2024 Dec 1;23(1). \u003c/li\u003e\n\u003cli\u003eMouk\u0026eacute;net A, Donovan L, Honor\u0026eacute; B, Baker K, Smith H, Richardson S, et al. Extending Delivery of Seasonal Malaria Chemoprevention to Children Aged 5-10 Years in Chad: A Mixed-Methods Study. Glob Health Sci Pract [Internet]. 2022;10(1). Available from: www.ghspjournal.org\u003c/li\u003e\n\u003cli\u003eNikiema S, Soulama I, Sombi\u0026eacute; S, Tchouatieu AM, Serm\u0026eacute; SS, Henry NB, et al. Seasonal Malaria Chemoprevention Implementation: Effect on Malaria Incidence and Immunity in a Context of Expansion of P. falciparum Resistant Genotypes with Potential Reduction of the Effectiveness in Sub-Saharan Africa. Vol. 15, Infection and Drug Resistance. Dove Medical Press Ltd; 2022. p. 4517\u0026ndash;27. \u003c/li\u003e\n\u003cli\u003eKang Y, Xu T, Hitti J, Duncan K, Sun R. Seasonal Malaria Chemoprevention in Mali: An Effective Intervention or an Unsustainable Burden? \u003c/li\u003e\n\u003cli\u003eMalaria Consortium. Expanding seasonal malaria chemoprevention in new geographies: Lessons from Mozambique. \u003c/li\u003e\n\u003cli\u003eMorlino C, Byrne I, Achan J, Baraka V, Barry A, Bousema T, et al. Barriers to the Uptake and Implementation of Malaria Chemoprevention in School-Aged Children: A Stakeholder Engagement Meeting Report. Frontiers in Tropical Diseases [Internet]. 2025 Sep 8;6. Available from: https://www.frontiersin.org/articles/10.3389/fitd.2025.1480907/full\u003c/li\u003e\n\u003cli\u003eCaminade C, Ayala D, de Chevigny T, Ngou O, Tchouatieu A, Girond F, et al. Climate change and malaria control: a call to urgent action from Africa\u0026rsquo;s frontlines. Vol. 24, Malaria Journal. BioMed Central Ltd; 2025. \u003c/li\u003e\n\u003cli\u003eUNICEF Mali Seasonal floods Update No. 1. 2024 Sep. \u003c/li\u003e\n\u003cli\u003eAbubaker Rom Ayuiel, Kevin Baker, Sarah Bond, Liberty Bunce, Eoin Cassidy, Louise Cook, et al. Malaria Consortium\u0026rsquo;s seasonal malaria chemoprevention programme: Philanthropy report 2023 [Internet]. 2024. Available from: www.malariaconsortium.org\u003c/li\u003e\n\u003cli\u003eTraore A, Donovan L, Sawadogo B, Ward C, Smith H, Rassi C, et al. Extending seasonal malaria chemoprevention to five cycles: a pilot study of feasibility and acceptability in Mangodara district, Burkina Faso. BMC Public Health. 2022 Dec 1;22(1). \u003c/li\u003e\n\u003cli\u003eBicaba A, Serme L, Chetaille G, Kombate G, Bila A, Haddad S. Longitudinal analysis of the capacities of community health workers mobilized for seasonal malaria chemoprevention in Burkina Faso. Malar J. 2020 Mar 19;19(1). \u003c/li\u003e\n\u003cli\u003eWorld Health Organization. Seasonal malaria chemoprevention with sulfadoxine-pyrimethamine plus amodiaquine in children: a field guide Second edition. Geneva; 2023. \u003c/li\u003e\n\u003cli\u003eOu\u0026eacute;draogo AL, Zhang J, Tinto H, Val\u0026eacute;a I, Wenger EA. A microplanning model to improve door-to-door health service delivery: the case of Seasonal Malaria Chemoprevention in Sub-Saharan African villages. BMC Health Serv Res. 2020 Dec 1;20(1). \u003c/li\u003e\n\u003cli\u003eBalla K, Malm K, Njie O, Hounto Ogouyemi A, Uhomoibhi P, Poku-Awuku A, et al. Introducing field digital data collection systems into seasonal malaria chemoprevention campaigns: Opportunities for robust evidence development and national e-health strategies. Vol. 7, BMJ Global Health. BMJ Publishing Group; 2022. \u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"malaria-journal","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"malj","sideBox":"Learn more about [Malaria Journal](http://malariajournal.biomedcentral.com/)","snPcode":"12936","submissionUrl":"https://submission.nature.com/new-submission/12936/3","title":"Malaria Journal","twitterHandle":"@malariajournal","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Seasonal malaria chemoprevention, Conflict-affected settings, South Sudan, enablers, barriers","lastPublishedDoi":"10.21203/rs.3.rs-7931566/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7931566/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eSouth Sudan, a country with a high malaria burden, faces considerable health system challenges due to decades of civil war, which disrupts access to essential services. For three years, the Malaria Consortium has implemented Seasonal Malaria Chemoprevention (SMC) in Aweil South and Aweil West Counties; however, coverage remains below optimal at 79%, falling short of established targets. This study examines the barriers and enablers to accessing and distributing SMC during the 2024 round.\u003c/p\u003e\u003cp\u003eMethods: A qualitative study design was used, involving 60 stakeholders involved in implementing SMC. Data were collected through 42 key informant interviews and 18 in-depth interviews with caregivers of eligible children who received all SMC doses or none, as well as those of ineligible children who received SMC. The data were analysed using deductive thematic analysis.\u003c/p\u003e\u003cp\u003eResults: Factors that enabled SMC distribution and access included government support, community trust, efficient logistics, integrated activities, access to vital information, involvement of Boma health workers, supervisor transportation, and organized malaria management. The main challenges included shortages of healthcare workers, drug shortages, geographic and transportation difficulties, caregiver relocation, delayed referrals, and poor communication.\u003c/p\u003e\u003cp\u003eConclusion: These findings underscore the necessity for targeted interventions to address resource constraints, enhance workforce capacity, communication, and logistics infrastructure, thereby ensuring sustainable SMC delivery in conflict-affected areas. Strengthening these areas will be crucial for maximizing the impact of SMC as a malaria prevention strategy in such environments.\u003c/p\u003e","manuscriptTitle":"Delivering Seasonal Malaria Chemoprevention in Conflict-affected Settings Experiences from Northern Bahrel Ghazal, South Sudan","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-12-02 14:08:07","doi":"10.21203/rs.3.rs-7931566/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-05-17T09:09:57+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-05-16T17:03:12+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"74587185628971424994497171896259122623","date":"2026-05-16T13:47:50+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"68454609409817599946938422251628545253","date":"2025-11-29T07:30:40+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-11-27T04:40:28+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-11-14T11:12:56+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-11-14T11:08:34+00:00","index":"","fulltext":""},{"type":"submitted","content":"Malaria Journal","date":"2025-10-23T10:57:24+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"malaria-journal","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"malj","sideBox":"Learn more about [Malaria Journal](http://malariajournal.biomedcentral.com/)","snPcode":"12936","submissionUrl":"https://submission.nature.com/new-submission/12936/3","title":"Malaria Journal","twitterHandle":"@malariajournal","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"96f2e6a7-6b70-452f-b886-274e7a92e1ce","owner":[],"postedDate":"December 2nd, 2025","published":true,"recentEditorialEvents":[{"type":"decision","content":"Revision requested","date":"2026-05-17T09:09:57+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-05-16T17:03:12+00:00","index":23,"fulltext":""},{"type":"reviewerAgreed","content":"74587185628971424994497171896259122623","date":"2026-05-16T13:47:50+00:00","index":22,"fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"in-revision","subjectAreas":[],"tags":[],"updatedAt":"2026-05-17T09:24:42+00:00","versionOfRecord":[],"versionCreatedAt":"2025-12-02 14:08:07","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7931566","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7931566","identity":"rs-7931566","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}