Institutionalizing Community-Oriented Primary Health Care for Universal Health Coverage in Fragile Settings: Lessons from the Revised Boma Health Initiative in South Sudan

Abstract

Universal Health Coverage (UHC) remains a major challenge in fragile and conflict-affected settings, where weak governance, health workforce shortages, insecurity, disease outbreaks, climate-related shocks, and fragmented community health programmes constrain access to essential primary health care (PHC). To address these challenges, the Ministry of Health of South Sudan introduced the Boma Health Initiative (BHI) as a nationally led, community-oriented PHC strategy linking households to the formal health system through Boma Health Workers. Following the BHI Mid-Term Evaluation (2019–2022), the Community Health Strategy was comprehensively revised for 2024–2028 to strengthen governance, institutionalization, integrated service delivery, financing, accountability, community participation, and sustainability. This study examined the strategic reforms introduced through the Revised BHI and their implications for strengthening community health systems and advancing UHC. A qualitative health policy and systems analysis was undertaken using national policy documents, strategic frameworks, programme reports, stakeholder consultation reports, technical working group outputs, and relevant international literature. The findings indicate that the revised strategy institutionalizes community health through strengthened governance, harmonized supervision, integrated reporting, standardized service delivery, and the integration of previously fragmented community-based health networks into a unified government-led platform. These reforms enhance health system resilience, improve equitable access to comprehensive PHC, and strengthen emergency preparedness. Despite persistent challenges related to financing, workforce capacity, and insecurity, the Revised BHI provides a practical model for institutionalizing community-oriented PHC and offers valuable lessons for strengthening resilient and equitable health systems in other fragile settings.