Implementing seasonal malaria chemoprevention in conflict-affected settings: experiences from Northern Bahr el Ghazal, South Sudan

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. 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 analyzed using deductive thematic analysis. 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. 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.