Transforming the Health System in South Sudan

South Sudan is recovering from five decades of civil war. A lack of infrastructure, human resources, and ongoing violence has ravished the country’s health services. MSH is helping the new Ministry of Health manage the transition to a national health system in the midst of renewed fighting in Abyei and as masses of people, anticipating the formation of the world’s newest country on July 9, re-enter South Sudan.

Through the second phase of the US Agency for International Development-funded Sudan Health Transformation Project (SHTP II), MSH is transitioning health service delivery from relief to development. Specifically, SHTP II is expanding access and coverage by: enhancing the quality of health services through an integrated package of high-impact services; increasing demand through community mobilization; and engendering the community’s confidence in health services through strengthening of County Health Departments (CHDs) and the Ministry of Health.

I spoke with Dr. John Rumunu, MB.BS, MPH, Director of the SHTP II project, about the challenges of improving health in a complex environment.

How is the latest turmoil in South Sudan affecting the public health system?

In general, in South Sudan, we are seeing many people displaced from the turmoil in Abyei. They have been uprooted from their homes and are displaced southwards. That movement of people is already instituting a complex emergency situation for the health system to try to absorb. Among the Internally Displaced People (IDP) population, there are many who are considered more vulnerable populations such as children and pregnant women. Additionally, the movement of IDPs into other areas is creating a high burden on the existing health system, which is already suffering from a lack of access and availability for the population. The health system access only extends to 25-30% of the population in South Sudan. Now more people are coming, and that means that this health system is becoming more stressed. There is a need to intervene to address this emergency situation. We are working to build the capacity of the local authority, mostly the County Health Department, to be able to respond to this emergency in their areas.

Another complication is that we are currently in the midst of the rainy season, and there is a need for non-food items, such as shelter. With a lot of people coming into one place, plus rains and poor sanitation, we are running into the danger of disease outbreaks like cholera. Depending on the status of immunization of children in the area where they are coming from, there is also a danger of outbreaks of childhood diseases like measles. Now we need to work on immunization of the displaced population as well.

We are seeing people moving mostly on foot—running for their lives. Their houses have been burned, and the area is occupied. The authorities have mobilized and are working to alleviate this situation, but transportation is an issue in the area. Generally, there is poor infrastructure, a lack of roads and of communications, which inhibits people from getting to a secure place.

As a post-conflict country, the authorities and partners have really tried, and are trying, very hard to build a system in anticipation of the new country in July. The South Sudan Development Plan has outlined this state capacity development, as well as delivery of basic services to the people. It is a very good start which has put plans in place which, if implemented, people will see the impact in the lives of poor people in South Sudan.

What are the human resources challenges in the health sector?

South Sudan has seen an influx of returnees from the north and neighboring countries in anticipation of independence. The country is going to be divided into two countries, so there has been a large influx of returnees coming back to their homelands. When people return they are included into their communities, but it puts a large burden onto the existing health services.

South Sudan already faces challenges of infrastructure, especially in terms of human resources. There are very few doctors, nurses, and midwives in the country—some hospitals are not even staffed with a doctor—and the need for more services, especially in light of the returnee population, is huge.

The population returning from the north and other countries are coming back with skills, so there is a hope that as people return, these skills will be used in improving service delivery.

The health system in South Sudan is really evolving. One challenge the system is facing is that most medical professionals want to work in urban areas like Juba, Wau, or Malakal, but most of South Sudan is rural. This means that access to formal health facilities is very low.

There is a huge need to increase the capacity and delivery of community based health care. The Basic Package for Health Services, outlined by the Government of Southern Sudan, stresses the importance of training Home Health Promoters (called Community Health Workers or Community Case Managers in other countries) to undertake community based interventions like health promotion, family planning counseling, as well as community case management of common childhood illnesses like malaria, pneumonia, and diarrhea. This will reduce the burden of disease of children under five years old and ultimately reduce the mortality of children under five.

Strengthening this linkage, between community and facility levels of care will strengthen the health system in South Sudan. In the interim, as the government and partners work towards establishing a health system in the country, this linkage will be very important. To cover all of the areas with health facilities will mean robust infrastructure, and that will take a long time to put in place. Having the community and facility linkages will provide a continuum of care that will—in the interim—be the best way to deliver services to the most vulnerable populations.

How is SHTP II improving health in South Sudan?

In SHTP II, we are seeing a transformation. Even with all the difficulties and challenges we are facing in health service delivery in the country, we are seeing results. Our main objective is to increase access and availability of services through training of local people to both deliver services and manage the services.

We have developed approaches to work with Village Health Committees, and we are addressing the fragmented health service delivery by developing standards according to policies and guidelines put in place by the government. We are training health providers on these standards.

In areas such as family planning, child health, and maternal and neonatal health, and we are seeing that translate into an increase in service delivery. Women are coming for antenatal care—not only once or twice, but up to four times or more. We are seeing an increase in children immunized and in people coming for family planning counseling. We are seeing a real transformation here on the ground.