Health Care in South Sudan at a Crossroads

Many observers thought that this year would mark a new stage of development for South Sudan's health system, but a feud with Sudan could prove a serious setback.

Fellows Spring 2012

By Andrew Green

April 28, 2012

Also published in The Lancet

This was supposed to be a year of transition for South Sudan's health system. After last July's independence, the country--shored up by international donors--was set to move away from emergency response and toward post-conflict health system development. But the government's decision to turn off the country's oil production--and with it 98% of the national revenue--over a pricing feud with Sudan, will slow that process.

In building a health system after decades of war, South Sudan was basically "starting everything from zero", according to Loi Thuou, the director general of medical services. The country had little health infrastructure, equipment, or trained medical providers"”and little money for the health sector. In 2011, the government spent about US$9 per person on health care. International non-governmental organisations (NGOs) filled in some gaps, providing more than 80% of the country's available basic health care, which still does not reach most of the population.

Nevertheless, the government was prepared to begin directing the development of the country's health system. Last year officials released a strategy--the Health Sector Development Plan (HSDP)--calling for a 5-year focus on providing a package of basic health services, with a specific emphasis on maternal and child health.

Recognising that even with anticipated oil revenue, government funds were limited, the plan necessitated strategic national investments, along with a continued reliance on NGOs to fund most health services. However, there was an expectation that the government would slowly begin assuming more "running costs", such as salaries and drug supplies.

Then, in January, South Sudan switched off its oil. The oil-rich south had been running its crude through Sudan's pipelines, but a row between the two countries over transit costs led to the shutdown. The decision has forced South Sudan to begin implementing an austerity budget.

Thuou said that the effect on the health sector would only be "temporary". Though it has forced the ministry to scale back on some of its infrastructure plans, he said, including development of new health facilities. The HSDP had called for the construction or redevelopment of at least 130 health facilities per year. NGOs and donors are eyeing other potential gaps in health-care delivery, including provision of basic drugs.

The oil shutdown comes as several key mechanisms for donor funding in South Sudan are coming to a close. Perhaps most importantly, the Multi-Donor Trust Fund (MDTF) is set to wrap up in June. Among other things, the MDTF was responsible for procuring drugs. From 2006, it has spent $30 million providing drugs to more than 1200 health facilities across the country. As the MDTF came to a close, the government was expected to take over that responsibility. "The challenge there is that the ministry of health budget can't cover and absorb those costs", said Aimee Lyons, Catholic Relief Services' health programme manager for South Sudan. "They're concerned about stock outs [of drugs] as early as August, 2012."

The financial shortfall comes on top of other challenges already confronting health-care development, including the reality that some areas of the country may not yet be ready to transition away from humanitarian relief. The World Food Programme has warned that 4·7 million people face food insecurity. And ongoing ethnic conflict along the country's border with Sudan have left hundreds dead and forced tens of thousands to flee.

In Jonglei state, where Sudan Medical Care is working, the local NGO had to close one of the primary health care units it was operating because the population had moved--driven away by cattle raiders. Deng Mayom Deng, the executive director of the organisation, said he plans to reopen the facility because "there was too much invested for it to just be left". That will depend on whether the government is able to curb the violence, though.

Still, after 7 years of relative stability, South Sudan's nascent health system is already more developed than it has been in decades, if ever. Even if episodes of violence continue, according to Sean Casey, the country director for International Medical Corps (IMC), the emerging health system could be able to absorb emergency cases.

He points to a hospital IMC manages in Akobo County, which was able to treat 61 gunshot victims following a cattle raid. It did so under the supervision of one doctor and one nurse. Like most of South Sudan's health care, this was possible only because of donor funding. With the oil shut off, it is likely to remain that way. "That's all external funding that allows that to happen", Casey said. "As long as these organisations are there providing support, things still work."

Andrew Green reported from South Sudan on a fellowship from the International Reporting Project.