South Sudan Health Sector in Post-Conflict Era: Challenges and Pitfalls

129480134PERTH, Australia - One of the fundamental challenges in nations emerging from war is their relative lack of capacity to institute or re-establish legitimacy, stable and efficient government institutions. Post-conflict reconstruction efforts are instrumental in helping these countries accomplish a successful transition from war to peace, and form self-sustaining state institutions capable of providing essential services to their citizens.

As the Republic of South Sudan (RSS) is at its infancy as a new born nation, setting its feet on post-conflict development remains a major challenge due to meager resources and inadequate skilled workforce – a typical situation that faces all post-conflict states, particularly in developing countries. As such, one must acknowledge that development in RSS is a challenging role that requires concerted efforts by all citizens.

The Republic of South Sudan is a two year old nation that seceded from the Republic of Sudan following a 2005 Comprehensive Peace Agreement (CPA) and a January 9, 2011 referendum exercise that culminated in the birth of the RSS on July 9, 2011. The Sudan which was the largest country in Africa before her divorce had suffered from one of the most protracted civil war in the continent. Given its protracted periods of conflict, in which an estimated two million lives were lost, and decades of underdevelopment, South Sudan has remained one of the most devastated nations, having one of the world highest infant mortality rates and of maternal death in childbirth. All health infrastructures and systems were severely destroyed as the southern region was the battle ground for both forces. However, eight years (2005 to 2013) from self autonomy through referendum and subsequent declaration of nationhood in 2011 have contributed nothing much than an absolute failure in re-establishing the once ravaged system during years of conflict despite the multi-donor and local funds committed to revive health sector. It’s this that the region is currently plagued by all kinds of infectious diseases that are both preventable and treatable, as well, as non-communicable diseases.

South Sudan government is one of the world’s largest but most ineffective government, mostly composed of weak self-proclaimed elite (aka liberators turned politicians) who lack technical capacity, mired in corruption, and beleaguered in instituting legitimacy in the face of its poor and helpless citizens who also lack skills and proper education, making it harder for them to search for jobs in the corrupt markets. Most officials in South Sudan are not accustomed to democracy and criticism and habitually harbour war and or guerilla mentality.

Presently, medical personnel, public servants, journalists, human right activists and other professional groups often complain of endemic harassment from government’s undisciplined security agents. Despite billions of dollars lost in merciless corruption, no official has ever been prosecuted given its weakest judiciary system. However, recently, His Excellency General Salva Kiir Mayardit suspended two ministers in the wake of another money scandal. The duo – his minister of cabinet affairs Hon. Deng Alor Kuol and the minister for finance and economic planning, Hon. Kosti Manibe Ngai were caught red handed in an attempt to empty government’s coffers in the face of failing economy, claiming they were following directive requiring them to purchase “anti-fire safes”. Pathetic! How would you focus on purchasing fire equipment when the vulnerable populations such as pregnant mothers, infants, elderly and people with immunosuppression are dying in the mainstream hospitals and local health centres? Is fire really a threat in South Sudan that it warrants such a big spending? How many people have died due to fire in South Sudan compared to that of infectious and non-communicable diseases? Can we afford to think of purchasing “anti-fire safes” at a cost of USD 7, 959, 400 while ignoring dying patients, endemic poverty, unsafe drinking water etc and not even a support in preventive health services? We are truly done in the hands of thieves.

The minister of health, Dr. Michael Milly Hussein, a ‘Stone Age’ doctor inherited from Khartoum system since elected to the ministry of health had no idea on what to start on. In 2012, his undersecretary of health blatantly lamented lack of statistics on mental health situation in South Sudan health system. How would they claim of delivering equitable health services to all South Sudanese when no basic statistics are available in order to prioritise urgent and needy conditions? This is to mention a few who extremely demonstrated failure within health systems in South Sudan.

Obviously, policy-making structures themselves are severely weakened by lack of commitment and developmental programs —creating a vacuum of authority and a lack of legitimacy in health systems decision-making. There is also a resulting lack of institutional memory, further complicated by the exodus of policymakers, academics, and other necessary actors in health policy during civil war in Sudan. Underlying these institutional weaknesses, there is generally a sense of torn social networks and a lack of trust. We have so far noticed cumulative effect of these impacts which fundamentally changes the nature of health service delivery in South Sudan.

To date, primary care delivery typically suffers the most; and the remaining service delivery capacity is likely to be at the secondary and tertiary level, principally in urban settings. But these institutions still face huge challenges of unskilled and inadequate qualified workforce. For instance, Juba Teaching Hospital, one of the oldest hospital in the region is a tertiary care centre which still lacks modern diagnostic equipment and a reference laboratory to mention a few. Furthermore, utilisation of health services is negatively affected by a fear of violence in some regions (eg, Junglei, Lack States and warrap etc), corruption, and informal disbursements to health workers.

While I acknowledge the continuous efforts by non-governmental organisations towards delivery of health services in specific geographic locales, healthcare service delivery in South Sudan is often reduced to a patchwork of programs and services offered through different channels.

To improve health service delivery in South Sudan, the government requires adequate and qualified workforce by recruiting Diaspora and local South Sudanese health professionals that have local knowledge because they are accustomed to local cultures. It is evident that expatriate service or their consultancy is more costly. The government and department of health concertedly need to curb corruption, nepotism and favouritisms, provide employment opportunities based on merits and establish legitimacy and accountability. No institutions can prosper without these factors. Once there is an adequate and qualified workforce, trust, legitimacy and accountability, eventual health reform can be sustained and purposive changes to improve the efficiency, equity, and effectiveness of the health sector with the goal of improving health status, obtaining greater equity, and obtaining greater cost-effectiveness for services can surely be provided. These are essential developmental programs mostly adapted by post-war countries in developing world.

To date, we are unable to get any health information due to lack of established research institutions where health data can be consulted for informing health policy. No well established health centres for either consultations or training of health professionals who could deal with most health challenges in the country. We have had number of health professionals who had written several recommendations in regard to health improvement in South Sudan, for instance, South Sudan Medical Journal website; an unsupported non-profit organisation has such wealth of information. Such important recommendations have surely been dumped.

Furthermore, non-existence or lack of effective health regulatory bodies is adding significant burden on health. For instance, we have seen explosive upsurge in pharmaceutical entrepreneurships, an industry that is used as fast-money-making business that is widespread across many towns in South Sudan. These businesses are not regulated in terms of what pharmaceutical products they are allowed to sell­, mainly on the counter drugs and drugs that require authorisation or prescription from qualified medical officers. Many individuals running pharmacy stores across various regions in South Sudan are either untrained or semi-trained and under no terms should they be allowed to run such businesses. Such exploitation has resulted in many treatment failures including that of multi-drug resistant organisms (MDRO) due to unnecessary use of many of antimicrobials or anti-malarial agents and has resulted in increase in morbidity and mortality rates. To curb this potential danger, health authorities require establishment of standardized guidelines coupled with establishment of reference laboratories. Many local laboratories in the country operate in the darkest corners without standardized protocols or certain requirements. These laboratories mostly lack well qualified personnel and operate on assumption that is based on patients’ clinical symptoms but not based on laboratory detection.

Angelo Ngor, a South Sudan living in Australia, is MID Candidate in infectious and tropical diseases, School of Pathology and Laboratory Medicine and Marshall Centre for Infectious Diseases Research and Training, University of Western Australia, Perth. Email: This email address is being protected from spambots. You need JavaScript enabled to view it.