SUMMARY OF THE HEALTH SERVICE PLAN FOR
SOUTH SUDAN, 2011 – 2015
Compiled by John Acres from the
Draft Health Plan, 2011-2015
CONTENTS
CONTEXT, GEOGRAPHY AND POPULATION
HEALTH NEEDS
Life expectancy and of Morbidity
The Health of women
Sexual Health and Fertility
Maternal Mortality
Maternity Care – Basic and Comprehensive Obstetric and Neonatal Care
Management of Abortion
Health of Children
Mortality rates
Under 5s : Malaria, Diarrhoea, Respiratory Infections
Immunisation
Malaria
TB, HIV/AIDS Neglected Tropical Diseases
Non-Communicable Diseases, Nutrition
Health Related Behaviour and Environmental Health
HEALTH SERVICES
Model for Health Sector Organisation, Functions and Management
Health Facilities : Hospitals and Access
Staff
Training
Health Training Schools
Medical Training
Nursing and Midwifery Training
PLAN TO TACKLE THE HEALTH NEEDS OF THE COUNTRY
Goals
Strategic Objectives and Service Delivery Programme Emphasis
Taking the plan forward
The Preferred Option
Key Issues Associated with the Preferred Option
Appendix 1 : 24 Priority Intervention Indicators and Targets
Appendix 2 : Assumptions and Calculations on which the Preferred Option is Based
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CONTEXT, GEOGRAPHY AND POPULATION
Context
The history of Sudan has been entwined with its northern neighbour, Egypt, for centuries. In 1956 it
gained independence from both Egypt and the United Kingdom, but has suffered from civil war
almost ever since. The war has been between the predominantly Arabic North with Nubian roots
and the Christian and Anamist South. The war has practically destroyed the whole infrastructure and
social fabric of Southern Sudan along with deaths and displacement of over four million people. The
Comprehensive Peace Agreement in January, 2005, provided some respite. Now, the outcome of the
referendum of January, 2011, has set Southern Sudan on a road to independence and the country
will become the Republic of South Sudan in July, 2011 South Sudan has a very long way to go to
rebuild itself and it is almost starting from scratch
Geography and Population
Southern Sudan is a landlocked country crossed (see map) with Kenya and Uganda on its Southern
borders and the Central African Republic to its West. The River Nile flows North into Northern Sudan
and Egypt.
The population was estimated to be 9,480,000 (2009) and is expected to increase to 12 million by
2010. This is as a result of


a high rate of natural population growth of 3% per annum
inward migration from the return of refugees from neighbouring countries and internally
displaced populations in Northern Sudan.
3
Historically, the majority of the population has been engaged in rural subsistence farming and cattle
herding. Rural livelihoods are re-emerging with resettlement after the protracted war. Urban areas
in the country are also rapidly expanding.
The 2006 Sudan Household Survey revealed very low literacy rates especially among women aged
15-24 years (less than 1 percent in four of the ten states of Southern Sudan).
It is one of the poorest countries in the world. It is estimated that more than 90% of the population
lives on less than 1 US$ per day and the poverty rate is estimated to be between 40% and 50%.
The prospects of oil revenue promise future economic improvements. Oil contributes around 98% of
Southern Sudan’s income and 85% of all Sudan’s oil (North and South) is in the South. (For the
period of the Comprehensive Peace Agreement, the revenues will be split equally. Minerals and
timber are another source of income.
4
HEALTH NEEDS
LIFE EXPECTANCY
Southern Sudan has some of the worst health status indicators in the world. The estimates for both
maternal (2054/100,000) and child (135/1,000) mortality are the highest in the world.
Life expectancy is low and lower than its neighbours. The average life expectancy in the UK (79) is 37
years more than in South Sudan (42). A major reason for this is the high child mortality rate in
Southern Sudan.
Health Indicator
Life Expectancy at birth
(years)
S. Sudan
42
N. Sudan
n/k
Uganda
51
UK
79
Tanzania
51.6 (2006)
Source: 1.SHHS – 2006 and South Sudan Commission for Census, Statistics and Evaluation (2004), 2.
Tanzania Demographic & Health Survey, 2006, 3. Kenya Demographic & Health Survey, 2006, 4. Uganda
Demographic & Health Survey, 2006
MORBIDITY
Southern Sudan has a heavy burden of disease. In general preventable, vector-borne diseases are
the most important causes of morbidity and mortality nationwide. The figure below shows the major
causes of morbidity in Southern Sudan.
Major causes of morbidity in all age groups seen at heath facilities
(UNICEF OLS Database: 2005-2007)
Others, 22.3%
Malaria, 24.7%
Skin, 5.7%
Eye, 5.9%
Diarrhea, 14.0%
Intestinal worms,
10.0%
Pneumonia, 17.6%
It is estimated that malaria and respiratory diseases account for almost 50% of all reported
diagnoses in health facilities.
5
Infectious disease epidemics such as meningitis, measles and cholera are also still common. The
annual incidence of Tuberculosis is estimated at 325 per 100,000 populations, among the highest in
the world.
THE HEALTH OF WOMEN
Information poor but sexual and reproductive ill health is one of the most common causes of death
and diseases for women between the ages of 15 and 44 in Southern Sudan.
Sexual Health
As in many developing countries, sexual and reproductive ill health is one of the most common
causes of death and diseases for women between the ages of 15 and 44. Low levels of education of
women and cultural practices, which include power dynamics at household, and community levels,
poverty and poor access and low utilization of health services contribute to the high burden of
sexual and reproductive ill health.
Sexually Transmitted Infections (STIs) are a major problem especially in the youth and have been
associated with the phenomenon of low fertility rates in some communities. Due to inadequate
access and exposure to modern medical services, repeated infections and re-infections are common.
This also presents serious challenge for prevention and control of HIV/AIDS. Where STIs services
exist, they are implemented as parallel programmes with no linkages between HIV/AIDS and
Reproductive Health1.
There are reports of Gender Based Violence (GBV) in Southern Sudan. Although the magnitude and
extent of GBV is not yet known, it is believed to be widespread. The most common forms of genderbased violence reported include rape, sexual coercion, domestic violence, wife battery, emotional
and psychological abuse, early and forced marriages and violation of women’s property rights2.
Fertility
The total fertility rate is high and is likely to remain high on account of lack of awareness of modern
methods of family planning and low involvement of men in family planning.
Fertility rates and use of contraceptive services
Total Fertility Rate
Birthrate in women aged 15 – 19 years
Contraceptive use rate
6.7/woman
200/1000
3.5% (SHHS 206)
Maternal mortality
Maternal Mortality Ratio is 2,054 per 100,000 live births, which is much higher than in neighbouring
countries and among the highest in Africa. It is 293 times the rate in the UK.
Maternal mortality is among the highest in the world at 2,054 deaths per 100,000 live births.
1
2
(Report on Situational Analysis of RH and ASRH in SS- 2007)
Report on Situational Analysis of RH and ASRH in SS- 2007).
6
Health Indicator
Maternal Mortality Ratio
S. Sudan
2,054
N. Sudan
535
Uganda
435
UK
7
Tanzania
950 (2005)
The high maternal mortality (and morbidity) in Southern Sudan is largely due to









haemorrhage
retained placenta
anemia
poor nutrition
obstructed labour/ruptured uterus
malaria
abortion
sepsis
poor state of health facilities for referrals and emergency response.
Maternity Care
Over 80 percent of deliveries take place at home, either under the supervision of traditional birth
attendants (TBAs) or village midwives or relatives.
There are very low utilization rates for maternal health services and poor access to Basic Emergency
Obstetric and Neonatal Care (BEmONC)
Antenatal Care by skilful health personnel uptake
Delivery attended by skilful health personnel
Institutional deliveries (delivered in the health facility
26.2%
10.0%
13.6
Basic Emergency Obstetric and Neonatal Care (BEmONC)
This is not yet available in many parts of the country and, where it exists, its quality is poor.
Most facilities lack basic equipment and the maternal and neonatal health workers (consisting of
mainly village midwives, Trained Birth Attendants and maternal and child health workers) lack the
necessary skills to perform simple life saving and nursing procedures.
There is thus inadequate access to skilled care throughout the continuum of pregnancy, delivery,
post-partum and post-natal periods. Referral of obstetric emergencies is very difficult. Roads and
transport are difficult and there are no organized emergency ambulances or transport services and
the cost of private transport are often too high for poor families. As a result there are frequently
long delays for women in obstructed labour leaving home and getting to a Comprehensive
Emergency Obstetric and Neonatal Care facility (CEmONC).
Comprehensive Emergency Obstetric and Neonatal Care (CEmONC)
Access to CEmONC, one of the most important basic services provided by hospitals and vital for
reducing the high rates of maternal and newborn mortality is very low in Southern Sudan.
7
The rate of Caesarean Section is a good indicator of access to CEmONC. The rate in the three
Teaching Hospitals of Juba, Malakal and Wau was under 0.5% in the population served by these
hospitals3. This is one of the lowest rates in Africa.
If a minimum of 5% of deliveries are obstructed and require a Caesarian Section, then at most only
one out of every ten women who need a Section are getting one.
There are insufficient numbers of hospitals providing CEmONC 24 hours a day. WHO recommends a
minimum of 1 CEmONC facility per 500,000 people, though the poor roads and sparsely scattered
population in Southern Sudan might require a lower minimum in some areas.
Management of abortion
Even though abortion is a major cause of maternal morbidity and mortality, post-abortion care is
poor. Only first trimester abortions are routinely evacuated in most health facilities. At the current
rates of access and utilization of health services, Southern Sudan is not predicted to meet the
maternal and child health Millennium Development Goals.
THE HEALTH OF CHILDREN
The health status of children in Southern Sudan is poor and probably among the worst in the world.
The high maternal mortality is also associated with a high neonatal mortality rate of 51 deaths per
1,000 live births mostly due to infections, low birth weight and birth asphyxia.
Health Indicator
Neonatal
Mortality
Rate/1000 births
Infant Mortality Rate/1000
live births
Under
5
Mortality
Rate/1000
S. Sudan
51/1000
N. Sudan
n/k
Uganda
30 (2009)
UK
3 (2008)
Tanzania
33 (2009)
102
71
76
5 (2010)
67
135
101
105
5.3
(2010)
122 (2005)
Source: 1.SHHS – 2006 and South Sudan Commission for Census, Statistics and Evaluation (2004), 2.
Tanzania Demographic & Health Survey, 2006, 3. Kenya Demographic & Health Survey, 2006, 4. Uganda
Demographic & Health Survey, 2006
Under 5s
The main causes of morbidity and mortality in children under 5 are ones that have known cost
effective life saving interventions. The main causes are

3
Malaria
(Report on Strengthening Hospital Management in Southern Sudan 2010)
8
o
o

Diarrhoea
o

In 2005 only 12 percent of households had at least one insecticide-treated
net. Following a malaria programme this has now risen to 60% (Malaria
Indicator Survey 2009/2010).
In 2006 less than 5% of children with fever were treated with an appropriate
antimalarial medicine within 24 hours of the onset of the fever (SHHS).
Following a Home Management of Malaria programme, this figure rose to
12% in 2009 (Malaria Indicator Survey).
The survey also showed that overall, 63.9 percent of children with diarrhoea
received oral rehydration solution and/or an appropriate household fluid.
Respiratory Tract Infection (mainly pneumonia)
o
Although 87.8% of children suspected to have pneumonia were taken to an
appropriate health care provider, only 24.5 percent of the
mothers/caretakers could recognize two danger signs of pneumonia.
(Data from Torit Civil Hospital Paediatric Ward (2007) showed that 62.3 percent of the OPD
attendance and 81.8 percent of admissions were due to malaria, diarrhoea and pneumonia.)
Immunisation
Although improving, these remain below levels desired for Diptheria, Pertussis and Tetanus as
illustrated below.
Immunization coverage for DPT3 since 2006 in Southern Sudan
100
90
90
80
80
70
Coverage (%)
70
60
50
50
43
40
30
30
20
20
22
15 15
10
0
2006
2007
2008
2009
2010
Performance Year
Attained DPT-3
cMYP Targeted DPT-3
9
2011
Nutrition
The average prevalence of acute malnutrition among children under five years of age was about 19
percent of which about 3 percent were severe. These levels of acute malnutrition surpassed the
WHO emergency threshold of a 15 percent. The prevalence varied with seasons and more
substantially across regions. The 2006 SHHS reported stunting levels among children under five of
around 19 percent.
Malnutrition in Southern Sudan is caused by different factors that change seasonally for different
population groups; coping mechanisms may not always be effective enough to prevent seasonal
malnutrition. Food insecurity in all its forms, e.g. lack of food availability, access and utilization, is a
problem for most communities in Southern Sudan.
DISEASES
Malaria
Malaria constitutes one of the biggest causes of morbidity and mortality in Southern Sudan
especially among women and children. It accounts for more than 40% of all health facility visits
(Southern Sudan Commission for Census, Statistics and Evaluation (SSCCSE) - 2004).
Plasmodium falciparum is the dominant parasite causing more than 90% of all morbidity except for
the border regions with Ethiopia where Plasmodium vivax does also cause malaria. High levels of
Plasmodium Falciparum resistance to chloroquine and sulfadoxine- pyrimethamine was documented
in 2004.
Malaria epidemics and more localized outbreaks occur and are caused by environmental and
climatic factors (e.g. massive flooding) but also by movement of populations with little immunity
into areas of high transmission (Internally Displaced Persons) as well as lack of access to any kind of
anti-malaria treatment in some areas.
Prevention and treatment of malaria
a) Long Lasting Insecticide treated mosquito Nets
Malaria programs of the Ministry of Health with the technical support of WHO have
promoted prevention activities focusing on distribution and promotion of the use of Long
Lasting Insecticide treated mosquito Nets (LLINs). Between 2008 and 2010, more than 4
million LLINs were distributed with a target of providing one LLIN for every 2 members of a
household. According to the 2009/10 Malaria Indicator Survey (MIS), 60.4% of households in
South Sudan own at least one insecticide treated mosquito net (ITN) compared to 12% in
2005 (SHHS – 2006).
b) Home Management of Malaria Programme
10
The Ministry of Health (MoH) and partners designed and is implementing the Home
Management of Malaria (HMM) programme to expand access to prompt treatment of
febrile children under 5 years of age with Artesunate+Amodiaquine (AS+AQ) at community
level. The proportion of under five years children who received appropriate antimalarial
treatment within the first 24 hours of onset of fever increased from less than 5 percent in
2006 (SHHS) to 12 percent in 2009 (2009 Malaria Indicator Survey (MIS).
Tuberculosis
Tuberculosis is one of the major causes of morbidity and mortality in Southern Sudan. The exact
burden is not known, but the death rate is estimated to be 65/100,000.
Incidence of sputum smear positive cases/100,000 population
Incidence of all forms of tuberculosis
Case detection rate %
Treatment success rate
101/100,000
228/100,000
19%
80% (2002)
86% (2006)
Although no formal surveys have bee carried out to determine TB resistance patterns, there are
indications of multi-drug resistant TB in Southern Sudan.
HIV co-infection in TB patients is high, as much 11.2% HIV in one study.
HIV/AIDS and Sexually Transmitted Diseases
HIV/AIDS prevalence is currently at low overall (3% the 2009 ANC Surveillance) though there is wide
variation between the regions.
During the civil war, social isolation is thought to have limited transmission. Prevalence is expected
to be increasing with people rapidly returning from counties in the region with high levels of HIV.
This, together with the low awareness and availability of modern family planning methods and low
involvement of men in this, incidence and prevelance is predicted to increase. It represents an
emerging cause of major morbidity and mortality in Southern Sudan.
A number of NGOs and some public sector ministries are implementing HIV prevention activities.
There are counseling and testing service providers in some states and some PMTCT sites have been
established. The antiretroviral therapy (ART) centres grew from 1 site in 2006 to 9 sites in 2009 and
14 sites in 2010.
Neglected Tropical Diseases
Southern Sudan is affected by a high burden of so-called Neglected Tropical Diseases (NTDs) (also
known as Diseases of Public Health Importance), most of which are easily preventable and/or
treatable. The main NTDs in Southern Sudan include: Visceral Leishmaniasis (VL, also called kalaazar), Human African Trypanosomiasis (HAT), Trachoma, Soil-Transmitted Helminth infections (STH:
11
hookworm, ascariasis and trichuriasis), Lymphatic Filariasis (LF), Onchocerciasis, Schistosomiasis
(Schistosoma haematobium and S. mansoni), Drancunculiasis (guinea worm), Leprosy and Buruli
Ulcer.
Control of Non Communicable Diseases
Non Communicable Diseases (NCDs) are thought to be a growing burden on public health
particularly in low- and middle-income countries including Southern Sudan, though there are no
systematic studies on NCDs to date in Southern Sudan. According to the Global Burden of Disease
Study conducted in 2001, 20% of deaths in sub-Saharan Africa were due to NCDs, and this burden of
disease is predicted to increase to 40% by 2020.
Mental illness (as a NCD) has been exacerbated by the effects of war trauma due to the prolonged
civil war in Southern Sudan which lasted over 20 years. Mentally sick individuals are commonly
detained in prisons for long and indefinite periods as protective measures against harming
themselves or the public. Currently no assessment or survey of mental illness in the country exists.
Nutrition
The prevalence of malnutrition in children has been described above.
Data on the prevalence of malnutrition among adults are not available. However, micronutrient
deficiencies are almost certainly widespread and severe.
Malnutrition in Southern Sudan is caused by different factors that change seasonally for different
population groups; coping mechanisms may not always be effective enough to prevent seasonal
malnutrition. Food insecurity in all its forms, e.g. lack of food availability, access and utilization, is a
problem for most communities in Southern Sudan. However, general lack of dietary diversity is a
substantial contributing factor to reduced food utilization in Southern Sudan.
There are many nutrition and health initiatives in Southern Sudan. The government is establishing
structures to provide widespread quality health and nutrition services. The process will take time
and the contribution of NGOs to health care provision in Southern Sudan will continue to be
substantial in the coming years. Most NGOs continue to provide this support as they strengthen the
capacity of the government to take over the service provision.
Overweight and its effects on health are increasingly becoming a burden on the health system in
Southern Sudan.
Health related behavior and environmental health
The prevailing cultural beliefs and low literacy levels greatly contribute to poor health seeking behavior
among the population.
12
Access to safe drinking water sources is still very low in Southern Sudan. The 2006 SHHS showed that
on average only 48.3 percent of the population had access to improved drinking water sources
(mainly water pump/boreholes) with a range of 22.2% - 57.2%.
Only Warap, Lakes, and Upper Nile States had access to improved drinking water source at the level
of 57.2 percent. The states of Jonglei, Western Equatoria and Central Equatoria had the lowest
accessible to improved drinking water source of up to 22.2 percent only.
Unsafe disposal and handling of excreta are major causes of infectious diseases in Southern Sudan..
The 2006 SHHS found that only 6.4 percent of the population was using sanitary means of excreta
disposal.
The rapid growth of urban areas in Southern Sudan represents an emerging environmental problem
for health. The populations of Juba has increased rapidly slums have already begun to emerge.
There is currently no planning effort to address this emerging urban health problem that is evolving.
.
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HEALTH SERVICES
The country is divided into three levels of Government. These are at National, 10 States and about
79 counties.
THE MODEL FOR HEALTH SECTOR ORGANIZATION, FUNCTIONS AND MANAGEMENT
Facilities
The service is structured to provide a continuum of care through organisation at




Village Level
Primary Health Care Centres and Units
General and Rural County Hospitals
Tertiary/Teaching Hospitals
14
The following table shows the various functions at these levels
Level of provision
Village/Boma
Provision
Health
promotion,
disease prevention and
some basic services.
Work through a Boma
Health
Committee
which is to actively
engage
local
community in health
activities
and
harmonise public &
NGO sector activity
Staff
Community
Health
Worker (9 months
training)
Maternal and Child
Health Worker (9
month training)
Home Health Promoter
(unpaid volunteer)
Population Served
Village
Primary Care Units
Open 6 days a week
and
provide
out
patient care, basic
preventive, promotive
and curative services.
As for PHC Units with
additional laboratory
services for diagnosis
and maternity care
Provide
preventive,
promotive, curative inpatient health services
and surgery
As for Rural/County
Clinical Officer
Nurse
Midwife
Community
Health
Worker
As for PHC Units
15,000
Primary Care Centres
Rural/County Hospitals
(30 exist)
General/State
Hospitals
(7 exist)
Teaching Hospitals
As
for
General
(3 exist - Juba, Wau, Hospitals, but also
Malakal)
more
specialised
services of general
surgery,
internal
medicine, obstetrics &
gynaecology
and
paediatrics
50,000
Several
multidisciplinary staff
200,000 – 400,000
As for Rural/County,
but more staff
400,000 – 600,000
As for General, but
more
staff.
Also
research and teaching
staff.
3 – 4 million
It is estimated that only 25% of the population in Southern Sudan is currently reached by health
services. Many existing health facilities are not are able to provide a full range of Basic Package of
Health Services. According to the report on Peer Review of BSF Grant recipients in Primary Health
Care, only 30 percent of the peer reviewed functional PHCUs were providing immunization by fixed
strategy and 75 percent of functional PHCUs were providing immunization by outreach and fixed
strategy.
15
SOUTH SUDAN HOSPITALS
H
H
HMalakal
H
H
H
Wau
H
H
H
H
H
H Juba
H
H
H
H
H
: Teaching Hospital
Access
Distance to health facilities is a significant barrier to access health care especially by the poor.
Households living within a walking distance of 5 - 10 kilometre radius of a health facility have
greater access to and utilization of the facilities. Over 75% of the population lacks access to a health
facility. The table below shows the available date on the distribution of various types of health
facilities in each of the 10 states.
16
Distribution of health facilities by type and State
State
Teaching
Hosp.
Upper Nile
Unity
N. B. E. Ghazal
W. B. E. Ghazal
1
1
State
Hosp
.
1
-
County
Hosp.
PHCC
PHCU
Private
Wings
Special
Hosp.
Others
Total
4
1
1
41
23
15
21
104
89
88
80
2
2
1
5
2
1
2
2
1
159
114
109
106
76
189
122
6
-
1
3
1
2
2
84
748
11
13
9
103
259
171
1,021
Lakes
1
5
20
C. Equatoria
1
2
3
53
E. Equatoria
2
3
41
W. Equatoria
Jonlei
Warrap
3
21
TOTAL
3
6
17
214
Source: Health Facility Mapping – MoH-GoSS – 2009
Substantial regional inequalities in access to health care lies within the low overall coverage. PHC
coverage in Equatoria states is broadly in line with Sub-Saharan African averages while it is
considerably lower in the Upper Nile and Bahr-el-Ghazal regions.
Out of the total 1,021 health facilities in the country, 24% require minor renovation, 17% require
major renovation and 23% require new facilities. 777 (76 percent) health facilities are functional and
244 (24 percent) are non functional.
Other health infrastructure challenges include: lack of medical equipment, transport and
communication equipment, water and energy. Standards building designs and medical equipment
lists for different levels of health facilities however have not yet been developed.
17
Staff
According to the inventory of human resources for health carried out during the Health Facility
Mapping Exercise by MoH-GoSS in 2009/2010, there are 7,668 health personnel in the country.
Inventory and distribution of human resources by States
State
Upper Nile
Unity
N. B. E.
Ghazal
W. B. E.
Ghazal
Lakes
C. Equatoria
E. Equatoria
W.
Equatoria
Jonglei
Warrap
TOTAL
Doctor Nurse MW
CO
CHW
Pharm Lab. Dental Theat. EPI Others Total
Tech
Attend
495
18
27
6
8
67
8
1,221
1,110
6
15
2
290
8
1,590
351
17
12
3
1
41
4
536
39
3
10
476
130
66
39
8
6
38
18
25
12
343
51
38
250
5
15
9
20
4
4
760
17
97
5
111
557
130
13
154
36
39
75
20
503
850
569
2
23
5
13
95
1
12
-
4
2
8
92
38
32
3
21
26
798
1,924
839
-
6
189
30
1,843
2
309
16
269
84
4,212
76
2
179
31
2
47
564
74
This workforce is comprised of a mixture of those who remained during the conflict and the
returning refugees. Reintegrating these two groups and equipping them to deliver quality health
services is a major task for rebuilding the health system of Southern Sudan. The returning refugees,
in turn, were trained in a variety of settings.
The current workforce consists of many low-level staff and a shortage of mid-and-higher-level cadres
such as doctors, midwives and pharmacy staff. Community Health Workers constitute 54% (4,212) of
the current health workforce in Southern Sudan. The majority of existing health workforce therefore
doesn’t have adequate technical capacity to deliver quality health services and address the priority
health problems.
According to the Inventory Survey of Human Resources for Health in Southern Sudan (2006), it was
estimated that only about 10% of the staffing norms are filled by appropriately trained health
workers. Reports indicate that few CHW and MCHW work in community settings, instead working in
urban areas and in facilities. They providing care that, by policy, should be provided by more highly
trained workers.
This issue represents a major policy issue for MoH which must contend with both poor community
levels services and undertrained staff providing clinical services.
18
7,668
Training
Most practising health professional cadres received limited professional health education during the
war that ended in 2005 and most have received less than 9 months of any form of professional
training.
Health Training Schools
There are 36 Health Training Schools in Southern Sudan. 23 are open and functioning, 6 are shut and
6 have been closed since 2006. Of the 23 schools which are open, 6 are under MoH-GoSS control, 3
are State MoH owned and 14 are owned and run by partners. The training schools are unevenly
distributed among the states.
There are 33 different training programmes/course offered in different training schools which
include: 2 degree; 10 diploma; 10 certificate; and 7 award courses. 75 percent of MoH-GoSS school
output is at certificate level. Total output from training school since 2006 is as follows: MoH-GoSS
schools - 635; Sate MoH schools - 153 and partners’ schools - 202.
Only half of the training schools follow the MoH-GoSS designed (or at least approved) curricula. The
different training schools set and determine the examinations for the different courses without
MoH-GoSS guidance and oversight. There is therefore no consistency in examinations across training
schools
The existing training schools are grossly understaffed, with high tutor: student ratios, much higher in
state MoH owned schools than in GoSS owned schools. Many of the tutors are part-time and not
well qualified. Partner owned and managed training schools have a much lower, more acceptable
and consistent tutor: student ratios.
In the past training of health workers has been mainly funded, managed and staffed by NGOs and
international agencies. Priority and funding changes of donors leave the future of many institutions
in question. .
Undergraduate Medical Training
The three medical schools located in Southern Sudan were transferred to Khartoum in 1988. In 2008
two year groups of medical undergraduates, were moved back to Juba. However, there were no
facilities for teaching and these students are in a vacuum.
Students have had virtually no books or training facilities. This is now starting to be addressed by a
South Sudan Medical Education Collaborative linked to Harvard University, which has upgraded
some classrooms, provided some books and equipment and brought some medical students over
from the USA to do some teaching.
Female students in Juba tend to have had homes in neighbouring countries. Males may have come
from refugee camps and be without relatives. They are without money and are malnourished. Their
accommodation in Juba has been a large bare hut with concrete floor. Despite these major physical
challenges they are hungry for knowledge.
There is current debate as to how best to provide for students in their last 2 years of training and
whether to send them to neighbouring universities.
19
Specialist Medical Training
There is no structure for specialist training. Doctors working in South Sudan have been trained in a
variety of places e.g. Khartoum, Kenya. Training would not have included anything about other
aspects of providing a clinical service e.g. teaching, educational supervision, audit, multidisciplilnary
working. There is not culture of teaching by clinical staff.
Nursing and Midwifery
Midwives
Starting in 2006, the training of Community Midwives was the first United Nations Population Fund
(UNFPA) initiative in the support of skilled birth attendants (SBAs). 96 students have graduated
since 2007 from different institutions.
A further 110 Community Midwives are being prepared to begin training in 2010. UNFPA is looking
into the possibilities of recruiting about 150 International Volunteers/Midwives by the end of 2010
to help the South Sudan Government to face the challenge of lack of qualified health cadres.
Nurses and Midwives
South Sudan’s own training for nurses and midwives started with the opening of The Juba College of
Nursing and Midwifery in May 2010 with 30 students – 18 nursing and 12 midwifery. It is expected
that the college will have trained over 100 nurses and midwives by 2015.
The main challenges of the college are:



Lack of national qualified nurse and midwife tutors,
Shortages of applicants for the diploma programme with an acceptable entry-level of
education. South Sudan’s high adult illiteracy rate (due to two decades of war) especially
among women has affected the candidate selection process and requires a re-assessment of
the interview and selection criteria2.
Lack of funds for students' housing and transport3. Some students face challenges in learning
English. Mary Lupai UNFPA’s National Programme Officer for Gender is helping to tutor the
students in communication skills.
20
PLAN TO TACKLE THE HEALTH NEEDS OF THE COUNTRY
This five year Health Strategic Plan for Southern Sudan (2011-2015) guides the development of the
health sector. It emphasizes Primary Health Care as the cornerstone of the health system
development and the provision of equitable and quality health services, free of charge, for all.
The plan builds on the Ministry of Health Government of Southern Sudan Health Policy (2007-2011)
and the Basic Package of Health Services, 2009, which is the guide for development over this time
period.
The Basic Package of Health Services
The Basic Package of Health Services comprises priority interventions for disease prevention and
health promotion, rehabilitation and selected curative services that address priority health problems
in an integrated manner to




improve maternal and child health
control communicable diseases
improve community nutrition, especially of mothers and children
control of most common non communicable diseases.
The Package, therefore, has four service components, which address the most urgent health
priorities in Southern Sudan. These include:
a) Integrated Reproductive Health Services;




Essential Obstetric Care
Women’s Reproductive Health Services
Adolescent Reproductive Health Services
Men’s Reproductive Health Services
b) Community Based Health and Nutrition Care;


Integrated Essential Child Health Care
Management of endemic and neglected Communicable diseases
c) Health Education and Promotion and



Basic Package of Health for Schools
Community Based Nutrition and food security programme
Community management of environmental health and hygiene
d) Management of Common Endemic Communicable and Non communicable Diseases.



Management and Oversight,
Establishment of functioning logistical system for efficient delivery of the BHSP
Extending the national health management information system
21
These Basic Services are further focused into priority interventions and approaches in the Strategic
Objectives of this Health Service Plan. These are

Family oriented community based services (including household behaviour change activities,
community health workers service and social marketing).
(These interventions mostly include preventive and promotive measures as well as some
management of neonatal and childhood illness. The responsibility of the health system is to
empower the community through information, education and other strategies as well as
accessible commodities and supplies.)

Population oriented scheduled services (i.e. outreach services and campaigns for
standardized services, and

Individual oriented clinical services (requiring decisions on diagnostic and treatment)
These are complimented by tertiary care (Essential Hospital Services) in providing a comprehensive
and continuum of health care to the population of Southern Sudan.
Goals and Strategic Objectives
Goals
The Goals for the HPS (2011 – 2015) are tied to the Millennium Development Goals (MDG) and the
global movement to work towards 2015 targets.
The health related MDGs are:
Goal 1: Eradicate extreme poverty and hunger;
Goal 4: Reduce child mortality;
Goal 5: Improve maternal health; and,
Goal 6: Combat HIV/AIDS, malaria and other diseases.
22
South Sudan Goals for 2015 that relate to these MDGs are as follows
Goals of the Health Strategic Plan (2011-2015), Indicators, Targets
Goals and
Indicator
Definition
Baseline
Value
(2010)
Target for Target
Data
MDG
for HSP Source
2015
2015
Reduce Infant
Mortality Rate
per 1,000 live
births
SSHHS
Reduce Under-5
Mortality Rate
Reduce Maternal
Mortality
Increase
Contraceptive
Prevalence Rate
Reduce stunting in
children under five
Improve
prevention and
care for Malaria,
Tuberculosis, HIV,
and other selected
infectious diseases
per 1,000 live
births
per 100,000
live births
SSHHS
SSHHS
SSHHS
SSHHS
SSHHS
Strategic Objectives
Twenty-five Strategic Objectives have been identified which are designed to achieve these goals.
They are based on a strong evidence base and measurable indicators that are being tracked. These
are listed in Appendix 1.
Service Delivery Programme Emphasis
In order to facilitate integrated service delivery, the priority health care interventions in the Basic
Package of Health Services, have been grouped into three operational clusters of similar and closely
linked interventions, which include:
-
Health Promotion and Disease Prevention
Maternal, Neonatal, Child and Reproductive Health
Control of Communicable and Non Communicable Diseases
23
TAKING THE PLAN FORWARD
The preferred option
There is more than one choice about how to deliver the plan. These are influenced, for example, by
the expected efficiency e.g. number of patients seen at a primary care centre in a day and variations
in the number of facilities provided. Three following scenarios were explored :
Scenario 1 :
Scenario 2 :
Scenario 3 :
With no additional development
With extra facilities
With extra, more qualified, staff
Following consultations, the scenario that would achieve the objectives at lowest cost (Scenario 1)
has been recommended.
The assumptions and calculations underpinning this scenario are given in Appendix 2.
Key issues associated with this option
There are major challenges that arise in the implementation of a plan to achieve the Strategic Plan
2011 = 2015. These include :
a) Maternity and child prevention in children
The essential challenge of the HSP is to multiply the volume of service by many times.
Reducing maternal mortality can only be achieved by dramatic increases in attended births.


births attended by trained health personnel need to multiply X 3 from 34,000 to 122,000
Caesarean sections need to multiply X 6, from 2,000 to 12,000.
A substantial increase in service coverage for targeted services including Ante Natal Care,
immunisation and treatment of childhood illnesses can only be achieved by increasing primary care
attendance
b) Buildings
It will take many years to improve or rebuild inadequate facilities. The challenge will be to focus
resources on the right number of existing facilities and maximise their utilisation and effectiveness,
rather than establishing new ones.
c) Increasing efficiency
There is a considerable amount of unexpressed need and the plan assumes that attendances at
Primary Health Care Units and Centres will need to increase their rate of attendance by 4 -5 times.
Supplies of medicines and equipment will need to reflect this and overcome supply chain issues.
24
d) Increasing skills
Achieving 30% of births attended by trained health personnel and 10% of these being by Caesarian
Section will required an increase in skills of staff and also equipment for the Basic and
Comprehensive Emergency Obstetric Care facilities.
The same applies to other types of staff and one of the challenges of achieving the plan is how to
manage and increase the skills of a large numbers of low grade staff in both clinical and non-clinical
roles. Options for consideration include training staff into higher level roles, such as nurse aides and
community midwives, as well as freezing recruitment and redundancy.
Over 50% of the proposed workforce will be based in primary care. 42% will be in hospitals. 9% will
be in County, State or MOH-GOSS administration.
Overcoming shortages of professions, however, will be one of the greatest challenges. The health
sector needs to



fill gaps in nursing, midwifery, clinical officers, laboratory and pharmacy staff
take account of the low staff baseline (which is itself uncertain)
manage and minimise the loss of staff.
As important as the number of staff, is their distribution and quality. Although there may
theoretically be enough doctors, many hospitals lack them.
The human resource strategy will need to quantify plans for pre-service, in-service training, career
development, incentives and other measures to get and retain staff where they are needed.
25
Appendix 1
Strategic Objectives for HSP with 24 Priority Intervention Indicators, and Targets
No.
Priority
Intervention
Indicator
Definition
Baseline
Value
(2010)
NUTRITION
1
Exclusive breastfeeding (<6
months)
2
Breast-feeding plus
complementary
food (6-9
months)
Percentage of infants aged
0-5 months who are
exclusively Breastfed
Percentage of infants aged
6-9 months who are
breastfed and
receive
complementary
food
3
Vitamin
A Percentage of children
supplementation
aged 6-59 months who
Coverage
received at least one high
done
vitamin
A
supplement in the last six
months (and at least two
doses in the last 12
months).
CHILD HEALTH
4
Measles
Percentage of children
immunization
aged 12-23 months who
coverage
are immunized against
measles
5
DPT3
Percentage of children
immunisation
aged 12-23 months who
coverage
received 3 doses of DPT
vaccine
6
Oral rehydration Percentage of children
and
aged 0-59 months with
continued feeding diarrhoea receiving oral
rehydration and continued
feeding
7
Insecticide-treated Percentage of children
net
aged 0-59 months sleeping
coverage
under an
insecticide-treated
mosquito net
8
Anti-malarial
Percentage of children
treatment
aged 0-59 months with
fever receiving
appropriate anti-malarial
drugs
26
Target
for
MDG
2015
Target for Data
HSP 2015 Source
SSHHS
SSHHS
SSHHS
SSHHS
SSHHS
SSHHS
SSHHS
SSHHS
9
Prevention
of
mother-to-child
transmission of HIV
transmission
Care seeking for
pneumonia
Percentage of all HIVpositive pregnant women
who received a complete
course of ART prophylaxis
10
Percentage of children
aged 0-59 months with
suspected
pneumonia
taken to an appropriate
health provider
11
Antibiotic
Percentage of children
treatment for
aged 0-59 months with
pneumonia
suspected
pneumonia
receiving antibiotics
MATERNAL AND NEWBORN HEALTH
12
Contraceptive
Proportion of women
prevalence
currently married or in
union aged 15-49
that are using (or whose
partner
is
using)
a
contraceptive
method
(either
modern
or
traditional)
13
Unmet need for Proportion of women that
family
are currently married/in
planning
union that have an unmet
need for contraception
14
Antenatal care (at Percent
of
women
least one
attended at least once
visit)
during pregnancy by skilled
health
personnel
for
reasons related to the
pregnancy in the X years
prior to the survey
15
Antenatal care (4 Percent
of
women
or more
attended at least four
visits)
times during pregnancy by
any provider (skilled or
unskilled) for reasons
related to the pregnancy in
the X years prior to the
survey
16
Neonatal tetanus Percentage of newborns
protection
protected against tetanus
17
Intermittent
Proportion of women who
preventive
received
intermittent
treatment
preventive treatment for
malaria during their last
pregnancy
18
Skilled attendant Percentage of live births
at delivery
attended by skilled health
personnel (doctor, nurse,
27
SSHHS
SSHHS
SSHHS
SSHHS
SSHHS
SSHHS
SSHHS
SSHHS
SSHHS
SSHHS
19
C-section rate
20
Early initiation of
breastfeeding
21
Postnatal care for
mothers
22
Postnatal care for
babies
who were born at
home
WATER AND SANITATION
23
Use of improved
drinking
water sources
24
Use of improved
sanitation
facilities
midwife
or
auxiliary
midwife)
Percentage of live births
delivered by Caesarean
section
Percentage of newborns
put to the breast within
one hour of birth
Percentage of mothers
who received postnatal
care visit within
two days of childbirth
Percentage of babies born
outside a facility who
received a postnatal care
visit within two days of
birth.
Percentage
of
the
population using improved
drinking water sources
Percentage
of
the
population using improved
sanitation facilities
28
SSHHS
SSHHS
SSHHS
SSHHS
SSHHS
SSHHS
Appendix 2
ASSUMPTIONS AND CALCULATIONS ON WHICH SCENARIO 1
(IMPLEMENTING THE BASIC PACKAGE OF HEALTH SERVICES)
IS BASED
Service Targets 2015
The essential challenge of the HSP is to multiply the volume of service by many times.
Reducing maternal mortality can only be achieved by dramatic increases in attended births.


births attended by trained health personnel need to multiply X 3 from 34,000 to 122,000
Caesarean sections need to multiply X 6, from 2,000 to 12,000.
A substantial increase in service coverage for targeted services including ANC, immunisation and
treatment of childhood illnesses can only be achieved by increasing primary care attendance. A
target of 1 attendance per person, on average, per year is proposed.

Attendances in primary care need to multiply X 5.
It is important to note that the number of staff and facilities in this service model are fixed. The cost
is the same whether it delivers 34,000 babies a year or 115,000.
Facilities Required
29
The number of facilities required by the BPHS norms and the draft hospital services plan are shown
above. The model provides over 8 PHC facilities per county. However, the model additionally needs
to take into account the distance people need to travel to facilities.
The baseline currently shows an excess of PHCUs, PHCCs and County/Rural Hospitals, relative to the
population need. In practice, however, many facilities are in very poor, with over half in temporary
accommodation. Even though they were all recorded as functional in 2009, many are operating at a
very low level.
The challenge for BPHS therefore is to focus resources on the right number of existing facilities, and
maximise their utilisation and effectiveness, rather than establishing new ones.
In practice, it will take many years to put all its facilities in order. The HSP needs to plan for
temporary fixes and improvements to facilities, and expect higher running costs for dilapidated
clinics and hospitals. It also needs to plan the capital requirement for rehabilitation and
improvement of facilities.
Workload – primary care attendances
To provide an average of 1 attendance per head of population per year by 2015, PHCUs and PHCCs
will need to increase their rate of attendance by 4 or 5 times. His means increasing to 11
attendances per day per member of staff, compared with the present very low level of
approximately 2-4 attendances per day.
Provided 11 attendances a day is considered a feasible rate, there is no need therefore to increase
staff numbers over the minimum numbers provided in the BPHS.
The major challenge in addition to facilities and staffing (below) will be to ensure that supplies of
medicines and equipment reflect this 5 fold increase.
The HSP needs to overcome the problems of its supply chain, and provide an adequately costing for
supplies and equipment.
30
Workload – births
To ensure that 30% of births attended by trained health personnel, and 10% of these as Caesarean
Sections, facilities will also need to increase their rate significantly. The target requires 9 ordinary
deliveries a month in a PHCU, and 25 CS a month in a rural Hospital.
The CEmOC and BEmOC facilities planned for hospitals and PHCCs respectively will require major
investments in premises, equipment, staff, supervision and training. The PHCUs, which are planned
to provide 40% of attended births, will also have important needs. The HSP needs costed plans to
improve supervision, support and communication, as well as equipment, taking into account the
extreme isolation of many PHCUs.
Staffing
The overall staffing requirement to implement BPHS is approximately 11,100. This is over 4,000
fewer staff than the recent baseline estimate for the health sector. However, it is a more skilled
workforce, with 25% of staff at Grade 10 or higher, compared with 20% or less currently.
One of the challenges of the model, therefore, is to consider how to manage large numbers of low
grade staff, including both clinical and non-clinical roles. Options for consideration include training
staff into higher level roles, such as nurse aides and community midwives, as well as freezing
recruitment and redundancy.
Over 50% of the proposed workforce will be based in primary care. 42% will be in hospitals. 9% will
be in County, State or MOH-GOSS administration. In the absence of clear norms, further work is
needed on hospital staffing levels.
Overcoming shortages of professions, however, will be one of the greatest challenges of the HSP.
The sector needs to fill gaps in nursing, midwifery, clinical officers, laboratory and pharmacy staff. It
needs to take account of the low staff baseline (which is itself uncertain) and to manage and
minimise the loss of staff.
31
As important as the number of staff, is their distribution and quality. Thus, although there may
theoretically be enough doctors, many hospitals lack them.
In order to address the gaps in the table below, the human resource strategy therefore needs to
quantify plans for pre-service, in-service training, career development, incentives and other
measures to get and retain staff where they are needed.
32