Summary of the Health Service Plan For

SUMMARY OF THE HEALTH SERVICE PLAN FOR SOUTH SUDAN, 2011 – 2015

CONTENTS

Page CONTEXT, GEOGRAPHY AND POPULATION 2 HEALTH NEEDS 5 Life expectancy and of Morbidity 5 The Health of women 6 Sexual Health and Fertility 6 Maternal Mortality 6 Maternity Care – Basic and Comprehensive Obstetric and Neonatal Care 7 Management of Abortion 8 Health of Children 8 Mortality rates 8 Under 5s : Malaria, Diarrhoea, Respiratory Infections 8 Immunisation 9 Malaria 10 TB, HIV/AIDS Neglected Tropical Diseases 11 Non-Communicable Diseases, Nutrition 12 Health Related Behaviour and Environmental Health 12 HEALTH SERVICES 14 Model for Health Sector Organisation, Functions and Management 14 Health Facilities : Hospitals and Access 16 Staff 18 Training 19 Health Training Schools 19 Medical Training 19 Nursing and Midwifery Training 20 PLAN TO TACKLE THE HEALTH NEEDS OF THE COUNTRY 21 Goals 22 Strategic Objectives and Service Delivery Programme Emphasis 23 Taking the plan forward 24 The Preferred Option 24 Key Issues Associated with the Preferred Option 24

Appendix 1 : 24 Priority Intervention Indicators and Targets 26 Appendix 2 : Assumptions and Calculations on which the Preferred Option is Based 29

2 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

3  inward migration from the return of refugees from neighbouring countries and internally displaced populations in Northern Sudan.

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 S. Sudan N. Sudan Uganda UK Tanzania Life Expectancy at birth 42 n/k 51 79 51.6 (2006) (years)

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.

It is estimated that malaria and respiratory diseases account for almost 50% of all reported diagnoses in health facilities.

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

5 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 gender- based 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 6.7/woman Birthrate in women aged 15 – 19 years 200/1000 Contraceptive use rate 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.

Health Indicator S. Sudan N. Sudan Uganda UK Tanzania Maternal Mortality Ratio 2,054 535 435 7 950 (2005)

The high maternal mortality (and morbidity) in Southern Sudan is largely due to

 haemorrhage  retained placenta  anemia

1 (Report on Situational Analysis of RH and ASRH in SS- 2007)

2 Report on Situational Analysis of RH and ASRH in SS- 2007).

6  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 26.2% Delivery attended by skilful health personnel 10.0% Institutional deliveries (delivered in the health facility 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.

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.

3 (Report on Strengthening Hospital Management in Southern Sudan 2010)

7 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 S. Sudan N. Sudan Uganda UK Tanzania Neonatal Mortality 51/1000 n/k 30 (2009) 3 (2008) 33 (2009) Rate/1000 births Infant Mortality Rate/1000 102 71 76 5 (2010) 67 live births Under 5 Mortality 135 101 105 5.3 122 (2005) Rate/1000 (2010)

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

 Malaria

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). o 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).

 Diarrhoea

8 o 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

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

9 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

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

10 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 101/100,000 Incidence of all forms of tuberculosis 228/100,000 Case detection rate % 19% Treatment success rate 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 kala- azar), Human African Trypanosomiasis (HAT), Trachoma, Soil-Transmitted Helminth infections (STH: 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

11 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.

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.

12 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. .

HEALTH SERVICES

The country is divided into three levels of Government. These are at National, 10 States and about 79 counties.

13 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

The following table shows the various functions at these levels

Level of provision Provision Staff Population Served

14 Village/Boma Health promotion, Community Health Village disease prevention Worker (9 months and some basic training) services. Work Maternal and Child through a Boma Health Worker (9 Health Committee month training) which is to actively Home Health engage local Promoter (unpaid community in health volunteer) activities and harmonise public & NGO sector activity

Primary Care Units Open 6 days a week Clinical Officer 15,000 and provide out Nurse patient care, basic Midwife preventive, Community Health promotive and Worker curative services. Primary Care Centres As for PHC Units with As for PHC Units 50,000 additional laboratory services for diagnosis and maternity care Rural/County Provide preventive, Several 200,000 – 400,000 Hospitals promotive, curative multidisciplinary (30 exist) in-patient health staff services and surgery General/State As for Rural/County As for Rural/County, 400,000 – 600,000 Hospitals but more staff (7 exist) Teaching Hospitals As for General As for General, but 3 – 4 million (3 exist - Juba, Wau, Hospitals, but also more staff. Also Malakal) more specialised research and services of general teaching staff. surgery, internal medicine, obstetrics & gynaecology and paediatrics

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

: 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 State County PHCC PHCU Private Special Others Total Hosp. Hosp Hosp. Wings Hosp. . Upper Nile 1 - 4 41 104 2 5 2 159 Unity - - - 23 89 2 - - 114 N. B. E. Ghazal - 1 1 15 88 - 2 2 109 W. B. E. Ghazal 1 - 1 21 80 1 1 1 106

Lakes - 1 5 20 76 - 1 - 103 C. Equatoria 1 2 3 53 189 6 3 2 259 E. Equatoria - 2 3 41 122 - 1 2 171 W. Equatoria - - Jonlei - Warrap - 3 - 21 84 - - - - TOTAL 3 6 17 214 748 11 13 9 1,021 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 Docto Nurse MW CO CHW Pharm Lab. Dental Theat. EPI Others Total r Tech Attend Upper Nile 39 476 39 38 495 18 27 6 8 67 8 1,221 Unity 3 130 8 18 1,110 6 15 - 2 29 8 1,590 0 N. B. E. 10 66 6 25 351 17 12 3 1 41 4 536 Ghazal W. B. E. 12 343 51 38 250 5 15 9 20 4 4 760 Ghazal Lakes 17 111 13 39 503 2 13 1 4 92 3 798 C. Equatoria 97 557 154 75 850 23 95 12 2 38 21 1,924 E. Equatoria 5 130 36 20 569 5 - 8 32 26 839 W. - Equatoria Jonglei - Warrap 6 30 2 16 84 2 2 - TOTAL 189 1,843 309 269 4,212 76 179 31 47 56 74 7,668 4

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 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

19 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.

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

21 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

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

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 Definition Baseline Target for Target Data Indicator Value MDG for HSP Source (2010) 2015 2015

Reduce Infant per 1,000 live SSHHS Mortality Rate births

Reduce Under-5 per 1,000 live SSHHS Mortality Rate births Reduce Maternal per 100,000 SSHHS Mortality live births Increase SSHHS Contraceptive Prevalence Rate Reduce stunting in SSHHS children under five Improve SSHHS prevention and care for Malaria, Tuberculosis, HIV, and other selected infectious diseases

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

23 - Maternal, Neonatal, Child and Reproductive Health - Control of Communicable and Non Communicable Diseases

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 : With no additional development Scenario 2 : With extra facilities Scenario 3 : 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.

24 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.

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 Definition Baseline Target Target for Data Intervention Value for HSP 2015 Source Indicator (2010) MDG 2015 NUTRITION 1 Exclusive breast- Percentage of infants aged SSHHS feeding (<6 0-5 months who are months) exclusively Breastfed 2 Breast-feeding plus Percentage of infants aged SSHHS complementary 6-9 months who are food (6-9 breastfed and months) receive complementary food 3 Vitamin A Percentage of children SSHHS 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 SSHHS immunization aged 12-23 months who coverage are immunized against measles 5 DPT3 Percentage of children SSHHS immunisation aged 12-23 months who coverage received 3 doses of DPT vaccine 6 Oral rehydration Percentage of children SSHHS and aged 0-59 months with continued feeding diarrhoea receiving oral rehydration and continued feeding 7 Insecticide-treated Percentage of children SSHHS

26 net aged 0-59 months sleeping coverage under an insecticide-treated mosquito net 8 Anti-malarial Percentage of children SSHHS treatment aged 0-59 months with fever receiving appropriate anti-malarial drugs

9 Prevention of Percentage of all HIV- SSHHS mother-to-child positive pregnant women transmission of HIV who received a complete transmission course of ART prophylaxis 10 Care seeking for Percentage of children SSHHS pneumonia aged 0-59 months with suspected pneumonia taken to an appropriate health provider 11 Antibiotic Percentage of children SSHHS treatment for aged 0-59 months with pneumonia suspected pneumonia receiving antibiotics MATERNAL AND NEWBORN HEALTH 12 Contraceptive Proportion of women SSHHS 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 SSHHS family are currently married/in planning union that have an unmet need for contraception 14 Antenatal care (at Percent of women SSHHS 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 SSHHS 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

27 16 Neonatal tetanus Percentage of newborns SSHHS protection protected against tetanus 17 Intermittent Proportion of women who SSHHS preventive received intermittent treatment preventive treatment for malaria during their last pregnancy 18 Skilled attendant Percentage of live births SSHHS at delivery attended by skilled health personnel (doctor, nurse, midwife or auxiliary midwife) 19 C-section rate Percentage of live births SSHHS delivered by Caesarean section 20 Early initiation of Percentage of newborns SSHHS breastfeeding put to the breast within one hour of birth 21 Postnatal care for Percentage of mothers SSHHS mothers who received postnatal care visit within two days of childbirth 22 Postnatal care for Percentage of babies born SSHHS babies outside a facility who who were born at received a postnatal care home visit within two days of birth. WATER AND SANITATION 23 Use of improved Percentage of the SSHHS drinking population using improved water sources drinking water sources 24 Use of improved Percentage of the SSHHS sanitation population using improved facilities sanitation facilities

28 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.

30 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.

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.

31 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.

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.