South Sudan has some of the worst rates of maternal and child mortality in the world. One in ten babies in South Sudan will not see their fifth birthday; and maternal mortality is 2,000 per 100,000. Today, for every woman liable to die in childbirth in Europe, 250 young mothers will die in South Sudan.
Such deaths can be avoided through relatively modest investments – so long as those investments are made in the right way. In October last year, I travelled to South Sudan to carry out a study, commissioned by World Vision, to identify key features of the problem, and the practical means by which they might be addressed. While the moral case for reducing maternal and child deaths hardly needs to be made, it is worth noting that such reductions actively support better levels of economic growth – something South Sudan desperately needs right now.
South Sudan is still a country in conflict. It requires both humanitarian relief and investment in dealing with the aftermath and security responses to the violence. But at the same time, the majority of the population are also struggling with the fundamental threats to life and livelihood of poverty and disease. To ignore this is to ignore the potential for popular dissatisfaction to re-create conditions for violence, conflict and crime. Better health is a fundamental part of human security.
So what is to be done? A good starting point would be to understand what drives maternal and newborn death rates in South Sudan. The study that I conducted in collaboration with World Vision (UK, Australia, Juba and Warrap State) arrived at some core challenges which, if properly addressed, could contribute to saving lives and improving the living conditions of communities across a country in which the dividends of peace have yet to materialise.
The first challenge is to stop blaming families and communities themselves. A common view among policy-makers and practitioners is that mothers and children die – in substantial part – because they prefer traditional, and dangerous, methods of obstetric, intrapartum and neonatal care to ‘modern’ treatment provided by the healthcare system.
Talking to women in villages, children at school, and community leaders, a very different picture emerges. The girls at Liet Nong primary school, in Warrap State to the north of the country, were remarkably well-informed, happily vocal, and clear about what they wanted. They wanted clinics and medicines and care, but they wanted them nearer to where they live. Certainly, they said, we can use medicines from the forest, but we only do that now because we can’t get help from a health centre that we can actually reach. A group of elderly women in Magai Village, some of them traditional birth attendants (TBAs), told stories of traumatic births and local rituals. But when it came to asking where they saw a solution, they asked where were the laboratories, where were the doctors, and where were the ‘microscopes’. These were not frivolous comments – rather they were a clear-eyed recognition of what was required and valued, but which was so far inaccessible.
In truth, many families do not, currently, use the local health facility (the Primary Health Care Unit – PHCU) in South Sudan – perhaps 20-40% of pregnancies, at the most. But this is not surprising, and should not be interpreted as a lack of demand. While PHCUs remain the poor cousin of national health spending (they receive around 6% of the total annual health budget), this critical part of the health infrastructure – close enough to people’s homes to make clinic attendance possible – will continue to under-perform. For now, more investment flows to the higher level Primary Health Care Centres (PHCC). Indeed the national health strategy is predicated on pregnant women being referred to PHCCs. The average distance from village to PHCC in South Sudan is 120km. With rained-out roads, limited transport options, and cash-poor families, travel to the nearest PHCC can take days. Post-partum haemorrhage – one of the principal causes of maternal mortality – can kill in less than two hours.
While the most accessible part of the healthcare system remains the least invested, rational villagers will continue to doubt their value, and continue to express this doubt by reverting to traditional practices over which they have, at least, some control. ‘Tradition’ and ‘culture’ are too often pointed to as the explanation for poor community health. The reality, often, is that tradition and culture are all that remain to people whose lives are circumscribed by poverty, exclusion, and a lack of access to the services they know they need and clearly want.
The remaining challenges flow more or less logically from this first observation. Although national health policies in South Sudan, including a constitutional commitment to free care, are fantastic on paper, most emphasis goes to investment in urban, secondary and tertiary care. The major focus right now, should be the Primary Health Care Unit, and in innovative ways to staff the PHCUs with qualified, credible health care workers. PHCUs should be able to provide time-critical obstetric and neonatal care in clean, safe and dignified conditions. This will address the real killers in childbirth: haemorrhage, infection, asphyxia. Preventive and health awareness services (for control of diseases like malaria, and to improve prevalent sexual health, for example) could be provided at the village by a corps of community health workers (possibly including rehabilitated TBAs) coordinated, trained and supervised from the PHCU.
This – as ever – means more money. Donors have done well in harmonising their aid investments. But they have been, up to now, too focused on the central level, and on various forms of administrative capacity-building, with much less emphasis on aid channelled to, and guided by, epidemiological evidence of priority problems and corresponding evidence of positive results on the ground. Reduction in maternal and neonatal deaths must be at the top of the list of the new ‘Health Pooled Fund’s’ goals, and in the first row of measures by which effectiveness of aid to South Sudan is assessed. The Republic of South Sudan should be asked to match international investments in health, by shifting some of its national budget – notwithstanding current austerity as a result of the suspension of oil exports – from security and veteran’s affairs to basic social welfare.
The issue of the current austerity budget, cutting national expenditure by more than half, requires some collective strategising among donors, Government of South Sudan (GOSS) and existing partners in the delivery of services including health. It is to be hoped that the suspension of oil production and its revenue stream will not last long. But whatever the outcome, this (partly endogenous) economic shock points to three key elements in financing for health in South Sudan. First, donors need to recognise that this is not the time to draw down or operationalise exit strategies (consistent with their own domestic austerity drives). New donor contributions should not be driven by day-to-day humanitarian concerns alone, but should be organised as investment in longer-term change in the structural conditions for well-being and growth across the country – education, health, infrastructure. Second, international NGOs may need to re-assess their current activities in South Sudan. They may ask donors for more resources, and GOSS for better access, but the quid pro quo is that they need to start generating better evidence that their programmes are building lasting benefit beyond the short-term. Third, GOSS needs to start thinking seriously about a long-run economic strategy to diversify away from its overweening dependence on oil. Diversification of this kind can attract the latest in entrepreneurial fads. A more grounded strategy – literally – is one that re-energises investment in the agricultural sector.
For the present, the key is not to advocate for health spending as an alternative to other fiscal requirements, in particular security. Rather, it is to argue that spending on fundamental public ‘goods’ (health, education, training, capacity, opportunity) is an investment in security – and a more sustainable and, ultimately less costly one than the conventional flow of funds into armed forces, military hardware, police services and penal systems. Whatever the international inputs and national strategy determined in the coming months to support the peace, providing humanitarian care to refugees on one hand, and preparing the way for longer-term economic recovery and diversification on the other, a focus on the problem of maternal and child health – transparently negotiated between donors and government, and consistent with prevailing humanitarian norms and development goals – should be central to the vision of, and plan for security in South Sudan’s future.
Dr. Sebastian Taylor is a Senior Consultant at the IDL Group
In a timely call for action (given their co-founder Jim Kim’s recent selection as World Bank President) Partners in Health take a stand against user fees for health care describing them as an ‘unjust rationing system’. They say that despite clear successes when donors support countries to abolish fees, ‘too few partners are stepping up to the plate’.
In their call to action at the end of last week, Partners in Health restate the growing consensus that user fees are inequitable and sharply limit access to health care for the poor; they act as a barrier to achieving the MDGs; they do not raise substantial revenue for the health sector and make public health interventions less effective. They also state that removing user fees increases health care utilization and improves health outcomes for the poor. They draw on some key successes:
Sierra Leone – in the first year (2010) of fee removal, with good donor support, medical care for children under five increased by 214% (2 million additional visits) and the number of maternal complications treated in health units increased by 150%, with a reduced fatality rate in these cases of 61%
Uganda – when fees were removed in 2001, against World Bank advice, use of outpatient facilities increased by nearly 90% nation wide, with strong indication that the poor benefited the most.
Haiti – Following elimination of user fees in six rural primary health care facilities from 2006 to 2009, Médecins du Monde observed a 662% increase in attendance for the 5-14 year old population and a 302% increase in total attendance. Overall preventative care doubled, as did facility-based births.
Without naming names, Partners in Health say it’s time “bilateral and multilateral donors answer this call to action [againt user fees] by acknowledging: (1) the negative impacts of user fees on poor people’s access to health care, and (2) their commitment to working with countries to eliminate these fees without requiring specific pre-conditions [emphasis added].”
Oxfam agrees and has been even more explicit that ensuring the World Bank in particular works with countries to make health care free should be one of Jim Kim’s top three priorities once in office. We have certainly seen some progress on this issue from the Bank in recent years with support being provided for fee removal in Sierra Leone for example. But it’s clear the Bank has a long way to go before they can say they have responded fully to the call for action from Partners in Health.