While browsing through CNN or the NYTimes recently, you might've heard that there's tension brewing on the border between South Sudan and Sudan. As you probably already know, if conflict does eventually break out, it unfortunately won't be anything new for folks in this region. Ever since Sudan gained independence from Britain in the '50s, they've enjoyed only 10 years of tenuous peace from civil war. That's worth repeating. In the sixty years since gaining sovereignty, there has only been around one decade (between the 70s and 80s) not plagued by regional strife. Recently, there seems to have been progress, though. In 2005, the Second Sudanese civil war ended with the signing of the Comprehensive Peace Agreement -- and in 2011, citizens of Southern Sudan overwhelmingly indicated a desire to form their own nation in a historic referendum.
Recovering from any kind of conflict is tough for any region -- but such prolonged exposure to unrest has had a devastating effect on the development of basic infrastructure here. Over time, this has impacted the one resource that no country can afford to sacrifice: health.
Don't believe me? There's a lot of evidence connecting conflict to deterioration of health systems, and consequently, of health outcomes (thank you, Prof. Stephen Smith!). But, let's make this concrete. In 2007, USAID conducted a health system assessment of Southern Sudan. Here's what they found:
In nearly every indicator, South Sudan was under-performing in comparison to peer nations in Sub-Saharan Africa, and even their neighbors to the north in Sudan. Their maternal mortality rate ranks among the highest in the world. Quick glances at their immunization coverage and births by skilled attendant (both astonishingly low) indicate that access to even the most basic health services is limited. I'm no expert, but this doesn't sound great.
Ok, awesome. Just what you needed to hear. More depressing statistics about African healthcare. Hip, hip, hooray. I get it. But, before we become too overwhelmed, we gotta realize that these numbers -- while a bit frightening -- point to something important: an opportunity for growth. They indicate a real problem that, given the proper tools and resources, can actually be addressed. How do we know this? Other nations recovering from long histories of conflict (Rwanda, Liberia, etc.) have proven that it is possible to make progress in establishing a functional health system.
South Sudanese officials seem to have recognized this, as well. In a National Health Plan released in 2007, they unveiled a lofty vision declaring that basic primary health and emergency services should be provided free-of-charge to all South Sudanese citizens -- and they reiterate this commitment in their 2012 Health Sector Development Plan. Before you get all skeptical on me, they (at least symbolically) put their money where their mouth was: in 2006, they budgeted about $13 per capita for health -- more than other post-conflict nations with similar GDP per capita.
While the Government of South Sudan (GoSS) may be throwing out progressive rhetoric, the real question (as always) comes down to one of implementation. Out of the many challenges facing the South Sudanese, they've identified two major ones: recruitment of adequate physical and human resources. Health infrastructure is poor -- only 26% of health facilities across the nation have been identified as in "good" quality, while 51% are in need of major renovation or replacement. And, even if you solve the problem of infrastructure, only 10% of people in civil service posts operating these facilities are qualified health workers. There's roughly 1.5 physicians and 2 nurses available to serve every 100,000 citizens. Wow. If any nation wants to take a stab at solving the issue of resources, though, it all comes down to financing -- so let's focus on it for a moment.
Even in Sub-Saharan Africa, paying for the health of a nation is not cheap. It's a massive weight to carry even in normal fiscal conditions -- but it's an even heavier burden now, when South Sudan is in full-on austerity mode. I'm talking like Greece-status austerity mode. Why? Well, GoSS has two main sources of revenue for public expenditure: $$$ from oil, and cash from international donors (Development Assistance for Health).
First, let's talk petro. In a nutshell, oil rules across Sudan -- most fields are in the South, and most refineries are in the North. Previously, the North had agreed to transfer 48% of all refined oil revenues to the South -- which comprised an astonishing 98% of incoming cash for the GoSS. Essentially, oil was the only way to sustain functioning government. Well, in the midst of tension on the border, South Sudan shut off the pipeline funneling oil to the north earlier this year -- a hardball move that demonstrated independence from the North.... but also jeopardized the financial stability of both nations. Negotiations are still underway between the two, and it looks like both nations have to come to some cost-sharing agreement quickly to avert this dangerous game of chicken, but who knows? So, for the time being, cross off oil as a source of revenue for health systems strengthening.
Now, we're left with money from other countries. An important source is the Multi-Donor Trust Fund (MDTF-SS). Essentially, the MDTFs grew out of a joint effort between the UN and World Bank to collect ~$500 million from 14 donor nations to fund pro-poor and pro-peace development efforts across both Northern and Southern Sudan. Below, lists a breakdown of key sectors the MDTF was earmarked for:
Health accounts for a pretty substantial portion of MDTF funds -- second only to infrastructure. So far, the donor allocation has helped fund pharma supplies, GoSS vehicles for improved delivery of health services, over a million bednets, and rehab of buildings at Juba Hospital. Cool, right? Well, the only problem is that the MDTF has essentially run out -- and, after speaking to Aduei yesterday, it seems like the World Bank and other international donors may be hesitant to give more given the slipshod handling of foreign aid and the country's general finances over recent years. The 2012 report cites that international donor funding will still exist in coming years, namely from the World Bank and USAID -- but does not cite an estimated figure. Thus, it's tough to predict what impact DAH will have in coming years. To make matters even worse, it doesn't help that -- at least in 2007 -- the country didn't have the ability to effectively collect tax revenue, either.
Take-home message: Financing is a huge question for the future of public-sponsored health care in the area. To even come close to accomplishing the goals of the Health Sector Development Plan, GoSS would have to increase investment in health to 10% of all public expenditures. Yet, over the past 5 years, the health budget has shrunk from 7.9% in 2006 to 4.2% in 2011. Development assistance for health has simultaneously fallen from $214 million in 2009 to $169 million in 2010. Where's the money going to come from? That's literally the "million dollar" question....
With this in mind, it should come as no surprise that over 65% of formal medical services are provided by a robust NGO sector in South Sudan. Though international and domestic civil society have picked up the slack with regards to health, a lack of coordination among these groups and the GoSS has been cited as a major obstruction to progress and efficient use of resources. In coming days, hope to gain more insight into the benefits and pitfalls of the "vertical" provision of care by NGOs in the area -- will hopefully post some thoughts soon!
Major Sources:
Southern Sudan Health System Assessment. (2007). United States Agency for International Development (USAID).
Health Sector Development Plan 2012-2016. (January 2012). Ministry of Health, Republic of South Sudan. Archived at Ministry of Information in Juba.
Recovering from any kind of conflict is tough for any region -- but such prolonged exposure to unrest has had a devastating effect on the development of basic infrastructure here. Over time, this has impacted the one resource that no country can afford to sacrifice: health.
Don't believe me? There's a lot of evidence connecting conflict to deterioration of health systems, and consequently, of health outcomes (thank you, Prof. Stephen Smith!). But, let's make this concrete. In 2007, USAID conducted a health system assessment of Southern Sudan. Here's what they found:
Ok, awesome. Just what you needed to hear. More depressing statistics about African healthcare. Hip, hip, hooray. I get it. But, before we become too overwhelmed, we gotta realize that these numbers -- while a bit frightening -- point to something important: an opportunity for growth. They indicate a real problem that, given the proper tools and resources, can actually be addressed. How do we know this? Other nations recovering from long histories of conflict (Rwanda, Liberia, etc.) have proven that it is possible to make progress in establishing a functional health system.
South Sudanese officials seem to have recognized this, as well. In a National Health Plan released in 2007, they unveiled a lofty vision declaring that basic primary health and emergency services should be provided free-of-charge to all South Sudanese citizens -- and they reiterate this commitment in their 2012 Health Sector Development Plan. Before you get all skeptical on me, they (at least symbolically) put their money where their mouth was: in 2006, they budgeted about $13 per capita for health -- more than other post-conflict nations with similar GDP per capita.
While the Government of South Sudan (GoSS) may be throwing out progressive rhetoric, the real question (as always) comes down to one of implementation. Out of the many challenges facing the South Sudanese, they've identified two major ones: recruitment of adequate physical and human resources. Health infrastructure is poor -- only 26% of health facilities across the nation have been identified as in "good" quality, while 51% are in need of major renovation or replacement. And, even if you solve the problem of infrastructure, only 10% of people in civil service posts operating these facilities are qualified health workers. There's roughly 1.5 physicians and 2 nurses available to serve every 100,000 citizens. Wow. If any nation wants to take a stab at solving the issue of resources, though, it all comes down to financing -- so let's focus on it for a moment.
Even in Sub-Saharan Africa, paying for the health of a nation is not cheap. It's a massive weight to carry even in normal fiscal conditions -- but it's an even heavier burden now, when South Sudan is in full-on austerity mode. I'm talking like Greece-status austerity mode. Why? Well, GoSS has two main sources of revenue for public expenditure: $$$ from oil, and cash from international donors (Development Assistance for Health).
First, let's talk petro. In a nutshell, oil rules across Sudan -- most fields are in the South, and most refineries are in the North. Previously, the North had agreed to transfer 48% of all refined oil revenues to the South -- which comprised an astonishing 98% of incoming cash for the GoSS. Essentially, oil was the only way to sustain functioning government. Well, in the midst of tension on the border, South Sudan shut off the pipeline funneling oil to the north earlier this year -- a hardball move that demonstrated independence from the North.... but also jeopardized the financial stability of both nations. Negotiations are still underway between the two, and it looks like both nations have to come to some cost-sharing agreement quickly to avert this dangerous game of chicken, but who knows? So, for the time being, cross off oil as a source of revenue for health systems strengthening.
Now, we're left with money from other countries. An important source is the Multi-Donor Trust Fund (MDTF-SS). Essentially, the MDTFs grew out of a joint effort between the UN and World Bank to collect ~$500 million from 14 donor nations to fund pro-poor and pro-peace development efforts across both Northern and Southern Sudan. Below, lists a breakdown of key sectors the MDTF was earmarked for:
Health accounts for a pretty substantial portion of MDTF funds -- second only to infrastructure. So far, the donor allocation has helped fund pharma supplies, GoSS vehicles for improved delivery of health services, over a million bednets, and rehab of buildings at Juba Hospital. Cool, right? Well, the only problem is that the MDTF has essentially run out -- and, after speaking to Aduei yesterday, it seems like the World Bank and other international donors may be hesitant to give more given the slipshod handling of foreign aid and the country's general finances over recent years. The 2012 report cites that international donor funding will still exist in coming years, namely from the World Bank and USAID -- but does not cite an estimated figure. Thus, it's tough to predict what impact DAH will have in coming years. To make matters even worse, it doesn't help that -- at least in 2007 -- the country didn't have the ability to effectively collect tax revenue, either.
Take-home message: Financing is a huge question for the future of public-sponsored health care in the area. To even come close to accomplishing the goals of the Health Sector Development Plan, GoSS would have to increase investment in health to 10% of all public expenditures. Yet, over the past 5 years, the health budget has shrunk from 7.9% in 2006 to 4.2% in 2011. Development assistance for health has simultaneously fallen from $214 million in 2009 to $169 million in 2010. Where's the money going to come from? That's literally the "million dollar" question....
With this in mind, it should come as no surprise that over 65% of formal medical services are provided by a robust NGO sector in South Sudan. Though international and domestic civil society have picked up the slack with regards to health, a lack of coordination among these groups and the GoSS has been cited as a major obstruction to progress and efficient use of resources. In coming days, hope to gain more insight into the benefits and pitfalls of the "vertical" provision of care by NGOs in the area -- will hopefully post some thoughts soon!
Major Sources:
Southern Sudan Health System Assessment. (2007). United States Agency for International Development (USAID).
Health Sector Development Plan 2012-2016. (January 2012). Ministry of Health, Republic of South Sudan. Archived at Ministry of Information in Juba.
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