Medicaid Expansion in NC: The Time is Now

Today’s a pretty big day in the state of North Carolina.  Why?  Well, today, Republicans in the NC General Assembly are introducing Senate Bill 4, a proposal to block the expansion of Medicaid and effectively deny access to affordable health care to over half a million residents of the state.  

I know what you’re thinking – “wait, haven’t we had this conversation already?”  Indeed, we have.  When the Affordable Care Act (ACA) was signed in March 2010, it was the result of a consensus that it was finally time to address the issue of access to essential health care in this country – especially for those most vulnerable to the rising costs of medicine, the poor.  The ACA extended coverage by two major mechanisms:  a mandate for individuals in the middle-class and above to purchase insurance, and the expansion of Medicaid – a joint state/federal public insurance program targeted primarily for low-income children and their parents – to cover all individuals below 138% of the poverty line.  

All was fine until the Supreme Court decision last summer.  Most of us heard about the survival of the individual mandate – the cornerstone of the bill that generated the most heated opposition.  But subtly lurking in the pages of that historic ruling was another major decision: the federal expansion of Medicaid was deemed coercive and unconstitutional.  Though the federal government was willing to finance the vast majority of the costs of expansion for a decade, states now had the ability to “opt-in” to the program.  

So, here we are – February 2013.  Nineteen states are definitely participating (including 4 with Republican governors), ten are definitely not.  North Carolina, a state under control by both a Republican legislature and governor, has remained one of the undecideds (until now), and it’s easy to see why.  Medicaid expansion was projected to extend coverage to upto 650,000 low-income citizens, while actually generating $65 million in returns to the state.  Yes, you read that right – the fact that the federal government is subsidizing over 90% of the expansion will allow the state to provide health insurance to its most vulnerable AND make money at the same time.  As a plus, economic models have projected the move to support 23,000 jobs.

I may just be a random college student, but even I can recognize a good deal when I see one. So why would Republicans feel so passionately about denying Medicaid expansion? Well, conservative policymakers have suggested their fears stem from the long-term prospects of the expansion which, if the federal government eventually decreased its cost-share, could pose a major burden on state finances.  

This is a valid concern, but its one that can be addressed.  Recently, Arizona Governor Jan Brewer – a staunch conservative – announced her intentions to expand Medicaid across the state and planned to incorporate a “circuit-breaker” provision that would automatically shrink the size of Medicaid if the federal cost-sharing rate were to decrease to the point where it threatened the state budget.  

That’s an example of real leadership.  What we have in North Carolina is a failure to lead.  This “debate” in the legislature today is not about what’s best for the people of this state – it’s an ideological tantrum being thrown over “Obamacare” and the existence of the welfare state waged by a few radical conservatives oblivious (or worse, indifferent) to the fact that hundreds of thousands of their citizens will suffer as collateral damage.  

As Senate Bill 4 is likely to pass the General Assembly, the hope for extending access to affordable health care in this state rests on the shoulders of one man: Gov. Pat McCrory.  Though he’s been shy to comment on Medicaid expansion (only stating that he’s been “studying” the impact of various options), he’s been boxed in by Republican action in the House and Senate.  

Now, it’s gametime.  Great moments call for great leaders willing to put their reputation on the line to stand up for what is right, and for what is just.  Rarely is a decision of this magnitude that affects so many so directly made at the state level.  As students and citizens, it is now up to us to convince Governor McCrory to make history and demonstrate the same courage shown by his Republican counterparts in Arizona, Nevada, New Mexico, and North Dakota.  

If you’re a North Carolinian at heart, pick up a phone and call Governor McCrory at (919)-733-5811 and let him know you’re counting on him to deliver on his dream of a better North Carolina for us all – and that he could start by opposing Senate Bill 4.  

Today is a BFD

Sorry for the 3 weeks delay in posting.  Lots has happened -- India's been a great experience so far, and Duke took action on an investment resolution proposed by students on "conflict-minerals" -- can trace the origins of my thoughts on that from a blog post on this site about a year ago! 

But, there's something pretty large about to happen in a few hours.  The Supreme Court is going to announce ruling on the constitutionality of the Affordable Care Act -- and no one knows what's going to happen.  Everyone's in suspense.  You've probably heard the buzz from everyone and everywhere -- this is unprecedented, this is historic, this is crazy.  It is. 

Today is one of those days that will create its own little panel in US history books 40 years from now, that bored 7th graders will reluctantly flip through, stopping to stare at pictures of that pearly white marble building that will decide the future of the individual mandate (and a lot more) today. 

I have no new thoughts to contribute that haven't been written ad nauseum already.  This is a subjective decision.  Whether or not you like broccoli, you can understand the rationale of both sides on this one -- and you probably have nightmares about the word "inactivity." 

Here's one student hoping for the best, praying that a pretty moderate piece of legislation that serves as our only real progress in reforming healthcare since the advent of Medicare can survive this challenge.  But, if not, it's not as if Anthony Kennedy destroyed the nation all of a sudden -- it's further confirmation that it's literally all on our generation to step up and find a way to fix US healthcare 20 years from now. 

Here we go.  Buckle up, folks.  This is going to be interesting. 

Final Thoughts from Juba: Ayn Rand and The Chemistry of Hope

I started this post sitting in Juba International Airport, the same place where two weeks ago, I showed up as some random Indian kid trying innocently (but unsuccessfully) to blend in this foreign land (and also trying to collect the object formerly known as my suitcase).  Now, after being whisked around the world over the past few days to the familiar house of my relatives in India, I'm still digesting all the life -- the conversations, trips, experiences, everything -- I've felt in the past fortnight.  But, as weird as it may sound, the only thought that remains constant during my stream-of-conscious reflections is not an image or snippet of a conversation I've experienced directly, but rather a quote from a book my friend Sarah recommended that I picked up during this trip -- none other than Atlas Shrugged.  Here's the quote:

Nobody can tell what the course of a country's future may be.  It is not a matter of calculable trends, but a chaos subject to the rule of the moment, in which anything is possible.

Not the most remarkable two sentences ever written, but a passage that stuck with me nonetheless.  As I tried to wrap my head around Ayn Rand's thought during this past week, though, I found a shred of myself defiantly resisting to accept it.  I mean, most of it made sense -- that yes, no one can define the trajectory of a nation, and that yes, anything is possible.  But, is the chaos she speaks of really that, well, chaotic?

As it turns out, we've spent centuries trying to discover order in a world composed of a series of random (and seemingly meaningless) interactions of complex entities with each other.  But, instead of thinking about the macro-level factors that define something like a country, we've focused our efforts on understanding the behavior of the most micro-level objects that define our lives.  Sound familiar?  It should.  We've simply called this process chemistry.  The entire discipline is centered upon a fundamental idea:  that with enough time, we can actually observe the "chaos" of billions of atoms colliding with each other, come to understand the inherent order subtly guiding the "chaos" we see, and then harness the "chaos" to produce a meaningful result.  

It's not always simple.  When combining a bunch of volatile reactants in a pot, no chemist knows precisely every interaction at any given point (just ask any Orgo kid about their percent error in lab) -- like Rand said, anything is possible.  Things could be fine and dandy.  Or, as my high school chemistry teacher Mr. Bibeau liked to show us, crazy shit could happen and things could blow up.  But, all of this comes with a crucial caveat the Rand seems to forget:  not every outcome is likely.  

After throwing a bunch of random reactants in a pot and staring at it for a while, you notice something interesting:  the system reaches equilibrium, meaning a certain reaction comes to dominate all the other possible interactions that could have taken place, and as a result, a certain outcome is produced that is ultimately dictated by given conditions.   That's the key part:  this newfound equilibrium is not just dependent on what you throw in the pot, but the environment of the pot itself -- like the temperature, or the presence of a catalyst.  If these things change, then we have ourselves a ballgame -- we might shift the equilibrium, and produce more/less of the product......or, we might even create a situation where a completely different reaction starts to dominate, and produces a brand-new outcome from the same set of reactants.

If this concept holds true for the building blocks of life, then why couldn't it hold for the institutions that guide it?  Just think about the larger-level, objective factors that guide the path of a country -- its history, its economic stability, its resources -- as the "reactants" of some equation.  Think about the eventual outcomes -- peace, war, prosperity, collapse -- as the "product."  Ayn Rand tells us there's a million different ways all those reactants could randomly interact, so there's no way to predict the product.  But, aren't we forgetting something?  What about those external conditions - the temperature, the catalysts - that define our equilibrium?  Ah, the analog of these, my friends -- the external environment, the "temperature" of a population, the presence of "catalysts" for change -- is simply what Rand refers to as "the rule of the moment." 

We've seen it happen before.  This will undoubtedly come as a surprise to all of you, but I was a pretty nerdy kid in high school -- channeling my affection towards my US history textbook in order to cope with my lack of luck with the ladies (jk....sorta), spending time in 5th period daydreaming of what it must've felt like to live in Philadelphia, the hub of the world's newest capital less than one year after the signing of the Declaration of Independence.  This must've been an awesome and ridiculously scary moment -- no one could have really known how this "chemical reaction" called a revolution would really work out.  The challenges were serious, the probability of success dim.  But, for those who valued thought, who valued action, who valued freedom -- no matter how rich or poor -- they knew this was their opportunity to define the rule of the moment.  You know the rest.  With a burning sense of urgency and hope, Americans joined together to raise the temperature for freedom and catalyze a revolution in the name of justice and equality for all.

That emotion used to be abstract, confined to the drab pages of a textbook.  Now, after just a taste of life in Juba, I think I understand.  You see, you can't let the dirt roads fool you -- they're just modern-day cobblestones, defining the humble character of this historic city.  You can't let the collections of lawn-chairs scattered near roadside stands mislead you -- they're the modern-day taverns and coffee shops, where the seeds of passion, idealism, and dissent are planted and cultivated day-by-day.  Don't let your eyes trick you -- Juba is the new Philadelphia.  It's the world's newest beacon of hope, minted as a sovereign capital just 11 months ago.   And, folks here know it, too.  Even though the days may pass by slowly on this tropical paradise on the Nile, there is a palpable undercurrent of energy, of optimism, of hope.

 Indeed, the challenges are enormous -- and at times, the emotion and optimism may be naive.  But, there are those who have their hope grounded in the clarity of reality -- and I can prove it to you, because I've seen it manifest itself in all the people we've met over the past two weeks.

You can see it on the face of Aduei Riak, a brilliant economic and legal scholar who trained in the States after escaping insecurity years ago -- and then, when faced with the opportunity to choose any job she wanted -- returned home to commit herself to public service as one of the only women officials in the Ministry of Defense.  She not only dreams of a better South Sudan, but has the savvy to realize her vision.

You can hear it in the hearty laughs of Chol Ajak, and his friends William and Malek, all members of the Sudanese diaspora who gave up the comforts of their lives (and families) in North America to leverage their talents in business in service of a bigger vision -- to create a South Sudan where anyone can follow the entrepreneurial "American" dream.

You can feel in the words of Mabior Garang and Jok Madut Jok -- one the son of the country's late national hero and director of a trendsetting international school, the other a prominent scholar working to unify the nation as a minister of culture -- as they speak with radical fervor of their shared vision of a free and equitable South Sudan.  Their means to this end may be different -- one dedicating his efforts to education, the other to identity -- but the end is all the same.

It's a hope and resolve that, in many cases, draws on larger-than-life convictions.  You'll realize it with a simple conversation with Dennis, a lifelong Sudanese resident and security officer at our compound, or Abei, a 3rd-year medical student serving as a clinical officer at a humanitarian relief camp.  In their free time, you'll find them reciting Catholic hymns or flipping through tattered pages of the Bible, gaining the courage confront life's challenges -- such as the discontinuation of nearly every medical school in the country -- with everlasting faith.

It's also a hope and resolve that, in many cases, has been long awaited.  You can tell from one glance into the eyes of hundreds of South Sudanese returnees from Khartoum and Kosti, who have somehow found a way sustain a bubbling euphoria amidst their sudden deportation into an unfamiliar land, relegated to conditions of transient squalor.

You can read hope in the actions of the foreign supporting cast, recognizing their role in empowering these individuals to help take ownership of their new land.  They are strong believers in incremental change, knowing that the smallest of their actions will collectively sum to support the largest of transformations in a country that desperately needs it.  You see in the ambitions of grad student Sheldon Wordwell, complementing his research in development practice by providing any assistance he can to game-changers on the ground -- whether that's coordinating the delivery of a tractor-trailer full of medical supplies to a rural clinic, or partnering with a local school to introduce an exchange program to break down barriers between "average" and "elite" in this new society.  You see it in the determination of Sean Casey, Adam Levine, Pranav Shetty, and others of the International Medical Corps -- using their skills in emergency medicine to literally "stop the bleeding" of this country, paving the way for others to come in and implement long-term solutions.  You see in the glint of eyes of international journalists - from Reuters to Al-Jazeera -- searching for a way to shine light o the crises of today, rooting desperately for the home team, and embracing the burden of knowledge that their perspective may dictate the response from the international community.

Sheldon and Mabior Garang

This is definitely not a random sample.  And, it doesn't have to be.   Many folks in Juba may be ambivalent about the trajectory of their country -- and for good reason, as their present suffering is not much different than before.  And, while there are surely more individuals out there eager to shape history, it doesn't even matter if there aren't; my experience meeting these folks has demonstrated that hope is not an empty abstraction we attach to difficult situations to fill some type of emotional void -- rather, hope is a sensation that is the direct product of the recognition of the foundations of progress.

This type of hope is not fleeting.  It does not depart at the first, second, or hundredth sign of adversity.  It's a sensation that occurs when everyone comes to the same realization -- that we actually have all the pieces to make this nation great.  It may be subtle, but its contagious -- and therein lies its value.  Hope has the potential to transform the environment in which the reaction of this nation, or any other, is taking place.  It may start with many or few, but all it needs is a critical mass -- because once that happens, the question of whether a nation will succeed shifts from one of if to one of when.  

No one knows what this country will look like tomorrow, next year, or next century.  The road to prosperity is long, perhaps extending for generations.  But, at least right now, these people are determined to control the chaos of every moment -- on lowering the activation energy for the right reaction to proceed.  They know the odds are often grim, but they're not in the business of abiding by probabilities -- they alter them.  They are unafraid to raise the temperature for progress, calling for the rapid installation of political freedoms.  They are the catalyzers of change, entering public service and setting lofty ambitions just like our Founding Fathers did 200-some years ago.

Time to grab your lab goggles, kids.  There's a revolutionary reaction taking place down in Juba. 

Will this get ugly?

Today marks the last day of my stay in Juba with my friend Stefani.  We've had an amazing day so far (and an amazing trip) -- I'm still processing and digesting, and am working on a summary post that will reflect on all the super-awesome people and experiences we've had! 

For now, though, I wanted to add some more insight into a more technical, solemn subject: the role of oil in the stability of the South Sudanese state.  In the context of that blog, I focused mainly on the long-term obstacles to development a robust health system over the next few years -- including the lack of reliable funding streams from the public sector.  Concept was pretty simple: when you lose oil money, your capacity to provide government-sponsored healthcare diminishes pretty quickly.  This seemed bad, but not devastating -- even without long-term development in the health sector (and others), the country wouldn't be that much different from the status quo, right?

This seemed to be the logic of the leaders of South Sudan -- that, even though pulling the plug on oil would definitely hurt, it's nothing that a country and a people that survived 50 years of conflict couldn't weather through.

It all sounds great!  .....Except for the tiny little fact that it seems mathematically impossible.  In the months after S. Sudan shut off the oil, it was reported that the World Bank notified key leaders that the country was hurtling toward the verge of economic collapse.  Models incorporating the decision to forgo the source of 98% of governmental revenues estimated them approaching total depletion of state fiscal reserves as early as this summer.

I had heard these rumors, and read some articles, but like many folks here, dismissed them to the back of my mind.  It was another problem that could, and would, be addressed sometime soon.  But for now, this country needed the emotional catharsis of finding some way to stick it to the North.  To show them who's boss.  To collectively flip them the bird.   Insert your favorite angry cliche here.

Then, I saw a copy of the leaked World Bank report from March 1st, and actually realized things could get pretty ugly.  The brief is quick to point out that the World Bank has "never seen a situation as dramatic as the one faced by South Sudan", and that collapse of GDP and depreciation of the S. Sudanese currency are rapidly approaching on the horizon. Later lays out a timeline for exhaustion of state reserves based on strength of austerity measures the S. Sudanese government decides to implement:

And, the WB lays out broad social implications of the oil decision, suggesting that the proportion of South Sudanese living in poverty is likely to rise from 51% in 2012 to 83% by 2013.  Enrollment rates in school are projected to drop from 50% in 2012 to 20% in 2013.  And finally, the under-5 child mortality rate is expected to double from 10% of live-births in 2012 to 20% in 2013.  These measures are similar to those of S. Sudan in 2004 -- essentially, the decision to shut-off oil could regress development in some areas to the point where it was before signing of the Comprehensive Peace Agreement in 2005. This report goes onto explain that the decision has alienated some members of the donor community, who are reluctant to fill-in-the-gaps in health, education, etc. for a country that isn't demonstrating the capacity or priority to care for its people. 

Ok, whew.  The situation is sobering.  However,  it's important to acknowledge the fact that I (and economists at the Bank) can talk about these statistics and numbers easily because I never had to live in this country during a time of instability or insecurity caused by tensions with the North.  I can't understand the resilience of this community, nor the ability to bear any burden in the name of their national sovereignty, because we're just observers on the side.   This may be a calculated decision made with knowledge of the hardships to come.  This may be a standoff that is soon to end given the recent talks in Addis with reps from Khartoum.

But either way, at least to me, the numbers don't add up. 


(Edit:  I literally just heard a reporter at the table next to me announce that, as of today, South Sudan is unofficially restarting oil in July.  I'm glad to know this post is much less relevant now.  Oye, South Sudan!)

Homecoming in Juba

Apparently, the new winner of American Idol (Phillip Phillips) was crowned a few nights ago.  I'm generally aloof pretty much everything around in life - including pop culture -- so I had no idea this happened. However, Stefani has been on-top of her stuff, and after becoming a fan of Phillip over time, she happened to start playing his music in our room.   

When his song started playing, I wasn't really listening -- I was expecting something random and poppy to come blaring out from her Mac speakers.  But, when I heard the opening lines of his winning song "Home", something clicked in my head:

Hold on, to me as we go
As we roll down this unfamiliar road
And although this wave is stringing us along
Just know you’re not alone
Cause I’m going to make this place your home

At any other moment, these glossy lyrics wouldn't have caught my attention in the slightest bit.  But, of course, this moment was different. 

Ever since South Sudan gained independence, life became tense for hundreds of thousands of Southerners living in the North.  Didn't matter if they had spent their entire livelihood in Khartoum or surrounding regions -- in a flash, they became foreigners in their own home.  This week, their story took another dramatic turn.  Over the past few days, more than 6,000 South Sudanese living in the North have been airlifted to a makeshift refugee camp outside Juba.    Most of them already spent the past year in settlement camps in cities of Kosti and Khartoum, treated as outcasts from a society that deemed their existence unwanted.

For some, this return marks a jubilant homecoming -- a time to finally return to their culture, their land, and their people after decades of instability.  For others, the move brings only more uncertainty and angst -- a detachment from a world where many have lived for nearly two decades or longer.  Yet, even though each of them may have a unique path that brought them to the dusty streets and sweltering heat of Juba, they all share one thing in common:  this place is now home.

Rows of tents were set up pretty quickly for returnees in Juba

Yesterday, I had the chance to spend a day at the returnee camp assisting the International Medical Corps in providing basic, primary care for those coming back.  Makeshift tents set up in days by the International Organization for Migration (IOM) and USAID served as a hospital, prepared to treat a wide array of incoming cases with a stock of essential medicines, bandages, and a few beds.  Three international physicians and a handful of local doctors were tasked with the challenge of managing health for the thousands of returnees, and had little capacity to treat serious illness -- yet, when you think about it, this physician-patient ratio was probably one of the best (if not the best) in the country.  I was impressed as the two docs I had a chance to really meet -- Adam and Pranav -- came together to supervise the clinic, creating a form of organized chaos that helped address the needs of a constant onslaught of patients.

My job throughout the day was simple: help register folks as they came into the clinic.  The only issue?  Virtually no patients spoke English.  I always knew there would be a day when the errant cries of my Arabic professors  ("Yaa Sanjee, stop sleeping through class!", "Yaa Sanjee, stop staring at the girl in the book!", "Yaa Sanjee, READ!") would come back to haunt me.  Yesterday was that day.

Thankfully, I spent most of my time working with Alice -- a wonderful local staff member who did the lion's share of translating patient information.  But, as the day progressed, I started to registering folks on my own -- and here's where it got fun.  I used my three semesters of Arabic knowledge to extract the patient's name and age....and then I was out.  We then proceeded to stare awkwardly at each other for about 15 seconds, until we acknowledged that no other verbal magic was going to happen.  From there on out, we entered one massive game of charades that become quite comical for everyone else (except for me) involved.  As we tried to figure out their chief medical complaint, I got the hang of (an admittedly pretty crappy) system:

Repeated thumping of chest and rubbing of throat =  cough, a signal to look for respiratory tract infections
Putting my hand on their forehead and yelling "SAHANA!" (hot!!)  =  fever
Pointing to head and making flash-like motions with both hands = headache
Pointing to stomach area and making *whoosh* noises = diarrhea

View of the clinic from the registration desk

Chilling with the registration log!

I'm not even sure if this exercise was useful for the doctors, who would interview patients more thoroughly once they saw them and use their diagnostic prowess to figure out what the deal was.  Eventually, we saw all kinds of cases -- from clinical malaria to moderate trauma to skin diseases/infections to even a suspected case of TB.  But, in any case, it was quite the experience.  No matter the barriers in communication, I relished the chance to get a glimpse into the lives of over 165 people I never would have met before, even if only for a minute or two.

There were all kinds of patients, from 2 month old babies to elderly women who couldn't even recall how old they were.  But, the interactions that struck the deepest were the ones with people my own age.  It was a surreal experience, watching a 20-25 year man or woman enter the tent and take a seat next to me, wearing a hardened expression that cracked at times to reveal a sense of resilient hope.  Many times, they carried 1-2 year old children battling fatigue and cough, seeming to know that finding a way to "cure" an extension of themselves in this camp represented the first of many challenges to overcome in this foreign land called home.

Whenever we see footage of refugee camps on CNN (and in the 30 seconds before we forget about them), we automatically associate them with a sense of despair and depression.  It's a reflexive connotation that seems pretty logical -- living in temporary quarters that lack access to food, sanitation, and personal space is definitely not ideal.  But, at least for now, that's not the vibe permeating the camp in Juba.  There's an undercurrent of energy, of vitality -- there's simply a buzz.  Maybe it's just the novelty of the whole experience; the camp has only been open for a week, after all.  Or maybe, just maybe, it's the fact that no matter how transient or fluid their life seems right now, there's one constant hope guiding their outlook:  they can finally make this place their home.  

A flag stands proudly outside the entrance to the campsite

Healthcare Financing in South Sudan: Drill, Baby, Drill

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.  

 

"This is from America?"

Whew, today was crazy.  Began travels in the early morning Friday, leaving Southwestern Virginia (thanks for getting up at 3 a.m., Mom and Dad!) for D.C.  While at Dulles, ran into a surprise -- after meeting up with Stefani at the gate for our next flight to Addis Ababa, ran into a few other Dukies (Cheyenne and Connor) who were also on our flight.  Those guys were off to Togo to work on developing rural health insurance schemes and build a sustainably-powered computer cluster, respectively -- check out Connor's blog here: http://hipstersintogo.tumblr.com/

The first leg of the trip was fun -- unfortunately, did not get to try any Ethiopian food during the in-flight cuisine (that's what you get for picking the vegetarian meal).   Did get a chance to finish "The Art of Fielding" -- thanks for those of you that recommended I check it out, it was good!  Had a few hours of a lay-over in Addis (my first ever steps on the continent), and then we were off to Juba.  

After touching down, we gathered our luggage and approached the airplane exit only to find..... a wave of heat.  That's literally my first memory.   Can't even really describe the feeling -- of getting all excited to take that the first step into this "mysterious" land, building it up and dramatizing it in your head like a Hollywood script, and then just getting smacked in the face by this heavy wall of 90-degree humid air.  Cleared the sinuses, for sure.  No worries! With senses dazed, walked straight off the tarmac into a one-room building to collect our luggage -- and here's where it got fun.

As we entered, we found ourselves joining a mob that somehow, someway used chaos to create order.   Our entire flight of about 100 folks pushed and pulled their way to their respective destinations -- the line for buying visas, the line for having your bags searched, the line for standing around and waiting idly.  It was sorta surreal watching soldiers clothed in black and grey camo overlook the whole process calmly.  We also found Aduei, an awesome family friend of Stefani's who met us at the airport to help guide us along.   

Then, the bags came.  Within minutes, the crowd that was dispersed throughout the small room was pushed back to form an irregular semi-circle -- and luggage started being dished out from a window outside to the small area of floor space just created.  Stefani quickly found her bag hiding in a little pile near the crowd -- a good sign!  My bag, on the other hand, took a little while longer.  After a few loads came and went, there was still no sign -- and because a large portion of the crowd also remained in a similar quest to find their treasured possessions, chaos ensued.  I (as always) had no idea what I was doing -- so Aduei decided to come to the rescue! She talked to a man working at the airport, and eventually, we were able to match luggage tags with the correct bag -- and I suddenly realized why we couldn't find my bag: I couldn't even recognize it!

Just some normal wear-and-tear.  It's cool, letting the world see your underwear and stuff.  No big deal, right? After taking my bag to get searched, an exchange with a soldier perhaps summed up everything about this moment perfectly:

Soldier:  ".....Hadha min Amreeka?!" (....this is from America?") 
Me:   *blank stare, nodding my head in ambiguous directions* 
Aduei:  ....Yes!
Soldier: ...Vat? How???   
Aduei:  It didn't come like that!
Me:  Yeah!  It didn't come like that!
 ....Several sentences later between Aduei and Soldier in Arabic, which I probably should understand by now but can't....
Soldier:  Hah, okay.  Nice string. *chuckle, chuckle, chuckle*

I mean, at the end of the day, string got the job done.  Some solid string.   Afterwards, we booked it through "customs"  (I flipped my passport open, someone nodded, I just kept walking) and took off for Aduei's car, where we were greeted by her friend -- a graduate student at UF spending time here this summer studying international development.  Thankfully, I didn't lose too much on the way -- my luggage leaked out some toothpaste, some clothes, and a shoe, but it was no big deal!   After driving about 1 km, we arrived at our hotel (nice!) and -- after taking notice of the pictures of the Obama Family and White House in the reception area -- settled into our room.

The facilities are very nice (as evidenced by the fact that I can submit this blog post), and are most definitely on the upper-end of accommodations in this area.  The lodgings seemed geared toward the ex-pat/NGO/UN community (Japan even has a liason office within the compound).  As foreigners, it's strange and a bit uncomfortable having access to all these Western amenities when it's clear that 95% of folks just outside the gated walls don't.  Made the realization resonate even further that we can't aimlessly spend our time in this hotel -- have to be very deliberate in pushing ourselves to reach out, and explore the area as safely and responsibly as we can, for it'll be tempting just to chill.  I'm excited to have arrived.  I'm excited to learn, to experience.  So thankful to all who have helped us along our journey.  We're here.

(Edit:  Hope to post more of my own photos soon.  Government officials and SPLA soldiers apparently aren't the biggest fans of people taking pictures of them, so you have to be pretty sneaky with your camera.  Check this blog's description of Juba International Airport for more info on what today was like!  http://wizzley.com/juba-south-sudan-tourism/)