By Dr. Garang M. Dut
OPINION – South Sudan mourns the late Hon. Manawa Peter Gatkouth, as it protests initiatives in his Ministry of Water Resources and Irrigation. At issue are plans to dredge River Naam in the Bhar El Ghazal basin, and resume the historically unpopular Jonglei canal project. It’s feared these will obliterate the Sudd and decimate livelihoods. However, South Sudan’s Minister for Cabinet Affairs, Hon. Martin Elia Lomoro, dismissed such advocacy as “criminal”. As well, the Government blames public criticisms for the late Minister’s heart attack. A group of self-identified ‘Social Media Criminals’ replied to the former, but the latter has yet to be explicated. To be sure, stress-induced heart disorder is medically established and called Takotsubo. Nonetheless, the cause is less consequential in this instance. Whatever the trigger, the late Minister needed time-critical intervention to re-establish blood supply to his heart muscles. This was required within a few hours from the onset of chest pain, and best done in South Sudan. In this sense, it’s South Sudan’s weak health system which is to blame and this is within the Government’s purview.
Ineffective healthcare is a threat to South Sudan’s national security and sovereignty. The late Hon. Gatkouth died in Egypt after insufficient medical care in South Sudan’s capital, Juba. Similarly, Justice Majok Mading died in a Nairobi hospital in 2019, having been evacuated from Juba. He led legal affairs at the Presidency and had suddenly collapsed at work. In March 2021, the young musician, Trisha Cee, bled to death when hit by water tanker in Juba. South Sudan lacks trauma system and a reliable blood bank for rapid management of injuries. More avoidable deaths occurred during the coronavirus disease (Covid-19) pandemic, when the country subsisted on four ventilators. This trend reflects chronic underinvestment in South Sudan’s health sector: no capabilities for managing medical emergencies such as heart attack, stroke, blood clots in lungs, or major injuries requiring massive transfusion.
South Sudan’s dependence on evacuation to foreign hospitals is false security. It is also unsustainable. As in the foregoing examples, some medical conditions are time-critical and only capabilities within South Sudan would save lives. The advanced care sought in foreign hospitals is only useful as adjunct to life-saving interventions at the first point of care.
Take the instance of stroke or heart attack. In stroke, blood supply to the brain is impaired by either a blocked (ischaemic stroke) or torn (haemorrhagic stroke) blood vessel. In heart attack, the heart fails at nourishing itself, due to blockage in its own blood vessel(s). While the heart’s main purpose is to circulate blood around the body, it must also supply itself. So, this impairment causes a self-perpetuating incapacitation which is time-critical because, when denied oxygen and nutrients afforded by blood supply, the brain begins to die within minutes and the heart lasts only hours. This acuity explains the futility of relying on distant and foreign hospitals, however advanced.
Emergency medical service would avert avoidable deaths in South Sudan. Such service would comprise of an emergency retrieval component incorporating road, riverine and air ambulances. It will also need a call centre which coordinates retrievals and referrals, and a network of suitably-equipped hospitals. In addition to Intensivists on a 24-hour roster, these hospitals should be equipped with resuscitation bays, surgical operating theatres and catheterisation laboratories. This around-the-clock availability is important because medical emergencies don’t come on schedule. These facilities should also have wards which specialise in critical care. These urgent investments should begin now to save lives the soonest possible.
Peace agreements may assuage the current imbroglio in South Sudan, but greater legitimacy for the Government lies in services delivery. Shortly after independence, the Government enjoyed favourable ratings in areas with some health service. And, even when these services weren’t government-funded, communities trusted the Government will improve on such responsibilities in subsequent years.
However, a decade after independence, continued dominance of humanitarian health response dashes hopes among the citizenry. Similarly, measly budget for the health sector betrays the Government’s desire for sector-ownership. A hackneyed explanation is that South Sudan is only a poor country, and its failings ought not be critiqued against rich comparators. But, it’s not in the scale of development such comparison is sought; instead, it’s in the duties owed by governments. The Government of South Sudan should meet its responsibilities in equal measure to its claims on sovereignty. It is commendable that, in principle, it commits to Basic Package of Health Services (BPHS) for all citizens. It is also opportune that international bodies, such as the LSE-Oxford Commission on State Fragility, Growth, and Development, support the use of development finance in ‘de-risking’ fledgling private sector. This would be helpful for sustainability of essential capabilities, such as procurement of pharmaceuticals among other consumables. Notwithstanding efforts from elsewhere, the onus for effective healthcare is on South Sudan’s government.
In the same logic, South Sudan’s policymakers should desist from decisions which undermine sustainability in the health sector. This is evident in three examples. First, the recurrent violence from political impasse disrupts an already fragile health system, where various actors work semi-autonomously across disease-specific programmes. The destruction to facilities and health personnel diminishes capacity in the health system. These disruptions also promote unsustainability as laissez-faire organization of the health system compounds the short-term nature of operations which perform to donor preferences.
Second, the retaliatory decision to halt oil production in 2012 hindered sector-specific investments. It distanced external support for the health system, as development partners begun to doubt the Government’s sensitivity to fiduciary and governance risks. This also thwarted the Government’s desire for greater sector-ownership.
Third, monetary and fiscal policies appear insensitive to services sector needs. For instance, the Executive Order No. 36/2015, which established multiple ethnocentric states presented challenges beyond healthcare. But above all, segmentation into smaller jurisdictions undermines sustainability in volume-dependent sectors. Health service requires expensive equipment and skilled workforce. So, resources need to be pooled across large populations. Similarly, currency devaluations have been instituted without contingencies for essential imports, including pharmaceuticals. These make for a futile health sector strategy which fails at realising aspirations of National Health Policy 2016-2026.
Notwithstanding South Sudan’s shortcomings, an international imperative remains in the interest of global health security. South Sudan is a global security frontier. While food insecurity underlies malnourishment which afflicts its children, its wetlands support hydrological stability of the Nile Basin and therefore regional stability. Its location means fragility and epidemics in its borders are contagious for the Eastern, Northern, and Central Africa. Yet, despite natural endowments, it’s yet to see functional health system. Indeed, when Ebola harassed its borders in 2019, South Sudan needed effective response in Uganda and the Democratic Republic of Congo (DRC) to protect its weak health system. This weak health system, its porous borders which are traversed by nomadic communities, and disaster unpreparedness, are weakling in global health security. Therefore, investments in South Sudan’s health system are both for its own sake as well as global health security. If nothing else, global health security is a basis for a concerted international support in health systems strengthening.
While emergency medical service isn’t cheap, South Sudan could invest wisely. The Lancet Commission on Global Surgery estimates the average cost of a surgical theatre in a low-income country at US$ 320,000. This means, permitting for overheads, foregoing the purchase of five US M1A1 Abrams tanks could, for instance, afford the country at least 50-bed capacity of lifesaving medical capabilities. Such investments would offer exponential benefits as lives are saved among individuals afflicted with disruptions to blood supply and complications in childbirth. More than other intergenerational debts, this would be justified.
The economics of healthcare necessitate government interventions to tame distortions or ‘market failures’. Public-spirited leadership is therefore indispensable: a private insurance scheme and a free market approach would neither be effective nor equitable where poverty is rampant. But unlike advanced economies which suffer greater costs as they replace old and expensive technology, South Sudan could leapfrog in health systems capabilities. In this respect, South Sudan must seek visionary leadership which is cognizant of technological frontiers.
As well, the health profession should help uphold the right to life in South Sudan. While religious leaders have sought to midwife peace in the country, it is the province of health profession to promote physical and mental health of the citizenry. Médecins Sans Frontières (MSF), which is a key stakeholder in South Sudan’s health-sector, adopts neutrality on rights-based principles such as the ‘responsibility to protect’ (R2P). While the scope for advocacy is controversial among humanitarian agencies, South Sudanese health practitioners are naturally ‘physician-citizens’ within their country. They carry a dual responsibility as members of intelligentsia which aspires to better polity, and as professionals sworn to higher ideals. By championing health as a human right, making it centrepiece among criteria for which a government is qualified, the health profession could guide South Sudan towards servant-leadership. This requires it to lead on discourses spanning the whole gamut of human condition, including clinical care, town planning, environmental health and suchlike. This professional guidance would help ensure health in all policies and also promote strategic approaches to health system strengthening.
As South Sudan seeks a path out of fragility, its government should rethink its strategy on legitimacy. Violent confrontations have proven futile, yet effective healthcare promises human security, political stability and economic development. Therefore, the Special Fund for Reconstruction (SRF) which is stipulated in chapter III of the revitalised agreement on the resolution of the conflict in South Sudan (R-ARCSS), should consider investments in emergency medical service as key priority. South Sudan’s health profession should lead in domestic processes which carry health implications. In any case, it remains the Government’s responsibility to ensure health system effectiveness, and this embodies the ideals of justice, liberty, and prosperity to which South Sudan aspires.
Dr Garang M. Dut is Fellow in Health Systems at the Australian National University. He was educated at Monash University, Melbourne University, Harvard University and Oxford University, and has experience in healthcare, government and academia.
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