South Sudan's English Daily Newspaper
"We Dare where others fear"
By Benjamin Takpiny
About 860 health facilities will be supported under the Health Sector Transformation Project (HSTP) with a grant from the World Bank. The project will be implemented by the government and UNICEF.
The Dawn Newspaper spoke to Dr. Harriet Pasquale Akello, Undersecretary in the Ministry of Health about this multi-million dollar supported project. Below are excerpts of the interview .
QN: Can you provide an overview of the current state of public healthcare in South Sudan, particularly regarding the availability of essential medicines?
ANS: First of all, I would like to thank you for giving me this opportunity to come and interview me regarding the health situation in our country. To answer your question regarding the current status of public health in South Sudan or public service provision in our public health facilities, I would just like to give you a bit of an overview on what is happening, especially at the lowest level of service delivery, which is the primary health care. So, primary health care in South Sudan is currently being supported through a grant, which we call the Health Sector Transformation Project. So, this Health Sector Transformation Project is a grant which will support us for the next three years. And it’s a World Bank grant for South Sudan. And this grant will be implemented through support of UNICEF.
Under this grant, of course, we have health service provision with focus on maternal and child health. And for this year, we are going to start with about 860 health facilities, which will be supported under this grant. And then gradually, the plan is to scale it to close to 1,200 health facilities.
So, that will be the ultimate goal of this project in the near future. For now, the kickoff start of this Health Sector Transformation Project just started on the 1st of July, 2024. So, we are only about three months from the time of inception of implementation of this grant.
Just to let you know that in regard to supply for medicine, this is one of the areas of concern under this grant. And of course, for health service provision to be successful, supply chain of medical supplies is very critical to ensure that we’re able to provide quality health services to the people. So, this has been taken into consideration under this Health Sector Transformation Project.
Drugs are procured on quarterly basis and distributed to health facilities. So, the good thing and the beauty of this project is the fact that they have considered the last mile distribution of these drugs. So, it’s not like before where drugs will be dropped at the county level and then health facilities are requested to come and pick from the county level.
So, this had actually posed a lot of challenges in regard to last mile delivery of the drugs. So, currently, these drugs go all the way to support health facilities. And we have just completed our first round of drug distribution.
The challenges in regard to medical supplies reaching or being available at health facilities include the challenge of proper quantification of medicines for the health facilities. And that’s why sometimes our facilities run out of stock. It is because to do a proper quantification of medicine, there are certain parameters that you really need.
Most of the facilities do not report accurately on consumption data. So, if you don’t know your consumption data accurately, of course, it affects the quantification. This is one of the factors affecting our quantification.
So, the key factor is the issue of consumption data. Secondly, we also have a challenge in regards to the accurate population data. So, for you to be able to know accurately the catchment population, we have a challenge.
The first challenge, of course, is we are using census data, which is old data, of course, because what we are using is a projection of census data, which was done since 2008. So, it’s more than 10 years’ data.
Normally, we should have an updated census data, but we don’t have. So, we use estimates. We do projections from the 2008 census data to be able to have our calculation of the population catchment area.
And for South Sudan, especially over the past years, there are so many factors which have affected our population data. Displacement, mainly the issue of displacement, you know. So, the fluidity of our population, you know, a lot of movement, population movement, also affects our population data.
So, it basically affects our quantification data in that regards. So, these are some of the factors. And, of course, even reporting on mobility at the health facility, we also have a challenge in that.
So, some facilities have very poor reporting rates, because at least that could have helped in giving us some estimates that will help us in doing a better quantification. So, mobility data in most of the facilities, reporting rates are very low, even below 50 percent. And not only that, even the completeness of the report itself in most of the cases is not up to date.
So, these are some of the factors affecting availability of medicines most of the time at the health facility. And, of course, the other factor which we cannot talk much about is the issue of leakage. Sometimes we also have leakages of these little medicines, which are provided at the health facilities, are leaked out to be sold in the market for reasons.
Of course, we know very well how poor our health workers are being paid. So, it gives them that, you know, so it’s more of a temptation, you know, because when people are not paid, they always try to find other means on how they can get money to keep them surviving. Though, I really have to acknowledge the fact that we have a very, very resilient health workers, you know, most of our front health workers are really resilient, because they go for months without salaries, but yet they are still there, available and providing services to the people.
QN: How does the allocation of the national budget affect healthcare funding and the availability of medicines?
ANS: Actually, this is where the issue starts from, because currently the health sector, I mean the health services in the country, is, I can say, almost 80% being run through support, through external support. When it comes to the actual domestic funding to support health services in the country, that is where we have a challenge, because with the budget of 1.3%, our budget this year is 1.3% of the total budget allocation in the country, this is really, really small, because with that budget we are only able to pay salaries. So we are able to pay salaries, and the budget does not even give room for us to be able to procure additional drugs, to be able to respond to this gap, so to be able to respond to the gap of medical supplies.
And this is where the problem actually starts, especially at the secondary and tertiary level of care, because most of the partners, most of the donors will focus mostly at the primary health care level. But when it comes at the secondary and tertiary level, that is where we have a lot of deficit in terms of providing support for quality health service delivery. We are not able to pay the doctors, even with the little money we have from the government, the payment of the doctors is one of the worst in the country.
Not only doctors, but generally health workers are poorly paid in South Sudan. And I think this has really affected the quality of our health service delivery, because everybody wants to survive, and of course without money there is nothing you can do. You have a family to support, you have yourself to support, you have to come to work every day, but the little money they give or they pay the health workers is not even enough to sustain their transportation to work on a daily basis.
And that is a big challenge. It trickles down to seriously affect the quality of health service delivery. My concern is the fact that when it comes to secondary and tertiary level of care, this is where the government should have really put in a lot of money, because at least we can leave primary health care to be supported by implementing partners to receive external support, but tertiary level is where the government should really put in a lot of money to have a continuity of care.
Currently we don’t have adequate support for continuity of care. If you have to do a referral of a case from the primary health care level to secondary and tertiary level of care, it becomes so difficult when it reaches that level. Because at the moment we have introduced what we call the cost sharing system in the hospitals, whereby everybody has to pay a certain fee.
Of course in the public hospitals it’s lower than what they can pay at the private health facility. But this fee is very important because it’s what keeps most of the hospitals running. And if there is no adequate support for the hospitals in the country, of course the price will always keep rising, because we want to make sure that the services are always available.
So with lack of additional support, we will always have to increase the prices for the tertiary level of care to make sure that we are able to meet the cost of bringing in medical supplies, bringing in reagents, ensuring that we have running equipment for diagnostics, making sure that we are able to keep the hospitals clean, and making sure that there is always power and water available for the hospital. So all this needs money, and we really hope that our voices will one day be heard, and our budget will be increased at least to a certain level that will be acceptable for us to run our hospitals in a very quality manner, to provide quality health services. So that is really our wish.
QN: Are there any ongoing or planned initiatives to improve the supply chain for essential medicines?
ANS: Yeah, I think I’ll still go back to repeat myself to respond to that. I really want to take this opportunity to be very thankful for this new project from the World Bank, the Health Sector Transformation Project, because at the moment, at least for this grant, we are very happy that hospitals are being included.
So it’s not like the previous grants or the previous support we used to receive from donors, where most of the time hospitals are not included in the support. So this is a way, you know, forward to start on improving our services at the health, at the hospital level. But again, the support we receive, it has a focus, you know, it has a focus on maternal and child health.
But tertiary care is broader than this, so it’s more than just maternal and child care. For example, if you go to Juba Teaching Hospital, you see all these trauma cases, you know. By the way, it is one of the great concerns we have been seeing at Juba Teaching Hospital, you know. The number of accidents we receive on a daily basis and other kinds of trauma is really, it’s really high. And it requires a lot of medical supplies for us to better manage the people. It requires the human resource, you know, the doctors, the nurses, you know, the entire health team to be available at all times to respond to this.
So with this World Bank grant, at least we are able to pay a bit of incentives. So doctors will be able to get something small, which can encourage them at least to be able to come to work on a daily basis, to be able to pay at least for their transportation. It’s really small, but I just want to encourage them to acknowledge the fact that better, I mean, it’s better to have something small than not to have it completely.
So it’s really a small incentive which can help in their upkeep, but it’s not enough. It’s not what we really expect our doctors to be having. So this is one of the solutions I see is having this project running.
But of course, in addition to that, it will be very, very important for the government to really invest and put a lot of focus on hospitals. If our budget can be increased to really support our hospitals, it will make a very, very big difference. And this is very important.
Otherwise, without additional increment of the health budget, we will not be able to make a difference in improving our health services at the hospital level. So this is really my cry that we really invest in hospitals. We don’t have so many hospitals for the tertiary level, but if we can focus on the few we have to make them fully functional, to make them provide quality health services, it will make a difference in the health of our people in South Sudan.
The donor’s money will never cover all our needs. And by the way, everywhere in the world, tertiary services are never free of charge. But we understand our economic situation, and even with the small fee we are putting at the tertiary level of care, patients are not able to pay that small fee. So to complement this, the government has to inject money to support these hospitals.
QN: Is there a specific message you would like to convey to the people of South Sudan regarding the Ministry’s commitment to improving healthcare?
ANS: My message to the people of South Sudan is that we all understand the difficulties people are facing with regard to the high medical costs in the country. But what I would like to encourage the people is really to make use of the primary health care services around them, because if you seek medical treatment as early as possible, it will really cut down on the cost you can pay when you allow yourself to reach a critical situation or a complicated medical case where you need to be treated at the tertiary or secondary level of care.
So my message is really to encourage people to always develop the habit of seeking medical care as early as possible. So this is my basic message to each and every one. Let us seek medical care as early as possible.
