The New State of South Sudan: An Opportunity for Better Health Care?
On July 9th, 2011, “The Republic of South Sudan” was born as a new state in the horn of Africa. The country officially joined the United Nations as the 193rd member on July 14th after over half a century of ongoing tension with North Sudan. The referendum to establish the new state was a response to the stipulation of the Comprehensive Peace Agreement (CPA) between the Sudan Peoples’ Liberation Movement (SPLM) and the ruling party in North Sudan, the National Congress Party (NCP), to hold a referendum on self-determination in the South. Although the new state is still suffering from the severe ramifications of the continuous attacks on its infrastructure since British colonial rule was lifted in 1956, there is a clear opportunity for the new state to learn from the numerous experiences of other countries in the region, and especially to avoid repeating the mistakes of North Sudan.
The establishment of a new state, which previously received only minimal infrastructural support from the North, which repeatedly destroyed the South’s infrastructure through repeated violence, presents a difficult challenge for instituting even the rudimentary self-sufficient structures of a state. The NCP and previous governments centered in the North have a clear record of gradual deregulation of critical services such as education and health care provision, especially to rural areas in South Sudan. In the early 90s, the NCP’s macroeconomic reforms exceeded even the radical privatization measures expected under the Structural Adjustment Programs (SAP) of the International Monetary Fund (IMF). The SAP’s curtailment of public funding for core social services such as health care produced the private health care systems we see in most, if not all, African countries today. However, the NCP members exacerbated these measures through “liberalization policies” which almost completely ameliorated public funding of the salaries of health care workers, rural primary care centers and medical schools. Hence, it effectively turned all these responsibilities into private enterprises for the profit of a few corrupt officials. This period saw a clear deterioration in health care provision throughout the country. However, the effects were felt more strongly in the South in the second phase of the civil war which lasted from 1983 and 2005. In this period, an estimated two million civilians died and at least 4.5 million were displaced either to the North or to neighboring countries such as Kenya and Ethiopia.
Currently, South Sudan faces one of the most despondent public health care situations in the world. South Sudan has an acute shortage of skilled health care workers with availability of access estimated at one physician for every 100,000 civilians. Furthermore, the country has the highest maternal mortality rate globally with 2054 maternal deaths per 100,000 live childbirths. Many diseases endemic to South Sudan such as malaria and guinea worm infection have already been eradicated in other countries. Consequently, the non-governmental organization (NGO) sector has been effectively replacing the role of the Ministry of Health by providing immunizations, anti-retrovirals for HIV/AIDS, and antibiotics for tuberculosis. However, repeated interruptions of NGO health care provision due to war led to a high rate of unplanned patient non-compliance with treatment regimens. For instance, Médecins Sans Frontières (MSF) workers were evacuated at least seven times in two and a half years from the region of Lankien during the civil war. Furthermore, the inadequacy of medical training in South Sudan poses a problem of continued dependence on international NGOs to provide care for citizens in spite of their intermittent presence in the region. This has translated into a high spread of drug resistant HIV and tuberculosis strains, making current intervention a public health nightmare. These problems are compounded by the lack of clean running water and sewage systems, even in the country’s developed capital; Juba.
In addition to the inefficient governance in Sudan before the cessation of hostilities, which centralized services at the expense of rural areas in the country, Northern Sudanese people continued to hold extremely racist views against people of the South. Many Southerners worked as domestic servants and were clearly discriminated against in the educational and vocational employment spheres. These views date back to earlier attempts by the Ottoman Empire to convert the people of southern Sudan to Islam. The discrimination became more entrenched in law in post-colonial Sudan in 1983 when then-president Nimeiri decided to establish Shari’a law which effectively discriminated against the people of the South as the majority of them were either Christians or followed traditional religions.
Within the South itself, many inter-tribal conflicts over power continued to occur after separation from the North creating new internal violence. Additionally, many of the areas within the disputed border between the North and South, such as Abyei and South Kordofan, have suffered repeated militia attacks from the NCP which has destabilized the self-determination of the region. These ongoing factors, combined with the economic ramifications of a long history of war and centralized governance, led to a continuation of the historical prejudice and exacerbated poverty and suffering, culminating today in a newly born country which faces daunting challenges to real self-sufficiency.
The history of South Sudan and its gloomy public health reality make the challenge of establishing an effective health care system difficult. Nonetheless, the genesis of this new state may actually provide an opportunity for the creation of an efficient system which differs from the privatized and elitist system of health-care provision in the North. South Sudan has the advantage of being debt-free with 38 billion dollars of debt transferred to the North as a stipulation of the CPA. This will have the dual benefit of maintaining the country’s resources for the sole purpose of funding the state instead of being allocated for debt repayment, and it also removes the influence of international agencies such as the World Bank and International Monetary Fund (IMF) from manipulating economic policy. Economically, the oil resources of the South can help to establish the necessary infrastructure for funding social services more effectively than the NCP did.
The country can also learn from other countries in the global south such as Cuba which successfully emerged from extreme socio-economic inequality to establish arguably the most efficient health care system in the world. The endemic diseases of Cuba before the Cuban revolution resemble those of South Sudan today but Cuba has provided a positive example of how to efficiently eradicate and effectively control the spread of many of these diseases. Furthermore, there is an opportunity to partner with countries like Cuba which is committed to South-South solidarity by providing free training for skilled health care providers and deploying medical brigades to impoverished countries to assist in their development.
The memory of the repeated violence in the region may actually instill a higher sense of commitment and political will in South Sudan to meet its challenges. The late John Garang, founder and historical leader of the SPLM, envisioned a united Sudan which invested in rural planning and development; an area that was clearly neglected throughout Sudanese history. Many of his followers in the South remain committed to this vision of solidarity and equality between the different ethnic groups and regions of the South.
In summary, South Sudan’s emergence from a deadly civil war also presents the difficult challenge of bringing a sense of dignity and equity to its citizens through effective development policies and social services. Although the country is far from attaining the health care standards recommended by bodies such as the World Health Organization (WHO), it has many other ingredients for making these standards an attainable goal in time. Neighboring countries and the global north have a clear role to play in standing in solidarity with people of South Sudan; however, they must do so without disempowering its citizens from the rights for which they have been fighting for decades. The road may be long, but with genuine political will the people of South Sudan may impress us all with their achievements.
1 Talha Burki (2011), Infectious Diseases Burden in South Sudan. The Lancet. 11:4 (266-267). ^
2 Regional Health Systems Observatory- EMRO. Health Care Finance and Expenditure. Health System Profile-Sudan. Chapter 6 (27-35). ^
3 Arjan Hehenkamp and S Hargreaves (2003), Tuberculosis Treatment in Complex Emergencies: South Sudan. The Lancet. 362: 1 (s30-s31). ^
4 World Health Organization Report. Sudan: Health Profile. Summary Report. ^