Malaria is a disease that spares no-one, but particularly affects women and children. Like the rest of Sub Saharan Africa, South Sudan is under siege.
Doctor Samson Paul Baba, Director General for Public and Community Health stated back in April that 20-40% of illnesses and more than 20% of mortality rates in South Sudan are as a result of malaria. The burden of mortality is disproportionately borne by pregnant women and children under the age of five. These are incredibly sobering statistics.
The Southern Sudanese environment itself conspires to facilitate infection with 95% of South Sudan exhibiting conditions which are exceptionally favourable for malaria transmission. To clarify, malaria transmission occurs throughout the year, with peak malaria transmission occurring towards the end of the rainy season and lasting between 5 to 8 months, dependent on the region. The scale of the challenge that this represents simply can’t be underestimated. Even the heat of the dry season, in some areas exceeding 40 degrees Celsius, has led to reports that the high temperatures degrade and compromise anti-mosquito nets reducing their effective shelf life from three years to less than a year.
Bearing this in mind, it was extremely worrisome to learn that the World Health Organisation (WHO) estimates that only 30% of Southern Sudanese currently have access to health services. The majority of these health services are provided by Non-Governmental Organisations (NGOs) through a mix of basic health units that offer mainly curative primary health care and/or communicable disease control programmes. Just under half of these NGOs have a long established presence in South Sudan as part of the Operation Lifeline Sudan (OLS) consortium that has been operating in South Sudan and providing essential humanitarian assistance for the last quarter of a century.
Unfortunately, that still leaves around 8.4 million people living without any access to malaria treatment, in malarial conditions ranking amongst the most perilous in the world.
So what are the realities for our nascent nation as it combats a disease described as particularly endemic in the region? Can we rightfully criticise the approach that our government has taken whilst tackling this rapacious disease?
With the advent of regional autonomy following the Comprehensive Peace Agreement (CPA), the Government of South Sudan (GoSS) found itself facing the consequences of acute underinvestment by successive regimes in Khartoum. During the years leading up to the independence referendum and eventual secession, it needed to build from scratch new systems for health care provision and found itself in desperate need of health care infrastructure, medical supplies and trained health care professionals to meet the needs of its people. The situation was exasperated by the expulsion of citizens of South Sudanese heritage from North Sudan.
The GoSS was quick to acknowledge the need to promote public health and equal, free access to primary health care, explicitly mentioning this in the Interim National Constitution of South Sudan. Further, the Southern Sudan Interim Health Policy (Draft December2005) declared malaria as a particular challenge and gave priority to maternal and child health interventions.
In coordination with the WHO, the GoSS developed the Malaria Control Strategic Plan for Southern Sudan covering the period 2006 to 2011. This ambitious strategy relied heavily on the support of a network of international and regional organisations to meet it stated goal to “rapidly scale up preventive as well as curative interventions for malaria”.
The results have been mixed as the challenges of providing services to a diffuse, predominantly rural population within the context of limited financial resources and extremely poor infrastructure began to bite. As of 2012, a programme to distribute anti-mosquito sleeping nets has so far managed to reach only 25% of the population – the target having been 60% by 2011.
The government’s annual budget in 2011 was $2.3 billion. Facing a hostile, belligerent and predatory regime to the north, and perhaps inspired by the adage “Igitur qui desiderat pacem, praeparet bellum” (If you want peace, prepare for war), over 60% of this budget was directed to the Security and Rule of Law sectors.
Following the decision to shut down oil production in January 2012, the GoSS released an austerity budget in March 2012. Although one of the core objectives of this austerity budget was to maintain core service delivery (particularly in education, health and agriculture) it nevertheless included a 20% reduction in operating and capital budgets for the Ministry of Health when compared to the draft 2011/2012 budget.
Kosti Manibe Ngai, Minister for Finance & Economic Planning opened his 2012/2013 budget presentation with the following salutary message. “Let us be under no illusions as to the seriousness of that decision. Shutting down the oil deprives us of what was 98% of our revenues. It is also a massive and unprecedented shock to our economy.” Fortunately this budget, passed in June, didn’t extend the budget cut for the Ministry of Health beyond the initial 20% austerity cut introduced in March, due in no small part to the plundering of already dwindling foreign currency reserves.
The total operating and capital budget amounted to SSP 1.7 billion, with 17% of this budget allocated to Education, Health, Natural Resources and Infrastructure. If equitably distributed across the four branches of government, this would mean a total budget (excluding salaries) of SSP 72.3 million for the provision of health services. A further SSP 40 million were allocated to the purchase of drugs and SSP 11 million to the maintenance of hospitals. This gives the Ministry of Health a total of SSP 123.3 million for the 2012/2013 financial year.
The Minister also added:
“In these times of austerity, aid will become an increasingly important source of development finance in South Sudan. The government greatly values the assistance our Development Partners have provided to date, and we hope we can rely on this to continue during this challenging period”
Consequently, in terms of assistance to health service provision, the GoSS has estimated a donor contribution of SSP 585 million. This is just under five times as much as the GoSS is putting into health service provision for its citizens. Please, take a moment to digest this.
Put another way, the total budget for the Ministry of Health for 2012/2013 amounts to $24.7 million (assuming exchange rate of SSP 5 to the dollar). This is a paltry $2.06 for every man, woman and child in land. If you factor in projected donor contributions of $141.7 million, then the total funding available for health provision jumps to $11.81 per person. Clearly only a proportion of this funding is available exclusively for the development and maintenance of malaria treatment and control programmes and infrastructure. Thankfully, NGOs have stepped in to cover the shortfall.
Susan Purdin, the head of U.S.-based aid group International Rescue Committee in South Sudan noted that:
“The health system as it is now is extraordinarily dependent on non-governmental actors. Many years and much money, used prudently, will be needed to transition from what it is to what is envisioned.”
When compared to other countries in the region, South Sudan is not as exceptional as it may seem in its dependence on external financial and material support in its struggle against malaria. In a 2011 review of its Ugandan Malaria Control Policy and Strategic Plan (which expired in 2010), a report noted that “resources are not commensurate with the malaria disease burden, and are largely donor dependent.”
In summary, the urgent need to respond immediately to the near overwhelming health challenges presented by Malaria in South Sudan requires the GoSS to seek whatever assistance is available. To do otherwise would be a gross and unforgiveable dereliction of duty. Whilst focused on the long term development of health care infrastructure, the sustainable and responsive provision of medical supplies and a critical mass of trained health care professionals, the government must nevertheless ensure short term provision of appropriate health services.
Put more eloquently by the Dr Yatta Lori Lugor, the Deputy Minister of Health, in a response to a question on the pitfalls of aid dependency:
“Dependency is when you don’t want to do something. South Sudan may be struggling to train its own civil servants and take on responsibilities, but it wants to run its own affairs eventually. There is no dependency here.”