Public Health and Health Policy in South Sudan
This article aimed to highlight the important of public health, and focus on legislative framework on water and sanitation as an approach to addressing some of the health challenges. This section of South Sudan Medical Journal is dedicated for articles on public health and health policy in South Sudan. As this is the only medical journal the South has ever launched, its vision should be holistic of improving health of the people of South Sudan and should include public health and health policy. It should inform the Ministry of Health, as the custodian of health of the people of South Sudan, in developing health policies. As the custodian of the nation health, the Ministry of Health, Government of South Sudan (GOSS) should address public health challenges. Its current mission1 of focussing on healthcare delivery (The Mission of the MOH-GOSS is commitment to ensure equitable sector-wide, accelerated and expanded quality health care for all people in Southern Sudan, especially women and children), while it is welcomed, remains limited as this does not address other areas of public health domain (see below).
Table 1: The three domains of public health2
Health and Social Care Quality
Surveillance and monitoring of health and determinants of health underpins all three.
This article is structured to cover the following areas:
- Public health: definition; and vision for health in South Sudan
- Water and Sanitation: proposals for a legislative framework
Public health: definition, and vision for health in South Sudan
Public health is defined as:
"The science and art of preventing disease, prolonging life and promoting health through organised efforts of society."3
Therefore, public health approach is population based; emphasises collective responsibility for health, its protection and disease prevention; recognises the key role of the state, linked to a concern for the underlying socio-economic and wider determinants of health, as well as disease; and emphasises partnerships with all those who contribute to the health of the population.4 It is an approach by which we can achieve health, as defined by the World Health Organisation (WHO):
"Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity."5
In 2006, the Health Association of South Sudan developed a vision of health for South Sudan. This vision offers significant input upon which to build on (Box below). It envisages
“A healthier nation, reduced health inequalities, and better quality of life.” A country where6…
- There is access to safe drinking water, adequate sanitation system, education, housing, and security for all the citizens;
- The people take responsibility for their own health and are engaged with healthcare service;
- There is reduced incidence of communicable diseases;
- There is a reduced maternal mortality rate; reduced mortality rate of under fives, comprehensive coverage of all children under 5 years by the immunisation programmes, reduced malnutrition rates, and increased life expectancy;
- There is clean environment, and adequate food supply;
- There is reduced corruption.
- There are healthy cities, towns and villages.
The importance of the above vision is that it enables the Ministry of Health and its partners to direct its resources towards activities aimed at realising the vision, which are most likely to yield maximum population health benefits. These activities include the following areas: sanitation; waste disposal; water; food safety; cigarette smoking; alcohol; housing standards; effective clinical service; professional regulatory bodies / framework to ensure quality in clinical services, etc.
Some positive initiatives in the right direction have been started by the Ministry of Health, GOSS, when it hosted the First South Sudan Health Assembly in Juba, in June 2007. Among other areas, the Assembly adopted resolutions to address issues on water and sanitation, including formulating legislative framework. The Assembly resolved that the Ministry of Health shall:7
- Identify and set up appropriate leadership at all levels;
- Provide appropriate training for human resources;
- Provide support to urban water firms, rural water (protected wells) and the establishment of reference laboratories in townships, for monitoring water quality;
- Establish an inter-ministerial committee on water and sanitation; setting up a parliamentary committee on water and sanitation; and health education promotion;
- Establish a legislative framework (public health laws) for regulating issues related to water and sanitation.
Water and Sanitation: Proposals for a Legislative Framework
In an effort to support the Ministry of Health in formulating legislative framework for South Sudan, the author, on behalf of Health Association of South Sudan, undertook a literature review on water and sanitation legislation from around the world to inform the above proposal.
Public Health Law has been defined as:
“The legal powers and duties of the state, in collaboration with its partners (e.g. healthcare, business, the community, the media, and academia), to assure the conditions for people to be healthy (e.g. to identify, prevent, and ameliorate risks to health in the population) and the limitations on the power of the state to constrain the autonomy, privacy, liberty, proprietary, or other legally protected interests of individuals for the common good. The prime objective of public health law is to pursue the highest possible level of physical and mental health in the population, consistent with the value of social justice”.8
Various countries around the world have legislative frameworks governing access to their citizens of water and ensuring its safety from pollution. Examples of some of these countries include:9
- South Africa: National Water Act (No. 36 of 1998).
- Uganda: Water Statute, 1995; Water (Waste Discharge) Regulation No. 32 of 1998;
- United States: Clean Water Act of 1977.
- Bukina Faso: a wide range of regulations and laws covering its sanitation policy.
- Ghana: a country whose sanitation experience is similar to that of
South Sudan, has a strategy with legislative recommendations to meet desirable water and sanitation goals for 2020. Among some of the main outputs expects are:
- National Environmental Sanitation Day;
- The national Environmental Sanitation Policy Co-ordination Council;
- Environmental sanitation technologies are under regular review and continuous improvement;
- All solid wastes generated in urban areas are regularly collected and disposed of in adequately controlled landfills or by other environmentally acceptable means; All pan latrines are to be phased out (by 2010);
- At least 90% of the population has access to an acceptable domestic toilet ,and the remaining 10% has access to hygienic public toilets;
Recommendations on Public Health (Water & Sanitation) Act for South Sudan:
Based on international experience, the following proposal for legislative framework on water and sanitation are made for South Sudan.
Establishment of Public Health (Water and Sanitation) Acts (2008) for South Sudan, which shall contain the following:
- Establishment of a body (e.g. Commission) whose responsibility it is to manage water and environmental sanitation. The body shall have legal powers to appoint appropriate Advisory Bodies e.g. Water & Sanitation Pollution Advisory Board; or National Study Board – responsible for investigation, and study of all technology, social and economic aspects of achieving required standards.
- Establishment of conditions enabling the private sector to provide and charge fees for environmental sanitation services;
- Establishment of incentives and of regulation, licensing and monitoring arrangements for water and sanitation;
- Control and ownership of wastes;
- Arrangements for budgeting and financing environmental sanitation services in the States Assemblies;
- Any other legislation required establishing and maintaining acceptable standards of environmental sanitation.
The South Sudan / State Legislative Assemblies shall promulgate legislation on water and sanitation addressing:
1) General (Water & Sanitation) Measures
a) Laws and regulations to enforce: The measures to take by administrative authorities for preventing or reducing communicable diseases.
b) The measures to take for assuring the protection of food commodities on sale.
c) The measures to take for assuring the disinfections or destruction of objects
d) having served with diseases or have been contaminated by them and generally any object served by a contagious vehicle.
e) The relative prescription for the complete deterioration of the quality of life, due to factors of pollution from air or water, industrial wastes, noise, effects of secondary pesticides, rat poisons, stagnation of water or bad conditions of conservation.
f) The first line of enforcement shall be the Health Inspectorate (or Environmental Health Officers), working by a combination of education and persuasion. The objective should be to make the community understand and accept its responsibilities with regard to environmental sanitation. Establishment of zones for the provision of environmental sanitation services;
g) Enforcement of public participation in critical environmental sanitation services;
h) Designation of areas and facilities for the disposal of wastes;
i) Adequate provision by developers for the collection, intermediate storage, treatment and disposal of solid and liquid waste; Licensing and monitoring of environmental sanitation service providers
j) Tariffs for environmental sanitation services and their collection by contractors, franchisees etc;
k) Ownership of wastes;
2) Protection of the sanitation of the environment
a) Pollution of Water and air
i) Measures to prevent pollution of water for consumption.
ii) Measures destined to prevent pollution of potable water.
iii) Anyone who offers the public with water to drink or for human food, and which includes frozen food should ensure that the water conforms to the potability norms and regulations.
iv) Management and disposal of hazardous wastes;
v) Storage of wastes on the premises of waste generators
b) Atmospheric pollution
i) Enforce regulations and measures necessary to combat all elements of pollution and protect the natural level of the environment and public health.
ii) Measures for the prevention and fight against noise and other alternative nuisances have to be observed at the local premise, environment premises and main agglomerations.
iii) Allowable toilet systems and excreta disposal methods;
iv) Rearing and straying of animals and pets;
v) The activities and behaviour of individuals and institutions, which cause or are likely to cause environmental pollution or vector breeding;
vi) Individual and communal recycling of wastes;
vii) Any other matters that demand local regulation to achieve and maintain a clean and healthy environment;
c) Mortuary and Cemetery
i) The conditions about running of mortuaries are precisely by means of regulations.
ii) Each town or agglomerations has to have a cemetery. The competent authorities are charged to assure the maintenance and protection of the cemeteries.
3) Hygiene Measure
a) Food Hygiene
i) The establishments for the preparation, sale and conservation of food products have to be clean, aired and fresh. The consortium about the sale and material contact with food products have to be free from all contamination.
ii) Banned from the preparation, conservation, packaging of foodstuff of chemical products and other elements and objects contrary to sanitation norms and juridical sensitivity to undermine the health of the population.
iii) All people working in manufacturing establishments and sale of foodstuff must be compliant with the measures of sanitation control, prevention and treatment.
b) Hotel, Restaurants and Bar Hygiene
i) All establishment for hotels, restaurant or bar must be in a state of good hygiene and compliant with continuous sanitary control. The functioning and operation have to conform to sanitary norms and juridical enforced to guarantee health of the population.
ii) The disinfections of establishment of hotels, restaurant or bar have to be effected periodically by public hygiene agents or the enterprise.
4) Housing-related Measures
a) In all agglomerations where sewage exists, any new building established in the avenue should be connected in order to drain directly rainwater, domestic wastewater and industrial wastewater.
b) Inclusion in development permits of conditions to prevent overcrowding, pollution, blockage of drainage channels, blocking of easement and encroachment on building reservation areas.
c) Enforcement of construction/provision of domestic toilets in every residential, commercial and industrial property
1 Ministry of Health, Government of South Sudan, Juba. Website http://www.mohgoss.sd/ (accessed online 3rd February 2008)
2 Faculty of Public Health – www.fph.org.uk
3 http://www.fph.org.uk/about_faculty/what_public_health/default.asp (1st November 2007)
4 http://www.fph.org.uk/about_faculty/what_public_health/default.asp (1st November 2007)
5 http://www.who.int/features/factfiles/mental_health/en/ (accessed online 3rd February 2008).
6 Vision developed by Health Association of South Sudan at London Workshop, 21st January 2006.
7 Ministry of Health, Government of South Sudan, First South Sudan Health Assembly, Juba, 19-21 June 2007.
8 Gostin, L. Legal foundations of public health law and its role in meeting future challenges. Public Health (2006) 120, 8-15.