Forty years of primary health care programming and its future in South Sudan
Patients at a PHC centre queue to register (© 2018 SSGMC)
Primary health care (PHC) is a whole-of-society approach to health and well-being centred on the needs and preferences of individuals, families and communities. It addresses the broader determinants of health and focuses on the comprehensive and interrelated aspects of physical, mental and social health and wellbeing.
The PHC revolution was initiated by health leaders in the Alma-Ata Declaration in 1978 and so is now 40 years old.
From its start PHC was recognised, advocated, and adopted as fundamental to the comprehensive delivery of better health for all, and to the promotion of social justice and health equity. PHC is now at the heart of health care delivery and the corner stone upon which sound health systems are built.
It is estimated that 80–90% of people's health needs across their lifetimes can be provided within a PHC framework, from maternity care and disease prevention through to vaccination, management of chronic conditions and palliative care. As populations grow and age, and multi-morbidity increases, the role of PHC workers becomes ever more important.
Faced with variable challenges, in different contexts across the globe, the dream of “health for all by 2000” has not materialised, although a lot of effort, both joined up and scattered, from governments and donors from all sectors has been devoted to this noble vision.
However, this vision has not been realised. Instead, the focus has been on individual diseases with variable results. Now the Sustainable Development Goals provide a new impetus to reach Universal Health Coverage via strengthened PHC.
The Global Conference on Primary Health Care in Astana, Kazakhstan in October 2018 witnessed a transformation process to revive and invigorate all pillars of PHC. The Astana Declaration was endorsed, indicating renewed political commitment and leadership from member states and global organisations to developing people-centred PHC, building on the principles, gains and lessons learned from the Alma-Ata Declaration. Hence a new dawn for better PHC.
According to the Astana declaration, the predicament of PHC lies in a number of challenges including immature or weak health systems, and inadequate funding, recruitment and retention of human resources for health.
The World Health Organization (WHO) emphasises the starring role of PHC and lists key strategies for attaining health and well-being for all, at all ages. First is the development of inclusive policies, strengthening country leadership and building health systems based on PHC. The second is the prioritization of key areas for health improvement and context-specific approaches. Thirdly, WHO supports a multi-sectoral approach to address the wide inequities and social determinants of health. This endorses the values of health equity and stimulates steadfast mechanisms towards achieving the Sustainable Development Goals and Universal Health Coverage.
Despite all the declarations, policies, strategies and commitment, statistics are showing us that almost half of the world’s population has no access to essential health services, and there is an estimated gap of 18 million health care workers to deliver these services, in spite of being so highly needed. With regards to health expenditure only eight out of the thirty countries, for which data are available, spent at least US$ 40 per person on PHC per year.
Recruitment and retention of health care workers, including community health workers, nurses, and doctors has been pointed out as a major challenge in most countries, and requires immediate action. Making PHC a more attractive working environment is crucial to recruit and retain the best staff.
Additional roles have been suggested for nurses and pharmacists in primary care, and efforts are being made or suggested - such as opportunities for professional development, infrastructure support, and technological innovations - to make the primary care world more attractive. Additionally, medical schools, by offering primary care clerkships, and exposing students to work in rural areas, can later on, help to recruit qualified family doctors for the most remote areas.
South Sudan earlier committed to the Alma-Ata Declaration and, recently, to the Astana Declaration, in order to revive PHC service delivery and accelerate the Sustainable Development Goals. The South Sudan National Health Policy 2016-2026 envisions a healthy and productive population living dignified lives. It aims at a strengthened national health system and partnerships for Universal Health Coverage and aspires to improve the health status of the people by effective delivery of the Basic Package Health and Nutrition Services (BPHNS).
The priority areas for South Sudan are improved health service delivery including organization and infrastructure development, strengthened leadership and management, improved management of health care/system resources, and strengthened health partnerships.
South Sudan’s health statistics are some of the world’s most alarming. The country suffers from a substantial burden of maternal and child health conditions, communicable and non-communicable diseases including malnutrition, as well as emergencies and disasters. Only 40% of the population can access PHC facilities.
There are a range of infrastructure and system challenges that need to be established upon which sustainable PHC services are built such as roads, poor infrastructure and health facilities, lack of equipment and technology, poor supply chain and repetitive drug stock outs, lack of community ownership and, most importantly, shortage of qualified human resources, their unmet training needs, and demotivated health care workers. However, in practice, and particularly in the case of South Sudan, service delivery has to go in chorus with setting up the systems because the need is severe and urgent.
The health system in South Sudan is structured in the order of community, primary, secondary and tertiary levels. Geographically, the Boma is the lowest level and comprise a group of villages, in which the services are delivered at Primary Health Care Units (PHCU) and by the Boma health committee. Primary Health Care Centres (PHCC) are placed at the Payam Levels, while hospitals exist at county or state levels. Hospitals may also be part of other organised services such as the police or military.
In a promising move the Ministry of Health has launched the Boma Health Initiative which deals with the implementation of the community arm of PHC at the Boma level. Since Independence in 2011, the country has committed to the Basic Package of Health and Nutrition Services (BPHNS), which focuses on women and children, being accessible to all free of charge.
Because of the magnitude of the task and the numerous challenges, a lot of resources need be channeled and programmed to address PHC, but only unshakable leadership commitment, and peace and stability will pave the way for documenting sustainable gains towards fulfillment of the PHC goals of the Astana Declaration in South Sudan.