Letter to the editor
Years of conflict in South Sudan have destroyed infrastructure and led to death and displacement of millions of people. With an estimated population of 12 million, its health indicators are among the worst in the world . The impact of failed health systems has increased morbidity and mortality; South Sudan has the highest maternal death rate (2,054 per 100,000 live births) and ranks 16th in infant mortality (68 per 1,000 live births) . Since 2005, the country has made little progress to provide basic social services to its impoverished citizens. This is because South Sudan prioritizes funding security (28% of the total budget in 2011) over other services. Consequently, social services such as education and health always get the lowest budgetary allocations (4% and 2% respectively in 2011, as shown in Figure 1 ).
This trend has been consistent over the years; in the 2012/2013 financial year, resources allocated to education, health and infrastructure averaged 7.6% whereas a whopping 28 % of the total budget was allocated to the armed services sector. In 2014/2015 financial year, the health sector received only 4% of the budget, compared to almost 50% of the security and rule of law sectors, as shown in Figure 2 . In 2016/2017 financial year, the health sector received only 1% of the health budget, compared to the military sector which was allocated 60% of the national budget. This uneven allocation between social sectors and security is a major barrier to the economic development of the country. In the 2018 financial year, the total budget approved by Parliament was 81 billion South Sudanese Pounds (SSP). Only 1.6 billion SSP went to the health sector.
Why invest more financial resources in health matters?
Inadequate obstetric care, lack of skilled workers, cultural barriers, poverty and lack of information are some of the reasons preventing women from accessing health services. Lack of roads and infrastructure, insecurity and long distances to health facilities are other reasons.
Most maternal deaths are preventable. Ensuring adequate antenatal care, ability to deliver under trained health workers and improving health infrastructure are keys to reducing maternal mortality. These require major investments and the current 2018 health budget allocation (1.6 billion SSP which is less than 1%) is simply not enough. Investing in training health workers, payment of salaries, purchasing and transporting of medical supplies to all parts of the country require at least an 8% increase in the health budget.
Girls’ and women education reduces maternal mortality
Research has shown that there is a positive correlation between education and health. Worldwide, as rates of schooling and literacy increase, rates of maternal deaths have fallen. Poor, uneducated women have poorer pregnancy outcomes compared to more educated women. A research study found that women with no education had 2.7 times and those with between one and six years of education had twice the risk of maternal mortality of women with more than 12 years of education . There are a number reasons why women’s education may reduce rates of maternal deaths. The main causes of maternal mortality are pregnancy-related: preeclampsia, bleeding, infections and unsafe abortion. The more the woman is educated, the higher the chances of her correctly identifying risk factors and/or adopting simple life-saving skills such as maintaining hygiene. They are also more likely to access sexual and reproductive health information, access safe abortion services, and may be more willing to go to health facilities for deliveries.
However, South Sudan’s investment in the education sector is dismal. In the 2017/2018 fiscal year, the education sector received 1,863 million SSP of the 44,000 million SSP set aside (8% of the total budget). As with the health budget, this amount is insufficient to provide adequate and quality education. Furthermore, most of this money is channelled into recurrent expenditure such as teachers’ salaries. South Sudan should increase the budget amount and target improving not only basic primary schools, but also focus on secondary schools and tertiary education. The government should also focus on creating favourable conditions which attract and keep girls in school, including addressing harmful cultural norms such as child marriage which keeps girls away from schools.
- Ngatho M, Anthony Z, Jessica B. Maternal and Child Health in South Sudan: Priorities for the Post-2015 Agenda. SageOpen 2015. https://doi.org/10.1177/2158244015581190
- Cometto G, Fritsche G, Sondorp E. Health sector recovery in early post-conflict environments: Experience from Southern Sudan. Disasters, 2010 34, 885-909. doi:10.1111/j.1467-7717.2010.01174.x
- World Bank. “Interim Strategy Note, the Republic of South Sudan.” Report No. 74767 -SS. January 30. 2013. http://documents.worldbank.org/curated/en/214241468103735161/South-Sudan-Interim-strategy-note-for-FY2013-2014
- UNDP. An analysis of Government Budgets in South Sudan from a human development perspective. http://www.undp.org/content/dam/southsudan/library/Discussion%20Papers/SS-Discussion%20paper%20final.pdf
- Saffron K, Lale S, João-Paulo S, et al. The relationship between maternal education and mortality among women giving birth in health care institutions: Analysis of the cross sectional WHO Global Survey. 2010. Maternal and Perinatal Health.