UK-South Sudan Alliance: a strategy for increasing capacity and access to primary care and public health

Introduction

No one doubts the need for increased healthcare capacity in South Sudan. This need is exemplified by the statistics for maternal and child health ^[1]. These elucidate the serious challenge of healthcare in South Sudan, with estimates consistently placing the country towards the bottom of world rankings for maternal and child mortality ^{[2, 3, 4]}.

The scale and nature of this challenge requires resources to be directed both towards current health care provision, and towards developing capacity. This paper sets out an integrated strategy for developing the capacity, accessibility and delivery of primary care, and public health. It calls for international resources to fund a pilot and subsequent scale-up plan.

The strategy outline

This is a sustainable strategy, embedded within the health service institutions of South Sudan, and in-line with the Government’s National Health Policy, 2016-2025. There are two care delivery elements: advanced healthcare centres, and provision for mobile service delivery. These will be supported by public health services, and the training and supervision of integrated healthcare teams. 

Advanced Healthcare Centres and mobile service delivery

A model for an integrated Advanced Healthcare Centre (AHC), is described by Hakim and Joseph ^[5], and is adapted here with the addition of a supervised, mobile primary care element. The AHC acts as a healthcare delivery centre, and as a support ‘hub’ for the mobile service, and for smaller outlying clinics. It will deliver primary care, basic secondary care, provide referral to more advanced secondary care (as available), and develop public health and data collection services.  The Centres will provide training, supervision and service experience for trainees, and communications systems will enable distant mentoring and clinical support. 

Integrated healthcare teams

Staffing AHCs requires the training and development of integrated healthcare teams. This will be led by the College of Physicians and Surgeons of South Sudan, in collaboration with the College of Nursing and Midwifery, the Directorate of Public Health, and Juba Teaching Hospital, extending to other hospitals as conditions allow. Integrated healthcare teams will include a doctor trained in advanced primary care. A full team will comprise a doctor, clinical officer, midwife, nurse, public health officer, laboratory assistant, community health worker, health visitor, and manager.

The process

The initial objective is to build, staff and resource a single, exemplary AHC, with mobile service provision. To be a ‘fair test’, this pilot centre should be located in an outlying district.

Lessons learnt from this pilot will inform a scale-up proposal. The initial goal is to provide one AHC per 50,000 of population, ideally rising to 1:10,000 in the long term. Hakim and Joseph ^[5] estimate that the lower figure requires 158 ADHs, the higher, 790. These figures can be used as multipliers to indicate staffing requirements.

The ability to train sufficient integrated healthcare teams to staff ADHs, is essential. The development of training capacity (Table 1, items 3-6, and 7) must proceed in parallel with the provision and resourcing of ADHs, and the mobile primary care service.

An initial three year development project will establish and test the required processes. It will have three aims: to complete the pilot; to embed training and support processes; to test and complete an initial scale-up programme. Thereafter, a full scale-up programme will be developed. It is envisaged that this will take place over ten years, divided into five two-year programmes.

Development and support activity will require direct donor funding. Service sustainability will require a budget agreed with the Ministry of Health. Cost centres for funding comprise: building and equipment; staffing; medical resources and consumables; training and development; UK support.

Is this strategy practicable?

The establishment of healthcare institutions in South Sudan, led by the Ministry of Health, include the Directorate of Public Health, the College of Physicians and Surgeons, and the College of Nursing and Midwifery. These, along with the University of Juba, and Juba Teaching Hospital, provide the institutional framework for capacity building.

Meanwhile, 2017 saw the launch of the fledgling ‘UK-South Sudan Alliance for Health Sector Development’ ^[6], a collaboration between the Ministry of Health and colleagues in the UK, with the aim of supporting capacity building and health sector development in South Sudan. This has the potential of co-ordinating UK medical and educational support for the strategy, including visits, e-learning provision, and distant mentoring.

It would be naïve, though, to believe that the answers to all the challenges are apparent at the beginning of the journey. What is proposed is a ‘learning project’, in which we focus upon clear, practical goals, then act, learn, and improve. Success will be measured by: increased clinical capability; increased reach, access to and delivery of primary care and public health services; improving health outcomes; and improved clinical training and support.

Conclusion

South Sudan now has the institutional framework required to support essential capacity building in healthcare. This paper proposes a strategy for increasing capacity and access to primary care and public health services. Strategy aims, objectives and outcomes are summarised in Table 1.

The launch of the UK-South Sudan Alliance for Health Sector Development provides the means to co-ordinate international support for this strategy. As a first step, and to ‘kick-start’ the project, a scoping visit is required to bring members of the Alliance together, in Juba.

The purpose of the scoping visit is to appreciate the current situation on the ground, and to agree strategy, objectives, and ways of working with the Ministry of Health, health institutions, and colleagues.

Significant funding and long term commitment is required to enable this initiative to be realised, and so, finally, this is a call for international funding to support its achievement.

Table 1. A strategy for capacity building in primary care and public health: stage one

AIM	OBJECTIVE	OUTCOME
1. Establish an exemplary Advanced Healthcare Centre (AHC), providing primary care, public health services, and acting as a hub for mobile service delivery, referral, training and clinical supervision of doctors in outlying clinics.	Build, equip and staff an AHC as a pilot project. Create integrated service delivery at primary care level by developing healthcare team working practices, and integrated health management approaches Evaluate the pilot, develop a costed, replicable model, and plan for scaling up provision. Fully costed and tested replicable model for scale-up. Increased clinical services Improved health outcomes	Fully costed and tested replicable model for scale-up. ncreased clinical services Improved health outcomes
2. Provide a supervised mobile primary care service, linked to the Advanced Healthcare Centre, to provide safe service delivery in outlying, less accessible areas.	Equip and supply suitable vehicles, including vehicle-to-AHC communication. Develop a clinical referral/advice service for practitioners in the field. Fully costed and tested replicable model for scale-up. Increased access to clinical services in outlying areas. Improved health outcomes	Fully costed and tested replicable model for scale-up. Increased access to clinical services in outlying areas. Improved health outcomes
3. Train and develop an integrated healthcare team to staff the AHC, in collaboration with and by supporting the training of Nurses, Midwives, Associate Clinicians and doctors (see also 4 and 5, below). Current status: training of Nurses, Midwives, Associate Clinicians, and the postgraduate training of doctors, is delivered through the College of Nursing and Midwifery, and the College of Physicians and Surgeons	Implement a training plan for an integrated healthcare team to staff the AHC and mobile service Provide educational support from the UK in support of training in medicine, nursing, midwifery, and of Clinical Associates in basic obstetrics and gynaecology (see 7, below), comprising training visits, e-learning, distant mentoring and clinical support. Local staff training Co-ordinated UK based delivery of clinical and educational support Trained integrated healthcare team available to staff AHC and mobile service	Local staff training Co-ordinated UK based delivery of clinical and educational support Trained integrated healthcare team available to staff AHC and mobile service
4. Improve and extend the clinical capability of graduate doctors to provide an increasing supply of safe, competent, front line/primary care doctors, for service delivery and supervision of non-medical clinical practitioners. Current status: Basic postgraduate medical training (BMT) established but not fully embedded in practice, through the College of Physicians and Surgeons (CPS).	Review the current situation re postgraduate medical education and agree action plan to improve and embed postgraduate medical education at Juba Teaching Hospital; extend to outlying hospitals as conditions allow Build educational capacity of the College of Physicians and Surgeons in relation to needs. Implement trainer training programme for doctors of Juba Teaching Hospital, and outlying hospitals. Increasing number of competent primary care doctors working in AHCs and elsewhere in the health service.	Increasing number of competent primary care doctors working in AHCs and elsewhere in the health service.
5. Implement training in advanced primary care (APC), with enhanced skills (in paediatrics and medicine, or O&G and surgery), to provide higher level skills for clinical practice, leadership, referral, and supervision of the wider primary healthcare team. Current status: role agreed in principle with MoH and CPS	· Develop and implement the APC curriculum within the College of Physicians and Surgeons’ strategy for postgraduate medical education. Embed the APC role within the healthcare system Numbers of post-BMT doctors trained in advanced primary care. Numbers of advanced primary care doctors taking up leadership roles within primary care provision.	Numbers of post-BMT doctors trained in advanced primary care. Numbers of advanced primary care doctors taking up leadership roles within primary care provision.
6. Develop the provision of Public health and pathology services to enable access to pathology services by clinicians, and to enable Public Health service delivery via AHCs.	Develop a strategy with the Directorate of Public Health, linked to regional developments via the College of Pathology of East Central and Southern Africa, and supported by the Royal College of Pathology. Train doctors and technicians in Public Health Create effective working between primary care provision/AHCs, and Public Health/pathology services. Surveillance and data collection of epidemic prone diseases.    Improved speed and accuracy of diagnosis. Improving healthcare services and general health resilience Long term decrease in population mortality	Improved speed and accuracy of diagnosis. Improving healthcare services and general health resilience Long term decrease in population mortality
7. Develop the UK-South Sudan Alliance to provide co-ordinated educational and clinical support Current status: the Alliance was launched in 2017.	Facilitate networking and communication between UK-South Sudan to agree and co-ordinate support strategy Implement a programme of visits to provide educational and clinical support Develop e-learning support. Provide distance mentoring and clinical support Develop active links with UK medical colleges, in support of clinical training and supervision. Co-ordinated delivery of clinical and educational support	Co-ordinated delivery of clinical and educational support
8. Develop data collection and management services to support patient care, and to provide evidence to inform research and development in clinical and healthcare services	Establish health data collection and research unit within the College of Physicians and Surgeons. Embed service/patient data collection into routine clinical practice. Evidence based strategy development Research opportunities	Evidence based strategy development Research opportunities
9. Ensure medical resources and logistics match growth in service capacity	Develop a health services resourcing plan to accommodate a planned uplift in training, numbers, and distribution of practitioners, arising from this strategy. Increased capacity and service delivery	Increased capacity and service delivery

Acknowledgement: Dr Jamie Harrison, MA, FRCGP

 

References

1. Bregazzi R, Developing healthcare in South Sudan. South Sudan Medical Journal 2015; 8(2): 38-9
2. Infant mortality rate, country rank, https://www.indexmundi.com/g/r.aspx?t=0&v=29&l=en [accessed 11.2.19]
3. Maternal mortality rate, country rank,     https://www.indexmundi.com/g/r.aspx?v=2223 [accessed 11.2.19]
4. Alkema L, Chou D, Hogan D et al Global, regional, and national levels and trends in maternal mortality between 1990 and 2015, with scenario-based projections to 2030: a systematic analysis by the UN Maternal Mortality Estimation Inter-Agency Group, The Lancet 2016; 387:462–74  https://www.thelancet.com/action/showPdf?pii=S0140-6736%2815%2900838-7 [accessed 11.3.19]
5. Hakim E, Joseph V. 2013, Integrated Primary Healthcare (iPHC): A Model of Practical Implementation of a Healthcare Programme at County Levels (request from [email protected])
6. Bregazzi R. Launch of the UK-South Sudan Alliance for Health Sector Development, South Sudan Medical Journal 2017;10(4): 92-3.

 

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