Letters to the Editor


Letters to the Editor

Below is a response to the article ‘Can primary health care staff be trained in basic life-saving surgery?’ by Sunday  Manoach Leet,  Abraham Kot Gai, Andrew Adek and Giuseppe Meo published in SSMJ (vol 5 no3). Please send your comments to the Editor at [email protected].


Dear Editor

In response to the article “Can primary health care staff be trained in basic life-saving surgery?” published in the August 2012 edition of the South Sudan Medical Journal perhaps we could make the following observations.

There is little doubt that non-medically qualified personnel can be trained to undertake surgical procedures and where this training exists and there are suitably able people every effort should be made to utilise their skills.  However, we have serious reservations about creating a surgical service which is based around non-medically qualified personnel for the following reasons:

  1. There is a lot more to surgical care than just the operation and this requires wide-ranging knowledge of a number of subjects, including anatomy, physiology, pathology, therapeutics, the medical care of the surgical patient and the recognition and management of complications.  All these form the basis of medical training.  Practitioners without this training can only provide part of the care and in our opinion should be directly responsible to a doctor who is in overall charge of the patient.
  2. It is recognised that there is a desperate need for immediate surgical care in South Sudan and a serious lack of healthcare professionals at all levels.  It is however important to recognise that the “task-shifters” are only going to be fire fighters of the immediate problems.  This does not address the issue of developing a structured health service for the medium and long term.  We believe that a doctor led system has stood the test of time but it is for the Government of the Republic of South Sudan to determine policy on this matter and we should respect their views. We would be concerned at the development of a healthcare structure which was not part of the Ministry of Health Strategic Plan. Furthermore we should not proceed with developing healthcare professionals, possibly at variance with government policy, without clarity as to their precise lines of responsibility, range of practice, validation of training, registration and where they fit into the long term structure.
  3. There is a substantial  number (possibly as many as 200) of doctors of South Sudanese origin across North and South Sudan who have had basic medical training, have the basic knowledge and achieved a medical qualification but have had no opportunity for postgraduate training to enable them to work effectively at the District level.  Surely it would be sensible to focus on developing this cadre of healthcare professional who would then be able to increase the medical staffing in the Primary Health Care Centres and County Hospitals, promote a comprehensive surgical service and would also be in a position to provide on the job training to non-medically qualified assistants who would work under their supervision and in a supportive role.

In conclusion, we believe that the training of “task-shifters” without the concomitant training of doctors to supervise them could be a retrograde step and this could even impede health service development. Furthermore they should be an integral part of a structured health service in line with the medium/longer term strategy of the Government of the Republic of South Sudan.


Tim Walsh, BSc, MS, FRCS

Eluzai Hakim, FRCP (Edin & Lond), DTM&H

Endorsed by John Adwok, Consultant Surgeon


One of the authors of the original article has sent the following reply to the letter above:


Dear Editor

There is no doubt that all the points underlined by the colleagues are correct and wise. We fully agree with their opinions. The aim of the article was exactly to spark a debate on the issue and collect contributions on the applicability of the task shifting strategy in South Sudan. We believe that it is absolutely important to support the Government of South Sudan in the development of the health sector and, as an organization, Comitato Collaborazione Medica has always worked in this direction and aimed to fulfill the Ministry of Health requirements. However, we also believe that South Sudan could benefit a lot from the application of the experience of bordering countries where the strategy has been endorsed by their Ministries of Health and applied widely. The strategy is applicable to qualified staff, including medical doctors, and is based on specific training and on selected high impact interventions.

 When we started our project of Primary Surgery in remote areas of South Sudan in 1991/92 the insufficiency of the  health care system was dramatic. The lack of professionals was impressive too and in some areas there were no qualified professionals of any level. Wherever Comitato Collaborazione Medica had the opportunity, it employed and trained qualified health professionals.

In this regard, we take the opportunity to wish an even closer and broader collaboration with the Ministry of Health, evaluating opportunities of training, especially on life-saving interventions for ministry employees.


Giuseppe Meo

Comitato Collaborazione Medica Consultant Surgeon