South Sudan’s Health System and Aid Dependency Insights from the Perspectives of the Public Health Experts in South Sudan

Joseph Cirilo Deng Majak

The Hebrew University of Jerusalem

DOI: https://doi.org/10.51244/IJRSI.2023.1011049

Received: 20 November 2023; Accepted: 23 November 2023; Published: 21 December 2023

ABSTRACT

South Sudan is one of the countries that depends largely on the foreign aid. Health system in South Sudan has been funded by the health pooled fund, a consortium formed by the UKAID, USAID and others to finance primary and secondary health services to the people in need. The other sectors of the government are equally funded by external aid and donors’-based funding. The idea of the external aid is usually to provide support, alleviate hunger, end poverty, foster economic development of the local economy and importantly help the government organs to transit and be more independent with some sustainable policies and projects.

This qualitative research attempt is to inquire more about the reasons of aid dependency especially for the health system in South Sudan from the perspective of national public health experts working in the humanitarian and government led institutions. Public health experts in South Sudan believe that external aid can be a blessing to the country if managed well and in line with the 2005 Paris Declaration on Aid Effectiveness that focused on donor harmonization, country ownership, alignment with the recipient country’s national development strategies, accountability between donors and countries to be an effective way to increase the positive impact of aid(6). The participants however admitted that this was not the case for aid management in South Sudan and that corruption, mismanagement and issues related to donor’s regulations have made it impossible for the external aid to make its intended effect and mandate to strengthen the local system and support the government’s reforms for a more sustainable approach.

INTRODUCTION

South Sudan’s health system before the past relied on the public funding with a huge support from the private sector ,the country’s health system is organized at primary ,secondary and tertiary level with a component of community health initiatives ,but the organization has been interrupted badly with the civil that blunged the country into a protracted humanitarian crisis .The health system has been fragile and is currently   overstretched with additional strain from the COVID-19 pandemic  .As per the WHO, nearly a quarter of all hospitals and one third of all primary health care centres remain non-functional and unable to respond to the growing health needs. The system depends hugely on the humanitarian assistance.

The country is said to have some of the worst health indicators in Africa and the world. As per the WHO, the maternal mortality rate is estimated to be 2,054 maternal deaths per 100,000 live births and 98.7 per 1000 live births as under five mortality rates. The ongoing conflict has led to widespread destruction, looting and importantly non-functionality of health facilities with reported health care workers being targeted and killed.(1)

South Sudan is lagging behind when it comes to fulfilling its obligation with regards to Abuja declaration which  In 2001 asked the African union member states to pledge to allocate at least 15% of their national budgets each year to improving their healthcare systems. The health system in South Sudan is currently very fragile and being funded by more than 80% by foreign aid and is totally dependent two funding mechanisms namely, the Health Pooled Fund (HPF) through a consortium led by Crown Agents (UK) and the other is Essential Health Services Project (EHSP) funded by World Bank (WB) through a consortium led by UNICEF.(2)

The humanitarian organizations are currently responding to the health needs in South Sudan and based on the humanitarian response plan for 2023(3) , there currently 6.8 million people, including 3.4 million children and 1 million people with disabilities who are in need of health services and other services that are considered to be essential .The response is however coordinated ,implemented and importantly funded by external aid with so limited support from the government of South Sudan .Troika has recently urged the government of South Sudan to meet its commitments without delay with regards to increasing its funds for the humanitarian assistance.

The country’s economy is deteriorating and the already stretched health system is facing a protracted health crisis that is getting worst with lots of shocks that have been hitting the country. There is lack access to basic health services and weakened the health system’s ability to provide the population with the basic health care they need. People living in host communities, IDP camps, and refugee camps still rely on humanitarian agencies to provide basic medical services and support with needed medical supplies.

External aid in South Sudan is surely having a positive impact on the country especially in accelerating growth, development and importantly reduction of the level of poverty. However, aid dependency is said to have some negative consequences and can harm the countries in many aspects. Some people argue that the dependency can make the country and its people unlikely to develop.

Some of the negative effects related to aid dependency are issues related to the whole population being unable to save, or to produce goods and importantly not to be able to work. As per the government, aid dependency can negatively influence the domestics consumption and even productions of items for exports and can also have its harm on the reform policies related to health financing and hence have an ultimate effect on the health system strengthening in terms of services and the quality of health care.

The effect of foreign aid on the health system can be attributed to the fact that donors sometimes come in with their own policies that need to be prioritized and implemented leaving the government with no option but to let go of its own home-grown development policies and adopting the plans of the donors.

Another example of aid dependency’s negative consequences is related to accountability towards the affected population. The government in most of the instances will instead of focusing on delivering services to the public and being held accountable to its population, will focus on pleasing and entertaining the donors in an efforts to show its compliance with the donor’s rules and requirements and hence neglecting its sole role and its moral and ethical obligation towards its citizens!

Long term planning of projects can be an issue associated with foreign aid simply because donor’s fundings are unpredictable and the pledges can be made with being adhered to and committed to with a realization. This can without any doubt effect the planning efforts of the government and citizens for their future. Donor’s promises and priorities change based on the context for instance, the current donor priority is on Ukraine and with the ongoing crisis and war on Qaza ,the priorities will totally change leaving all the planned activities unimplemented.

Finally, reducing aid dependency is something desired by most of the intellectual, reformist and importantly by the vulnerable people and this is true with regards to the times of budget cut. Despite the fact that aid is beneficial to the countries and people, yet dependency on it has to be reduced and hence, this research is trying to explore the reasons behind it and the way forward to reduce, get rid and finally becoming aid independent for a better tomorrow.

Statement of the Problem

The gross domestic product per capita in South Sudan was forecast to increase between 2023 and 2028 by in total 104.8 U.S. dollars (+25.11 percent). This overall increase does not happen continuously, notably not in 2025. According to this forecast in 2028, the GDP per capita will have increased for the third consecutive year to 522.26 U.S. dollars.(4)

South Sudan government spending on healthcare has been decreasing from 8.4% of the national budget in 2007 to only 4% in 2020 which is totally behind the commitment of Abuja declaration which mandate the countries in the African union to stick to 15% of support to the health services .(5) .It’s believed that since 2012 ,South Sudan health system has been under external support (i.e., the US Agency for International Development (USAID), World Bank (WB) and the UK Foreign Commonwealth and Development Office(FCDO) and since then, these big donors have been supporting almost 90% of the health care services in South Sudan with an idea of building the capacities and finally handing over the facilities to the ministry of health of South Sudan gradually till 2025.

External aid that has been provided to the ministry of health in South Sudan was meant to strengthen the health system that was totally collapsing with an idea that the government to take over health financing and become independent with the time and qualified to take over, yet it has been observed that the dependency is becoming worst and with the possible cut of funding from the international donors and the shifting of funding to more conflict areas like Ukraine and the frustration that happened to the donors with no commitment from the government of South Sudan to fulfil its commitment towards finding a lasting solution to the issue, it’s very essential at this juncture to talk to the public health experts about their understanding of why the problem of dependency is still a major problem.

It’s believed too that the issue of dependency on external aid in the context of South Sudan has not been an area of concern and research by the academic community and hence, there is a lack of information and data on the matter. This research will inform policies and will add to the research data on South Sudan context from which further research could capitalize on and provide more insight into the matter of dependency on foreign aid.

Research goal & Research questions

This research proposal is trying to address the following questions and the answers will be used to achieve the general and the specific objectives associated with this proposal and are as follow:

1. Is South Sudan’s health system dependent on external aid?
2. What are the reasons behind the aid dependency for the health system in South Sudan?
3. What could be done to solve that based on the perspectives of public health experts?

STUDY METHODOLOGY AND ETHICAL CLEARANCE

The study was conducted in Juba /South Sudan deploying qualitative mixed methods using Focus group discussions & in-depth interviews will be conducted with a total of 20 study participants. The interviews were done and conducted in English or by translating from Juba Arabic. The data was analyzed using thematic analysis.

Its worth mentioning that the administrative clearance to carry out this qualitative research was provided by the Ministry of Health with the ethical review board. The research employed an exploratory qualitative research design that allowed the exploration of the perspectives of the public health experts in South Sudan on the issues aid dependency of the health system.

We utilized a purposive sampling to recruit the public health experts from different organizations and institutions simply because the purpose of the research was to get some detailed and in-depth understanding of external fund dependency. Those who met the eligibility criteria were invited to take part in the study. Below are the criteria used for inclusion:

1. having more than 5 years of work experience in public health in externally funded projects
2. Having at least a bachelor’s degree in public health or health related degree
3. Having worked for 1 year in an area related to health system strengthening.

The exclusion criteria included: having no or little experience of public health in South Sudan; and having no expertise in health system strengthening.

Email invitations were then sent to the included participants. later on, a participant information sheet was shared and a consent was sough via email from the participants. A skype interview was then scheduled. Out of the 25 participants who were invited, only 20 were able to participate in the study. Its true that the participants that were invited were reminded by emails many times. The profile of these participants is given below.

As part of the data analysis, we have done thematic analysis to analyse the interview transcripts that was done. We were able to look deeper into data collected while identifying the emerging themes and ideas that came out from such discussions and that were considered as relevant and connected to the topic of the research.

Table 1 Demographic breakdown of participants by profession and sector of work. Total respondents n= 20.

Significance of the Study

It’s believed too that the issue of dependency on external aid in the context of South Sudan has not been an area of concern and research by the academic community and hence, there is a lack of information and data on the matter. This research will inform policies and will add to the research data on South Sudan context from which further research could capitalize on and provide more insight into the matter of dependency on foreign aid.

LIMITATIONS OF THE STUDY

Positive aspects of the study design

1. The research method or deign chosen (in-depth interview) was able to uncovers valuable insights and enabled the author to find out the real story from public health experts in South Sudan. The participants opened up on a one-one-one basis and surely that helped for a real disclosure. The method allowed for questions to be added or altered in real-time manner when needed and this has allowed for more details to be added.
2. It’s worth mentioning that the study allowed for rapid completion of the investigation and is independent of follow up. The study also was not costly to conduct and did not require a lot of time and finally the findings and the outcomes were easy to be analysed and to create new theories and hence, the study is believed to form basis for further investigation for other researchers who are interested in health financing and things to do with external aid and aid dependency.

limitations faced by the study

1. The sample size is small due to the nature of the country in terms of having qualified public health workers who could meet the inclusion criteria to be interviewed and some lacked the professional experiences. In addition to that, given the length of each interview, the author had to reduce the number for issues associated with costs.
2. During the analysis time, the data were somehow ambiguous, and this has resulted in a more difficult analysis.
3. Due to the time constraint, it was not possible to include more participants.
4. Finally, because the South Sudan is still under lots of security pressure, it was difficult to get participants that could trust the researcher with their inputs and hence, that could be a source of bias especially when it comes to reasons behind the aid dependency.

RESEARCH RESULTS

100% of the participants of the study principally agreed that the health system in South Sudan is dependent on external aid with some going further to elaborate that the government’s funding to the health sector has been below the 15% of the GDP cut point outlined during Abuja declaration with lots of gaps being fully bridged by the big donors like the health pooled fund and others like the world bank.

When asked about the reasons behind the aid dependency, 90% of the public health experts interviewed agreed that lack of political will and the fact that the government has no clear policies to reform the health sector was the main reason behind the external aid dependency. About 75 % of the participants too admitted that donor behaviour is also considered to have a significant influence on the issue of aid dependency with the fact that donors provide local NGOS with little encouragement, incentives, or support to build local fundraising capacity.

Corruption and lack of system has been incriminated by the participants too to be one of the reasons for why foreign aid is dominating the context .98% of the participants think that corruption is hindering the government from coming up with a sustainable approach to address the matter of aid dependency.

Finally, donors’ regulations and political agenda has been mentioned by 99% of the public health experts interviewed as an unofficial reason of why donors want their fund to be the main financing method to the health system. The participants believe too that donors want to advance their political agenda and to impose their western ideologies such as respect to LGBTQs and freedom of speech on countries of the global South.

The public health experts generally agreed on the following recommendations:

1. Ministry of health to develop a broad mix of resources, including both external and domestic funds. There is a need for more technical capacity building and research base to support fundraising locally for the benefit of the vulnerable population.
2. South Sudan government and the ministry of health to identify priorities and to match donors accordingly to avoid reliance on donors’ ideas and hence be able to advance its reforms agenda.
3. The Ministry of health should proactively prepare for transition, even where transition is not an immediate reality.
4. The ministry of health to tackle and addresses health system
5. More advocacy for development of stronger partnership among stakeholders especially local NGOs and private sector to do more locally in terms of financing health services.

CONCLUSION AND RECOMMENDATIONS

With the huge inflows of foreign aid over the last decade, South Sudan still ranks among the poorest states in the world. there are no officials’ studies conducted on the causes of the foreign aid dependency in South Sudan and most of the literature available are inconclusive and often illustrate contradictory results.

Public health experts in South Sudan believe that external aid can be a blessing to the country if managed well and in line with the2005 Paris Declaration on Aid Effectiveness that focused on donor harmonization, country ownership, alignment with the recipient country’s national development strategies, accountability between donors and countries to be an effective way to increase the positive impact of aid(6). The participants however admitted that this was not the case for aid management in South Sudan and that corruption, mismanagement and issues related to donor’s regulations have made it impossible for the external aid to make its intended effect and mandate to strengthen the local system and support the government’s reforms for a more sustainable approach.

As per the participants in the study, South Sudan had received bilateral and multilateral loan package as per the terms and conditions set by donor countries such as the International Monetary Fund (IMF) and World Bank. But unfortunately, it was not able to pay back loan consequently South Sudan was engulfed in debt trap circumstances and ruined its domestic economic infrastructure. This has led to a condition where it has failed to set its own pace and directions for development and hence, the country has been dependent on external to fund its essential sectors that are linked to services delivery like health, food security and importantly agriculture.

Declaration by author

This work is composed of my original work, and contains no material previously published or written by another person except where due reference has been made in the text.

I have clearly stated the contribution by others to my document, including statistical assistance, survey design, data analysis, significant technical procedures, and any other original research work used or reported.

The content of my work is the result of effort I have carried out and does not include a substantial part of work that has been submitted to qualify for the award of any other degree or diploma in any students centre, neither has been developed for my daily work. I have clearly stated which parts of my work, if any, have been submitted to qualify for another award.

I acknowledge that I have worked under a Creative Commons License and an electronic copy of my work can be uploaded on the Institute’s webpage.

REFERENCES

1. South Sudan (SSD) – Demographics, Health & Infant Mortality – UNICEF DATA [Internet]. [cited 2023 Oct 8]. Available from: https://data.unicef.org/country/ssd/
2. Anib VA, Achiek MM, Ndenzako F, Olu OO. South Sudan’s road to universal health coverage: a slow but steady journey. Vol. 41, Pan African Medical Journal. African Field Epidemiology Network; 2022.
3. HRP 2023.
4. South Sudan – gross domestic product (GDP) per capita 2018-2028 _ Statista.
5. Abuja declaration on health financing- Yahoo Search Results [Internet]. [cited 2023 Oct 8]. Available from: https://search.yahoo.com/search;_ylt=AwrFRu.kySJlmhwCGnlXNyoA;_ylc=X1MDMjc2NjY3OQRfcgMyBGZyA21jYWZlZQRmcjIDc2ItdG9wBGdwcmlkA25EV09ZVG8xU3ZhbGk2VGNTcDVCYkEEbl9yc2x0AzAEbl9zdWdnAzEEb3JpZ2luA3NlYXJjaC55YWhvby5jb20EcG9zAzEEcHFzdHIDBHBxc3RybAMwBHFzdHJsAzM3BHF1ZXJ5A2FidWphJTIwZGVjbGFyYXRpb24lMjBvbiUyMGhlYWx0aCUyMGZpbmFuY2luZwR0X3N0bXADMTY5Njc3ODY3Ng–?p=abuja+declaration+on+health+financing&fr=mcafee&type=E210US739G0&fr2=sb-top&iscqry=&mkr=8
6. THE PARIS DECLARATION ON AID EFFECTIVENESS: FIVE PRINCIPLES FOR SMART AID [Internet]. Available from: www.oecd.org/dac/effectiveness/results

Author

Joseph Majak is a medical doctor and public health specialist with an over 10 years’ experience in Africa and the Middle East in managing and providing technical assistance in public health programs in the areas of Child and maternal health, family planning immunization, infection prevention, Emergency response & outbreak investigation and health system strengthening.

Joseph Majak has a bachelor’s degree in medicine and surgery and a Master of Public Health from the Hebrew university of Jerusalem in Israel, He works currently as a medical coordinator for Syria mission with MdM France and is based in Jordan where he provides technical support to the local partners in Syria offering health related and emergency projects to the people of concerns in conflict affected areas in Syria.

Mr Joseph Majak has an extensive experience in providing technical assistance to ministries of health (MOHs) in strengthening public health systems and building capacity of health care workers. He has worked in management and technical capacity at International and national level providing management and technical oversight.  Joseph is familiar and experienced in working with DFID, SIDA, WFP, FAO, UNICEF, ECHO, USAID, and other donor programs and knows their regulatory, financial, and legal requirements.