Report of the Salisbury, Sudans Medical Link Team visit to Western Equatoria

“Growing Healthy Communities, Saving Lives in South Sudan”.

Introduction

The Salisbury, Sudans Medical Link (SML) supports the Episcopal Church in South Sudan (ECSS) in delivering healthcare to its people and local communities. This is mainly through the provision of consignments of medicines to 16 primary healthcare clinics as well as sponsoring and funding the training of clinical officers, nurses, midwives and laboratory technicians for suitably qualified Christian students. In November 2022, three team members of the SML (Dr Karen Mounce, Mrs Anne Salter and Dr Robin Sadler) self-funded a visit to Western Equatoria, South Sudan.
This report outlines the findings of that visit which will support and inform the continuous development of the strong partnership and links between the Salisbury Diocese and the ECSS.
The programme for these visits was planned by the Episcopal Church of South Sudan and the Salisbury Diocese in fellowship and partnership. We are grateful for the support of Archbishop Samuel Peni and the Bishops from Ezo, Nazara, Yambio, Maridi and Olo who supported us with safe travel and hosting arrangements. This joint planning enabled the team to visit 16 primary healthcare clinics, 2 hospitals, government clinics, the Maridi Training Institute, a meeting with 11 students as well as meetings with government officials, attendance at a Youth Forum and Church Services. In addition, the team visited schools and a theological college. A total distance of 450 miles was travelled. Local communities provided a warm effusive welcome to the SML team, with music, dancing and speeches given by community elders, chiefs, pastors and clinical staff. It was clear that the SML was highly regarded and valued.

Why Visit South Sudan?

The vision of the Salisbury, Sudans Medical Link is that “The Episcopal Churches of South Sudan (ECSS) and the Salisbury Diocese collaborate in a Christian Partnership of fellowship and faith focusing on improving health outcomes in South Sudan.

Unlike an aid agency, the SML is based on mutuality: that two churches separated by distance and culture can care for one another in sharing resources, experience and practical help. Central to the SML is prayer for one another, strengthened by relationships between people from different countries.

(In terms of governance, the SML is a recognised subcommittee of the Salisbury Sudan Link Committee (SSL). The Diocesan Board of Finance is the overarching registered charity and the work of SML is overseen by the executive body, the SSL).

During 2019 – 2022 visits to South Sudan were curtailed because of the Covid-19 pandemic. The team visit in 2022 was planned to re-establish the personal connections and to monitor how the funding is being utilised in clinic settings and for the training of students. We hoped that the visit would enable fellowship and greater understanding of cultural, spiritual and health benefits of working together.

The aim of the visit in 2022 was to:-

To renew friendships and partnerships with Bishops and their staff.
To take sincere greetings from the Salisbury Diocese
Ensure accountability to our donors and sponsors that funding is well spent and not wasted
Review training and impact of health care workers
Observe pharmaceutical deliveries, drug utilisation and prescribing practice.
Assess clinic settings and equipment
Improve understanding of the level of support and professional development training for clinical staff
Meet participatory groups such as the Mothers Union who have a role in improving health.
Meet people and schools linked to communities in the Salisbury Diocese

Current situation in South Sudan

South Sudan is a land locked country in Africa that became independent from the north in 2011. Sadly the assumption that independence would result in freedom has not been realised as yet. The 11 million population still relies on subsistence agriculture and gathers charcoal for fuel. One million people live in IDP camps and 2-3 million in refugee camps. A country the size of France, South Sudan has only 186 miles of paved road and 90% of its population are without access to electricity or clean water. An estimated 60% rely on food dropped by the World Food Programme. (Some define it as a non-functioning state without the institutions required for democracy). South Sudan has great potential though. The fragile peace is holding and travelling across Western Equatoria, the visiting team felt safe. Dr Sadler noted that the infrastructure had hardly changed in the last 15 years.

The country’s maternal mortality rate is 789 deaths per 100,000 compared with 9 per 100,000 in the UK. 99 under-fives die per 100,000 compared to just 4 in the UK. Malaria, diarrhoea or pneumonia are what kills most but it’s because they are so malnourished that they are so vulnerable”.

We were able to meet a number of government officials on our visit and there was a consistent message. The County Health Director and Commissioner in Maridi were relatively open in acknowledging the government systems were struggling due to lack of funding. The Pooled Health Fund and other initiatives were ending as NGOs withdrew. The hospital in Maridi was running out of medicines regularly and ECSS Bethsaida clinic was picking up those patients, for which they were very grateful. We heard similar stories in Nzara with even the RC hospital St Theresa’s running out, as well as Yambio hospital near closing down, and Ibba hospital struggling to find staff.

It is notable that we saw no evidence of mosquito nets in community settings which are essential, especially for pregnant women and children. This is perhaps a litmus test of the government’s commitment to the population’s health.

The national minister of health, Yolanda Awel Deng, is quoted as saying the ministry is financially incapacitated and cannot stock the hospitals with essential medical drugs. ‘As I speak now, South Sudan does not procure any single emergency drug for our population’. She said most drugs being used are procured by health partners and other donors. In recent years the SS government has abandoned a significant number PHCUs. ECSS has taken over a few of these buildings but the government will not supply medicines. For example, 34 clinics around Maridi were reduced to 22, and currently only 7 are supplied. This position is repeated over Western Equatoria

What did we find when visiting the health clinics?

The population attending clinics was hugely variable. Some clinics provided services for a number of outlying villages. Others were impacted by internally displaced persons, nearby schools, army personnel, government clinics with no drugs. The largest clinic by far was Bethsaida Clinic in Maridi where in October 2022 they saw 567 under 5’s and 1,842 over 5’s.

Staff supported by the ECSS and SML across the clinic settings varied in number and experience (see appendix 2 ). A newly established clinic in Yubu where the ECSS recently responded to an identified need was served only by one nurse and a community health worker in a very basic but clean environment. Meanwhile in Bethsaida clinic, we saw an example of 15 ECSS staff and 20 government staff working together to provide a range of services including family planning. (There was no focus or agreement on family planning services at any other clinics). Joint working appears to have given Maridi a good name. None of the clinic registers recorded anyone over the age of 60 which aligns with current thinking that the average mortality rate in South Sudan is likely to be in the region of 55 years.

Public Health promotion did not feature prominently across the clinic settings but we did observe some excellent work in Ibba with early stage community mapping and health education to communities by their programme manager who had completed a 3 year public health medicine course in Kampala. Unfortunately he was hampered by a lack of resources to support his programme. In addition we recognised that the Mothers Union has a key role in preventing illness through sharing knowledge around first aid, malaria prevention, cleanliness and hygiene and immunisation awareness.

Where clinics appeared to be working well they were supported by the local Pastor, Chief and a well-established committee who checked the drug supplies and valued the clinical staff.

It became very clear that the SML is well thought of and that drug supplies provided by SML are often their only source of medical support. Some simple drugs such as antibiotics and antimalarial drugs are literally “lifesaving”. It was disappointing that preventative approaches such as mosquito nets were not available in any of the communities.

The morale of the staff was variable and ranged from confident, articulate individuals striving to make things better, to those who seemed to be struggling with the burden of illness presented to them and the lack of available resources. Some staff don’t appear to have the confidence or feel able to deal with day to day equipment issues e.g. scales just left in a box because the batteries ran out. Emotional and clinical support for difficult cases was not always in place. However, we did see some staff supporting each other e.g. Nurse supporting a midwife with deliveries and another nurse who always gave public health messages before prescribing. A small number of staff appeared to have “scrubs”, a white coat or a pink overall for midwives but this was not in all settings. Staff expressed that they would like a uniform to distinguish themselves from the patients and to improve hygiene.

Payment for staff was a contentious issue. The agreement between the ECSS and the SML is that students will be sponsored for 3 years with a further period of about 9 months of internship. The expectation is that they then return to their village/community for an agreed period and this is considered as voluntary work. In some areas the committee members’ ensured clinical staff received a stipend. Some clinics charged patients for registering and a consultation fee, elements of which then were able to support the clinical staff. There was no systematically agreed system and some dissatisfaction with some staff groups who felt they should be paid.

Our overall impression of the environment for the majority of clinics was that they were in a very poor state of repair. Often holes in the floor were not repaired, couches and delivery beds were not clean. We saw limited evidence anywhere of cleaning regimes. There was a lack of lighting, fridges and equipment in many of the clinics. Midwives delivered babies by torchlight.

Continuous professional development was generally not in place. Some staff were able to access an occasional study day. There was a general keenness for further training. Community health workers were often diagnosing and prescribing after just a 9 month training. Traditional Birth Assistants (TBA’s) providing essential maternal and infant health care during delivery and ongoing community care had minimal training but were generally supported by a trained midwife

Record keeping was generally of a good standard with regular reporting on a monthly basis to the government. This information needs to be shared with the SML to inform understanding around demand management.

Clinical equipment was not at a “basic level” and diagnosis was generally by clinical observation only. Often there were no thermometers, stethoscopes, sphygmomanometers, scales or mid-upper arm circumference (MUAC) measuring tapes to help identify malnutrition (see Appendix 2). Basic sanitation as people entered the clinics was generally provided by a hand sanitiser. At Bethsaida Clinic we observed a regulated system with temperature recording and hand sanitisation before entering the clinic which we deemed to be good practice.

Health Coordination in terms of procurement of equipment, local monitoring of drug supplies and agreed baseline quality standards for clinics were not in place.

Medicine supplies

The supply of medicines from SML to South Sudan has been active for many years whilst the distribution, pharmacies and delivery have changed over time. Medicine orders are received 4 monthly by SML and delivered to various distribution points with Nzara co-ordinating kits to Ezo and Yambio in addition to 13 local clinics. (Ibba, Olo and Maridi receive individual kits). Recently Archbishop Samuel Peni has requested that all the western deliveries be centralised from Yambio. Medicines orders undergo a tender process and are sent out from stores in Juba. Generous Pharma has become a preferred provider with good products manufactured in India and packed in kits for each clinic.

When the medicines arrive, SML receive proof of delivery by photos and a view of expiry dates and the quality of manufacture. Half of the payment is sent on shipping, and the final half on proof of receipt. Clinics come to a centralised point to pick up their medicines for the local Primary Healthcare Units and Primary Healthcare Centres. The bulk of the order is for treatment of malaria, pneumonia and water borne diseases. Vaccination programmes are delivered by “World Vision”

What did we find?

Firstly, we have to report that every clinic and community are exceptionally grateful for the medicines they get and their clinics and staff. The clinics take care of the medicines, neatly set out on shelves or in a lockable box. Many clinics have a security man. Some remote clinics keep the store in the Pastors home. The clinic books clearly set out the patients, diagnosis, and treatment. We did not see any store management to account for all the medicines except at the government hospital in Ibba.

Every site requested more medicines, some running out of malaria treatments within a few weeks, others in 3 months. We witnessed this as they were waiting for a delivery when we arrived. Both malaria treatment and rapid malaria test strips were finished. Other medicines were still in good supply, and we will need to readjust the amount of these, understanding that the needs are not uniform across the clinics. The new data we should receive from the clinic reports on a monthly basis will help in adjusting orders. Our approach to Malaria treatment needs an update from the experienced clinicians.

To meet increasing demand from vulnerable, isolated communities with no health provision, the ECSS tried to support by adjusting a proportion of medicines from 2 or 3 clinics to provide for clinics that had no drug supplies at all.

We understand that the SS Government has regulations on PHCUs and PHCCs and what can be prescribed and given on site. Medicine orders will take this into account in future.

Review of Training Institute and training programmes.

The SML currently have 11 students studying at the Maridi Training Institute (AMREF) and the SML team arranged to meet the principle Taban Patrick, and the students led by their representative Emmanuel Esai.

Principal Taban Patrick (TB) welcomed us into the college and was generous with his time.

The college complies with the South Sudan national curriculum and national external examinations. The new research module requires data and storage and laptops are necessary to support student learning. TP thought these devices could be handed on to the next students coming through. He reported there is internet on site and daytime electricity. There is computer availability and a basic skills laboratory.

There are 6 tutors. Midwifery is led by a midwife with Batchelor degree and there is also a Nurse tutor. A Doctor is a tutor for several modules in medicine and surgery. Keeping trainers is increasingly difficult as they find better paid posts elsewhere. An example of this is the national trainer training college in in Juba.

The Institute currently has 58 students in training to be Clinical Officers and 77 midwives in training. TP reports pressure from government for Clinical Officer Training and Midwifery to reduce the maternal and infant death rates. This focus has inevitably led to a lack of students coming forward for nursing.

A picture has emerged that some SML students have struggled with independent learning and are finding some modules problematic. The opportunity for a more robust recruitment process at the outset was discussed and a way forward agreed. Firstly students need to meet the required academic level and to be selected as appropriate for training by the ECSS. TP agreed that he could then meet potential students and assess through interview with a further academic test. Bishop Moses and Archbishop Peni both supported this approach.

The SML team met with 10 students and had a group discussion. Students were able to voice their opinions and provided a rich source of information in relation to the curriculum and support for learning. They struggled with the turnover of teaching staff and commented on the setting of inappropriate exam questions, lack of continuity and parts of the curriculum missed. They were concerned about the lack of academic help if problems arose and stated that they weren’t able to access the skills lab after first year. The internet was not always working and with only 1 hour to use Wi-Fi they had difficulty downloading computer notes. They were disappointed with the lack of contact from their sponsoring Diocese. On a positive note they valued the opportunity provided to them by the SML to attend the Institute and were grateful for the additional funding received from SML for laptop provision and travel costs to enable them to see their families.

Actions taken whilst in South Sudan.

The visits across Western Equatoria, carried out in partnership with the ECSS enabled the team to have a deep understanding of the health services and challenges faced by the population. There were some immediate actions that we initiated whilst in the country and these are detailed below.

Feedback session with ECSS led to direct messaging to clinics to improve hygiene and cleanliness of environments which was very encouraging.
Early discussion around the potential of a health coordinator role based in Western Equatoria.
Clarity and agreement that SML are unable to expand the number of clinics further and that the focus of work will remain in Western Equatoria at this stage.
Costings requested for basic clinical equipment and some early funding provided.
Funding provided for locally made “scrubs” for staff in Nzara on the basis of a specific request.

Recommendations.

The considered view of the SML Team is that resources and training need to focus on Western Equatoria with the ambition of “doing things well” rather than spreading resources across a wider area. The visits identified health gaps across Western Equatoria that do not fall under the current remit of the SML but which we feel could improve health by developing strategic links. These are identified below. We aim to support the improvement of clinical outcomes through the means identified below. (ECSS indicates Episcopal Church of South Sudan. SML indicates the Salisbury Sudan Medical Link. Joint indicates joint responsibility).

Direct Support (Jointly agreed in Partnership ECSS and SML)

Monthly report from the clinic settings to enable the SML to monitor prevalence of health conditions and drug usage. This has been agreed by the ECSS and should not be too problematic as regular reporting of this to the South Sudan Government already takes place. ECSS to send electronically.
Revision of drugs supplied, based on knowledge obtained during the visit and on further data when supplied. SML to revise and to be agreed with ECSS.
Agree checklist of basic clinical equipment that should be available in every clinic. Joint
Need for staff uniforms and “scrubs” to improve hygiene and professional roles. Joint
Jointly agreed partnership approach to revise the student selection process in South Sudan with the aim of supporting students with their learning, subsistence and support. SML and agreed by ECSS.
ECSS to revise the partnership agreement with students with clearly defined agreement around responsibilities of the Church and students including length of service post qualification. ECSS and agreed by SML.

Salisbury Diocese and Sudan Medical Link

Presentations across the Diocese to promote the work of the SML and to increase knowledge and fundraising
Consider how the website could be used more effectively to link across the Diocese
Promote parishes, individuals and groups to sponsor and provide ongoing support to students.
Develop regular “giving” from interested individuals as part of an SML Partnership approach. Invite clinicians who may be interested in visiting South Sudan.

Strategic Relationships to be developed by SML.

Link with international organisations that support mosquito net provision to provide nets for pregnant mothers and children in Western Equatoria.
Link with the Nursing and Midwifery Council in South Sudan to share information about our training programme and to enquire about potential Joint Training and updates and opportunities for clinical staff in partnership with the SML.
Information around the paucity of Early Childhood Development and support for play in rural areas to be shared with the Education sub-group and how this can be supported strategically.
Consider whether laptop computers can be provided by an external charitable organisation for students in training. Joint.

Conclusion

This report has been developed for the Salisbury Diocese and for the Episcopal Church of South Sudan in the spirit of faith and joint partnership. We are indebted to the clergy, staff and individuals in South Sudan who helped with the organisation and support required to travel such long distances.