An analysis by Juliana Bol
In 1987 African ministers of health launched the Bamako Initiative, vowing to accelerate access to health by strengthening primary health care service delivery, prioritising maternal and child health. This was followed by the 2001 Abuja Declaration in which African Heads of States committed to earmarking at least 15% of national budgets to the health sector, to accomplish the goals of Bamako and in recognition that lack of progress in achieving health targets is hampered by scarcity in health financial resources. (Note: This 15% is in addition to the 0.7% of Gross National Income (GNI) pledged by donor countries as Official Development Assistance (ODA) to the developing countries).
South Sudan has the highest maternal mortality ratio (MMR) in the world, at 2,054 deaths per 100,000 live births, and some of the poorest indicators on infant and child mortality at 84 and 105 deaths per 1,000 live births respectively.1 In South Sudan, we often speak of a commitment to improving the health of men, women and children, but in the 2014-15 national budget, this commitment to health translates to a paltry 3.5% of the Total Government Expenditure (TGE).2
|Sector/Spending Agency||Percent of Total Gov. Expenditure (TGE)|
|Transfers & Other||20.9%|
|Rule of Law
|Nat. Res. & Rural Dev.
|Social & Hum. Affairs||0.9%|
|Total Gov. Expenditure||SSP 10,842,316,325|
* Full RSS budget: www.grss-mof.org
The World Health Organization (WHO) estimates that countries need to spend at least USD 61 per capita on health in order to achieve Millennium Development Goals targets for health.3 Using the already low 2008 census population estimates as a reference, we spend less than USD 144 per person.
While South Sudan is fortunate because the international community has committed to considerably contributing to financing health programs across the country, it is wise to note that the 15% allocation for health (Abuja) was not inclusive of, but in addition to donor funding.
Given the poor health indicators and health infrastructure we inherited as a result of the war and the deliberate neglect by the Khartoum government of the periphery, our key objective must be increased per capita spending on health beyond Abuja. Our words must translate into action.
A minimum distribution of 2.3 health workers (doctors, nurses and midwives) per 1,000 population5 is recommended to deliver essential maternal and child health services, and to improve health outcomes in general. The health sector in South Sudan faces a critical shortage of qualified and equipped health-workers. Many of the existing health workers were trained years ago during the war, and have had few opportunities to upgrade their skills since.
With adult literacy of 27%6 our key priorities must include education; at primary, secondary, adult and tertiary level and, in particular, accelerated training of the nurse-midwife cadre and teachers. We must significantly increase the percentage of children graduating from schools nationally and encourage especially girls to pursue careers in the health and education sector.
We promised that education would be our post-referendum dividend, but note that current commitment to educating the children of South Sudan is a mere 5.6% of government expenditure; this is inadequate. Compare this to the 7.1% apportioned to police (twice the investment in health), 3.44% to prisons and the priorities appear to be policing and/or imprisoning our citizenry. Our words do not translate into action.
There is a recognition that malnutrition contributes to poor health and education outcomes, and maternal, infant and child mortality. We speak of agriculture as the cornerstone of efforts to diversify the South Sudan economy and to reduce over-reliance on food imports and food aid, and yet we devote a meagre 0.7% to agriculture. With most of these disbursements expended on salaries and operating costs, very little remains for capital and sector-specific infrastructural enhancements or investment.
Whilst we remain poor, hungry and maltreated, it will be difficult to meaningfully contribute to the reconstruction and development of this nation.
In total, 72% of the population is below the age of 30 (2008 census), and yet only 0.3% of total spending is availed for culture, youth and sports, and 0.13% for gender, child and social welfare. Contrast this to the 2% allocated to the Office of the President and the 1% to the fire brigade and there is urgent need to reconsider our financing priorities. All this gives an impression that social and humanitarian affairs, women and children, agriculture, infrastructure, reconstruction and development are peripheral to political affairs, the executive, the police and prisons, and the military. This is not the message we want to send.
The most important resource in any country is its people. The utmost potential for sustained economic growth in future is contingent on investing in human capital today. Developing the capacity to compete in this global economy means engaging the youth, strengthening health systems, guaranteeing food security and alleviating poverty, in addition to protection, rule of law and defence. While one might justify allotting 37% of the national budget on security and an additional 14% on rule of law (progress cannot occur amidst instability) this does not signify overlooking human resource development.
Whilst we remain poor, hungry and maltreated, it will be difficult to meaningfully contribute to the reconstruction and development of this nation. As we enter into a period of forced austerity – due to lowered revenues from the oil sector – this will necessitate reducing current rates of spending. It will be wise not to take the shortsighted viewpoint and further downgrade spending on social, welfare and economic issues.
It will be imprudent to focus only on today and to forget that investing in health, nutrition, and education is inextricably linked with economic growth and poverty reduction, and is also synonymous with peace and stability. The yardstick of the success of a country is how the majority of its population lives. Let us take a minute to think about how the majority of our population lives. Hopefully this will remind us of our obligation to improve the status of all South Sudanese.
NB: This article focuses on planned government spending as a barometer of national priorities; it does not touch on actual disbursements, the planning and implementation of projects or accountability.
Juliana Bol has worked in the health sector in South Sudan for the past five years. She is currently pursuing a Doctorate in Public Health (DrPH) at Johns Hopkins University and can be reached at [email protected].
1 2010 South Sudan Health and Household Survey (SHHS).
2 2014-15 Republic of South Sudan Budget. Historial-outruns-and-budgets-SS-05-14-v11-2014. www.grss-mof.org
3 WHO The Abuja Declaration: Ten Years On: http://www.who.int/healthsystems/publications/Abuja10.pdf
4 Assumes an exchange rate of 3SSP = 1USD
5 Achieving the health-related MDGs. It takes a workforce!: http://www.who.int/hrh/workforce_mdgs/en/
6 Key Indicators for South Sudan, National Bureau of Statistics (available online)