Postgraduate Medical Education in South Sudan
It is hot, and rather sticky, in Juba. The traffic kicks up red dust from the road, and the chaotic driving must surely be a cause of many of the broken bones that arrive daily at Juba Teaching Hospital. I ask if it is safe to walk to the hospital, 1km away from my hotel. “Yes, it is safe,” replies the receptionist, smiling. I ask because in December 2013 the city, and then the country, fell into a civil conflict from which it is still struggling to recover.
The billboards proclaim that South Sudan is the emerging giant of Africa, ‘Many tribes…one Nation’. But there is much to be done for this to be achieved. “Women will make the peace, in the market place,” I overheard a woman say, “We need a system of social services. No one should be hungry. No one should drink unclean water.”
I asked the same question, is it safe, to a group of Medical Officers, sitting drinking tea under a tree. They too nodded. They left university as graduate doctors about six years ago. Since then they have worked here in Juba, and in the outlying districts. Yet there is no formal educational programme to help them learn the skills they need for more advanced primary or secondary care. For newly graduated doctors, clinical skills are learnt from work experience, initially in hospital. Here, they receive some bedside teaching, and clinical supervision. After twelve months, they may be placed in charge of single-doctor primary care units, in isolated rural areas, an experience known as “Hard time.”
The MOs asked me about going to the UK to take the Royal College medical examinations, or perhaps to Uganda. These opportunities may be possible for some; but their medical skills are needed here, in South Sudan. Before moving on, I asked them about a woman I had last seen living under the overhanging roof of our bungalow, with a solemn 3 year old daughter and a babe in arms. They knew who I meant; she was ok, they said, and pointed to a corrugated iron shack.
I left the MOs drinking their tea, and risked crossing the road to visit the hospital. I wanted to see if it had changed, and to reassure myself that the doctors were ok. They work in difficult conditions at the best of times. In the first days and weeks of the outbreak of fighting I knew that they had been overwhelmed.
It is obvious to any who take a detour past the out-patients clinic of Juba Teaching Hospital, or who choose to look into one of the dozen or so Wards, that the people of South Sudan are crying out for adequate healthcare. The country does not have sufficient medical capacity: there are not enough doctors and nurses, and they don’t have enough medical centres and medical supplies. This is a chronic problem. It existed before the recent fighting, before the consequent cholera outbreak, and will continue whether or not Ebola arrives at Juba Airport.
The result is that, for most of the 11.71 million population, the provision of both primary and secondary care is wholly insufficient to meet their basic needs. For many, it is simply not accessible. One young woman I spoke to cannot afford to treat the toothache that keeps her awake at night. Another relies on prayer; the particular medical help she needs is not available. Statistics provide further, compelling, evidence. Some 90% of women give birth without access to trained medical assistance2. There are 2054 maternal deaths per 100,000 live births3, and 68 out of every 1000 infants die within 12 months, (99 within five years)4. Overall, life expectancy is 55 years5.
The international community prioritises primary care in its aid programmes, and with good cause; the foundation of any national healthcare system is effective primary care. Yet a healthcare system also needs secondary care, and both primary and secondary care need more doctors. To this end, the South Sudan Government is establishing a College of Physicians and Surgeons, with the task of laying the foundations for a national programme of postgraduate medical education.
Two years of structured postgraduate training will better equip young doctors for a period of supported service in the outlying districts. Following this, they will be offered opportunities for specialist training in advanced primary care, or in secondary care, with appropriate postgraduate academic qualifications. In parallel with this we will seek funding to build and equip more advanced healthcare centres. If successful, these will deliver primary care and basic secondary care, and provide referral to more advanced secondary care6.
I was greeted, on arrival in Juba, with the words, “Welcome to the real Africa.” South Sudan gained independence in July 2011. It has not been easy; there are deep rooted problems of social structure, resources, infrastructure, and politics. From these tensions emerge acute crises, the scale of which distracts from long term, strategic developments, such as postgraduate medical education. Yet the Ministry of Health, and the consultants of Juba Teaching Hospital are committed to improving medical education, and that is our task.
Dean of Postgraduate Medical Education, South Sudan.
Visiting Research Fellow in Healthcare Education, St John’s College, Durham University.
12014, World Population Review. http://worldpopulationreview.com/countries/south-sudan-population/
2“Women’s Security in South Sudan” (2012). http://www.irinnews.org/report/95900/south-sudan-the-biggest-threat-to-a-woman-s-life
3UNDP. http://www.ss.undp.org/content/south_sudan/en/home/mdgoverview/overview/mdg5/ 2,054 maternal deaths per 100,000 live births, representing a 1:7 chance of a woman dying from pregnancy related causes over a lifetime.
5The World Bank http://data.worldbank.org/country/south-sudan
6E Hakim and V Joseph, 2013, “Integrated Primary Healthcare (iPHC) in South Sudan, A Model of Practical Implementation of a Healthcare Programme at County Levels”. Strategic Health Consultancy.