Developing Quality Primary Health Care in Yei, Southern Sudan - the challenges and successes

The Martha Primary Health Care Centre (PHCC) originally started as a health unit in 1980. It was the idea of a school head mistress. It ceased to function during the war. The facility was re-developed in 2003 with a building funded by the Diocese of Salisbury (UK) and managed by the Diocese of Yei (Episcopal Church of Sudan ECS) The Diocese of Salisbury also funded the training of a nurse and a clinical officer.

 

In 2006, a Nurse Practitioner with extensive Primary Care experience in UK and a Diploma in Tropical Diseases was sent by Church Mission Society Ireland (CMS Ireland) as a volunteer to work with the ECS in Yei to help further develop Primary Care. Later in 2006, CMS Ireland in partnership with the ECS Diocese of Yei was successful in attracting a grant from Irish Aid to build and equip, train staff, and fund medicines and salaries for a year to provide a high quality PHCC. The facility was built in 2007 by the International Medical Group Contract Division, Kampala, and opened in February 2008. The new building is positioned beside the original building (the picture shows some of the staff outside this new building). The older building is used for preventative work including ante-natal, immunisations and HIV testing and counselling. Sick patients attend the new building, which is equipped to a high standard. Patient numbers have risen sharply.

The PHCC (see the picture below) places high emphasis on health education, and in 2007 carried out a Community Health Survey to identify health needs and also health beliefs of the local population. This formed the basis of the early health education programme funded by a UK charity.

 

The Irish Aid budget included the training of 10 Health Care Assistants in Kampala at the International Hospital, and funded training for a Laboratory Technician, a Clinical Officer and four Nurses. The Health Care Assistants were trained to a very high standard, studying modules in following treatment pathways, ante-natal care, health education, immunisation, management, assisting in the laboratory, and pharmacy management.

The PHCC aims to provide excellent affordable outpatient Primary Care to all local residents with no discrimination of tribe, race or religion.

Martha PHCC now has a competent, enthusiastic and committed staff team of 22, led by a trustworthy dedicated management team of three senior staff and managed by the Clinical Officer (CO) under the Diocesan Health Committee. The lead clinician for the PHCC is the very skilled CO, and the new projects are managed by the Nurse Practitioner from UK. Nursing, laboratory technician, midwife and CO students are sent to Martha on placements.

Treatment protocols, an excellent stock and ordering system, financial systems, staff contracts and continuing education policies are in place. Reports are sent regularly to MOH and County Health Department for surveillance and record keeping purposes.

Martha PHCC works in partnership with the American Refugee Committee for HIV work, with Population Services International (PSI) to provide malaria nets and treatment and TPO Health Net who provide psychological counselling. The PHCC is also very grateful to the Diocese of Salisbury in UK who have had a medical link with Sudan for many years, and supply some medicines each year as well as funding the training of the Clinical Officer.

 

Patient numbers and diagnoses for August 2009

Number of sick patients treated	Children immunised	Ante-natal mothers	Total patient number	Percentage of mothers HIV positive
1430	1286	1060	3776	2.5%

 

Numbers of patients with specific major diseases required to be reported to MOH during August 2009

Disease/syndrome	Under 5 yrs	Over 5 yrs	Total
Acute watery diarrhoea	14	6	20
Diarrhoea with blood	8	4	12
Malaria	376	248	624

 

Other significant diseases diagnosed during August 2009

Disease/syndrome	Total numbers
Bilharzia	12
STIs	79
Intestinal parasites	128

 

Martha PHCC operates an affordable cost-sharing scheme. With a strict accountability system, Martha PHCC pays its staff without fail each month, is well stocked with medicines and equipment and covers 70% of its own costs.  Martha PHCC follows Government of South Sudan Ministry of Health (GOSS MOH) guidelines for treatment.

In December 2008, CMS Ireland received a substantial grant from the Basic Services Fund for Sudan (BSF) - included in this was an allocation for a Mobile Health Unit to operate from Martha PHCC (see picture below).

 

After working with the County Health Departments of Yei River and Morobo Counties, five villages have been identified as needing health provision. Starting in October 2009, each village will receive a weekly visit from the mobile unit, which will be staffed by a Nurse or Clinical Officer, a Community Health Worker, a Midwife and an HIV Counsellor. The aim will be to treat the sick, provide ante-natal care, give child immunisations, run a malnutrition project, give health education and raise the capacity of local health staff including traditional birth attendants. If needed, a sick patient could be taken to hospital at the end of the day. BSF funding allows for the training of another nurse and midwife. Each village will have its water and sanitation needs addressed. Village health committees from each village have been trained in borehole maintenance and basic health.

Four of the Martha staff are receiving up-skilling training thanks to various donors. Two are at the new International Health Sciences University in Kampala sponsored mainly by two Primary Care facilities in the UK, and one by the Church Health Association Sudan. One Nurse has just returned from the University of Liverpool (UK) and another nurse is a medical student in Khartoum (whose course fees are funded by GOSS and some of his living expenses by some doctors in Winchester, UK).

There have been many successes as described above but also many challenges and frustrations. The particular challenges have been:

1. Maintaining drug supplies at optimum levels due to logistical issues.
2. Encouraging medical ethics and time keeping with staff (the staff are now well committed and of excellent calibre)
3. Accessing competent training in South Sudan due to organisational and communication issues with the MOH. This is largely due to geographical and IT difficulties but also due to the financial constraints on MOH. As a small team, it is hard to regularly visit Juba where the relevant offices are.
4. Martha PHCC pays for most of its medicines and so far has not received any from the MOH. We are hoping that our regular requests for medicines sent in to MOH will soon be successful.
5. Martha PHCC pays for all its staff salaries, apart from the two on the MOH payroll who are paid irregularly. When they are not paid, the PHCC has to pay them direct.
6. Current bank problems since March 2009, resulting in the PHCC being unable to access its funds.

It is hoped that the above problems will be resolved to ensure the sustainability of a quality primary care service.

Future Plans

Due to the generosity of donors in the UK, Martha PHCC is hoping, in the very near future, to expand its services by creating extra space by renovating an unfinished large building adjacent to the current facility. There is also the possibility of setting up a much needed eye care service.

Extra funding has been received from Irish Aid and BSF to:

• begin a second similar high quality PHCC outpatient service in Lainya Diocese and
• provide mobile outreach to Internally Displaced People’s camps (IDP) near Lainya (see picture on cover).

The outreach started in August 2009 and the new PHCC will open in January 2010.

Also it is hoped to arrange a link between Yei Civil Hospital and a hospital serving a similar sized population in the UK.

All this could not have been achieved without the help of donors and the commitment of an excellent staff team, to whom I am greatly indebted.

 

(Photographs supplied by Poppy Spens.)

More from the November 2009 issue