Analyzing Access to Surgical Services in Central Equatoria State, South Sudan: A Baseline Cross-Sectional Assessment to Inform National Surgical Policy and Planning

A May 2024 baseline assessment of public healthcare facilities in Central Equatoria State, South Sudan, reveals that while essential Bellwether surgical procedures are performed, access to quality and affordable care is severely compromised by critical deficits in workforce, financing, and infrastructure, necessitating a national policy and strategic plan to address these gaps.

The Gist

Imagine South Sudan's healthcare system as a massive, ambitious construction project. The goal is to build a sturdy, safe "House of Health" where everyone can get the medical care they need, especially when they need surgery.

This paper is like a building inspector's report for the "Central Equatoria State" (CES) region, which includes the capital city, Juba. The inspectors went in to see if the current "houses" (hospitals) were actually ready to handle emergencies, or if they were just fancy shells with holes in the roof.

Here is the breakdown of their findings in plain English:

1. The "Three Big Tests" (Bellwether Procedures)

To see if a hospital is truly "surgery-ready," the inspectors gave them three specific tests, like a driver's license exam for doctors:

• C-Section: Delivering a baby surgically.
• Laparotomy: Opening the belly to fix internal injuries or infections.
• Open Fracture Repair: Fixing a broken bone that has poked through the skin.

The Result: All three public hospitals in the region passed these three tests. They can do the basics. It's like saying, "Yes, these drivers can start the car and drive in a straight line."

2. The Reality Check: The Car is Running, But the Engine is Broken

Just because they can do the surgery doesn't mean they can do it safely, easily, or affordably. The report found that while the "drivers" (doctors) are there, the "cars" (hospitals) are falling apart.

• The Workforce (The Drivers): There are very few specialized drivers. The report found only about 2.3 specialists (surgeons, anesthesiologists, OB/GYNs) for every 100,000 people.

  • The Analogy: Imagine a city of 100,000 people that needs a fire truck, but they only have two firefighters on duty. The rest of the time, they have to ask the local baker or the librarian to jump in and fight the fire. While these "task-shifters" (non-specialist doctors) are doing their best, they aren't fully trained for the most complex fires.

• The Infrastructure (The Tools): The hospitals are missing essential tools.

  • Power & Water: Electricity is like a flickering lightbulb (on only 66% of the time). Running water is inconsistent.
  • Imaging: They have no MRI machines (the super-detailed cameras for the brain) and very few CT scanners. It's like trying to fix a car engine without a mechanic's manual or a flashlight.
  • Blood: Getting blood for a transfusion within two hours is a gamble. In one hospital, they can do it; in the others, they can't.

• The Money (The Fuel): Surgery is expensive for the patients.

  • The government doesn't pay for much of it. Patients have to pay out of their own pockets for medicine, transport, and the surgery itself.
  • The Analogy: It's like being told you can fix your broken leg, but you have to buy the cast, the crutches, and the gas to get to the hospital yourself. Many people simply can't afford the "fuel" to get the treatment, so they stay home and suffer.

3. What's Missing? (The Specialized Services)

The hospitals can handle the "big three" emergencies, but they can't do the specialized repairs.

• They cannot fix cleft lips, remove cataracts (cloudy eyes), or fix hydrocephalus (fluid on the brain).
• The Analogy: These hospitals are like a basic grocery store that sells bread and milk. If you need a specific type of cheese or a rare spice, you have to drive to a different country. For many patients, that "other country" is too far to reach.

4. The Paperwork (Information Management)

The hospitals are mostly running on paper. They don't have good computer systems to track who got sick, who died, or what went wrong.

• The Analogy: It's like a restaurant that doesn't keep a log of what dishes are returned. Without that log, they can't figure out why the food tastes bad or how to improve the menu.

The Bottom Line

The authors conclude that while the hospitals in Central Equatoria State are technically capable of doing basic life-saving surgeries, the system is fragile.

It's like having a lifeboat that can float, but it has a leaky hull, no oars, and no life jackets. If the water gets rough (a major disaster or complex illness), the boat might sink.

The Recommendation:
The paper urges the government to stop patching the leaks one by one and instead build a National Surgical Plan. They need to:

1. Train more specialized "drivers" (doctors).
2. Fix the "cars" (ensure steady electricity, oxygen, and tools).
3. Pay for the "fuel" (insurance so patients don't go bankrupt).
4. Keep a proper "logbook" (better data) to learn and improve.

Without these changes, the promise of safe surgery for the people of South Sudan remains out of reach for too many.

Technical Summary

1. Problem Statement

South Sudan lacks baseline data regarding the capacity of its surgical system, hindering the development of a National Surgical, Obstetric, and Anesthesia Plan (NSOAP). While surgical conditions contribute significantly to the global disease burden, over 90% of the poorest global population lacks access to safe surgical care. In South Sudan, the readiness of facilities to provide essential services, the availability of workforce, infrastructure, financing mechanisms, and information management systems remain undocumented. This study addresses the critical gap in evidence needed to inform national policy and strategic planning for surgical care.

2. Methodology

• Study Design: A facility-based, cross-sectional quantitative assessment conducted in May 2024.
• Setting: Central Equatoria State (CES), South Sudan, chosen as it hosts the capital, Juba, and represents the country's maximum potential access to surgical care. The study covered a population of approximately 1.57 million.
• Facilities Assessed: Total sampling of all three public referral facilities in CES capable of providing adult surgical care:
  • Juba Teaching Hospital (Tertiary level).
  • Yei Civil Hospital (County/First-level referral).
  • Kajo Keji Hospital (County/First-level referral).
  • Note: Al Sabah Children's Hospital was excluded as the focus was on Bellwether procedures applicable to general populations.
• Data Collection Tool: A validated and contextualized Surgical Assessment Tool (adapted from the Harvard Program on Global Surgery and Social Change and WHO). The tool assessed five domains:
  1. Service Delivery (Bellwether procedures).
  2. Infrastructure (Utilities, equipment, diagnostics).
  3. Workforce (Surgical, Anesthesia, Obstetric specialists and non-physicians).
  4. Information Management (Data collection, reporting, research).
  5. Financing (Budgets, insurance, out-of-pocket costs).
• Procedures: Data was collected via facility walkthroughs (in-person or virtual due to security constraints in Kajo Keji), review of logbooks, financial records, and interviews with facility administrators and unit heads.
• Analysis: Descriptive statistics (percentages, means, medians) were used to summarize data.

3. Key Contributions

• First Baseline Data: This is the first comprehensive assessment of surgical capacity in South Sudan, providing the foundational data required to develop a National Surgical Plan.
• Policy Framework: It establishes a benchmark for the "Bellwether procedures" (Cesarean section, Laparotomy, Open fracture management) as a proxy for overall surgical system functionality in the region.
• Identification of Systemic Gaps: The study moves beyond simple service availability to highlight critical deficits in the "six building blocks" of health systems (specifically workforce, infrastructure, and financing) that compromise the quality and safety of care even where services are technically available.

4. Key Results

A. Service Delivery & Capacity

• Bellwether Procedures: All three facilities (100%) reported the capacity to perform the three Bellwether procedures.
• Surgical Volume: Total volume was 6,134 cases across the three facilities, equating to 390.7 procedures per 100,000 population.
• Specialized Care: Advanced procedures (cleft lip/palate repair, clubfoot correction, hydrocephalus shunts, cataract surgery) were unavailable at all sites.
• Safety: While 100% of facilities used pulse oximetry, only one facility (33%) consistently used the WHO Surgical Safety Checklist.

B. Infrastructure & Diagnostics

• Utilities: Electricity was available only 66.7% of the time; internet was available 33.3% of the time. Oxygen was "often" available but not guaranteed.
• Diagnostics:
  • X-ray: 100% availability.
  • Ultrasound: 66.7% availability.
  • CT Scanner: 33.3% availability (only at the teaching hospital).
  • MRI: 0% availability.
  • Laboratory: Complete Blood Count (CBC) available at only 33.3% of facilities.
• Blood Supply: Only 33.3% of facilities could administer blood transfusions within 2 hours.

C. Workforce

• Density: The Surgical, Anesthesia, and Obstetric (SAO) specialist density was 2.27 per 100,000 population (Abstract) / 1.97 per 100,000 (Results section), far below the Lancet Commission benchmark of 20 per 100,000.
• Distribution: 87.1% of specialists were concentrated at the tertiary hospital (Juba Teaching Hospital).
• Task-Shifting: 36 non-physician clinicians were providing surgical and anesthesia care, indicating heavy reliance on task-shifting due to specialist shortages.
• Support Staff: Critical shortages existed in radiologists, pathologists, and biomedical technicians.

D. Financing

• Budget: The average annual facility budget was $269,616, ranging from $3,960 to $800,000.
• Insurance: Only one facility reported 100% insurance coverage; others had minimal or no coverage.
• Out-of-Pocket (OOP): Patients faced significant OOP costs, particularly for transportation ($53.33 mean) and surgery-associated medication ($53.33 mean).

E. Information Management

• Data Systems: 66.7% of facilities relied solely on paper-based records.
• Reporting: Prospective data collection on patient outcomes (e.g., DVT, stroke) was non-existent (0%) in most facilities.
• Research: No facility-level surgical research projects were ongoing.

5. Significance and Recommendations

• Policy Impact: The study confirms that while South Sudan has achieved the minimum threshold for Bellwether procedures, the system is fragile and inequitable. The data is essential for drafting a National Surgical, Obstetric, and Anesthesia Plan (NSOAP).
• Strategic Recommendations:
  1. National Scaling: Replicate this assessment in all states to build a complete national evidence base.
  2. Infrastructure Investment: Prioritize reliable electricity, oxygen supply, and diagnostic equipment (CT/MRI) at county levels.
  3. Workforce Development: Scale up structured task-sharing programs with rigorous training and supervision for non-physician clinicians while aggressively recruiting SAO specialists.
  4. Financing Reform: Develop strategic purchasing mechanisms and insurance schemes to reduce catastrophic out-of-pocket expenditures.
  5. Data Systems: Implement electronic medical records and mandatory morbidity/mortality reviews to improve accountability and quality improvement.

Conclusion: Despite being the most developed state in South Sudan, Central Equatoria State exhibits severe deficits in surgical infrastructure, workforce density, and financing. The findings underscore the urgent need for a coordinated, government-led strategy to transition from basic service availability to safe, high-quality, and equitable surgical care.