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By Morrish O.

Identify one health policy in your country of work. Find out how it was

According to (Wildavsky, 1979); (Buse, Nicholas, & Gill, 2012); (Colbatch,

2006), a health policy is defined as an authoritative alternative decision
made and action taken by governments that pertain to health. One example
of such policy in the republic of South Sudan is the task shifting policy, a
proactive policy developed in June 2015 by the South Sudan Ministry of

This policy aims to address the problem of poor access and utilisation of
health care in the country through optimizing the roles of health workers by
shifting task from more to less specialized cadres that could be trained to
meet the specific health care need of the population. The task shifting
policy is hinged on the Human resources for health building block of the
health system.

A Collaboration of government, civil society, professional organisations,

bilateral and international agencies initiated a series of broad consultations
addressing the human resource crisis through task shifting starting in August
2013 when the current minister of Health of the Republic of South Sudan Dr
Riak Gai Kok was appointed Minister of Health.

With financial support from the Health Pool Fund (HPF) and United Nations
Population Fund (UNFPA), The South Sudan Ministry of Health, chaired the
committee that produced the initial draft of the policy which were
nationally reviewed and revised in 2014. As a first step, the Health
Situational Analysis was carried out by the Karolinska Institute to profile,
identify and quantify the scope and nature of the health care crisis and
recommendations and guideline for task shifting was initiated.

Following the developments, the South Sudan Ministry of Health initiated a

process to formulate the task shifting policy. In addition, discussions with
key policy makers at the ministry of health identified the need for a policy
brief to inform the development of a national policy for task shifting,
specifically for improving access to maternal, child health including
emergency surgery for obstetrics and gynaecology, HIV/AIDS, Malaria and TB
care, mental health including sexual gender based violence and ophthalmic
care. This was in consideration of a number of factors that contribute to
poor access and utilisation of basic essential health care services in the
Republic of South Sudan. These include inadequate infrastructure, supplies
and financing, as well as inadequate human resources for health. The
shortage of healthcare workers in the country is exacerbated by mal-
distribution and inadequacies of numbers and skill mix.

The task shifting policy aims to address poor access and utilisation of health
care services through optimizing roles of health workers by shifting task
from more to less specialized health cadres that could be trained to meet
the specific healthcare need of South Sudanese.

Framing the problem

Task shifting (optimizing health workers roles) was considered as an

important solution to addressing the country’s health workers shortage at
the frontline. Other problem highlighted were mal-distribution of health
workers, health workers performance (quality of care). The health
situational analysis that was carried out as part of the initial activities
towards informing decision pertaining the task shifting policy establish that
the acute shortage of human resources for health in South Sudan is one of
the major factors impeding the delivery of the basic package of health

The decision to come up with the task shifting policy was influenced by
discussions with key policy makers in the Ministry of Health with respect
poor health indicators, underutilization and limited access to healthcare
services. The Karolinska Institute conducted a survey of policy makers on
priority health policy issues in the short and medium term based on the 2014
health situational report. Maternal, child health including emergency
surgery for obstetrics and gynaecology, HIV/AIDS, Malaria and TB care,
mental health, sexual gender based violence and ophthalmic care was cited
as areas of policy interest for task shifting.

Also highlighted is an uncoordinated practice of task shifting by different

actors conducting training and engaging health workers in task shifting with
no monitoring to ensure quality of care and efficient use of available
resources. The task shifting practices were also not positioned to ensure
provision of well-motivated workforce that has the required incentives and
support to provide committed health services.

The context

The Republic of South Sudan is the youngest nation on earth when it became
the 193rd member of the United Nations and 54th member state of the
African union when it was born on July 9th 2011 through a self-
determination referendum seceding from Sudan (Salman, 2013) (Wikipedia,
2017). It’s one of the least developed countries with the worst health
indicators in the world (The World Bank, 2017). The Under-five infant
mortality rate is 106 per 1000 live birth, whilst maternal mortality rate at
2054 per 100,000 live births (SSHHS, 2006). ANC attendance (1st visit) is
47.6%, 17% for four visits and the infant mortality rate is 64 per 1000 live

There are only three proper hospitals in the country and the country is faced
with acute shortage of health cadres virtually at all levels which has
profoundly affected health sector planning, service delivery and utilisation
of essential services ranging from antenatal, postnatal, infant paediatrics,
HIV, tuberculosis and other basic health care services. Only 20% (n-26/132)
of the doctors positions, 2% (n=1/65) aneasthetist officers positions, 8%
(n=836/10655) nurses positions and 3% (n=291/10655) Midwives positions are
in post.

Assessment of other areas such as surgery, mental health, orthopaedic also

revealed insufficient distribution of health workers with majority of the few
health workers concentrating in urban areas were less than 20% of the
population live.

Further, the constitution of the Republic of South Sudan recognizes health

care services as a basic human right and thus commits the government to
promote and improve public health by increasing access to health care
services to its population (To achieve this, the government of the Republic
of South Sudan has come up with pertinent plans aimed at addressing both
the development and health challenges facing the country.
The ministry of health task shifting policy is therefore a strong expression of
the common goal and commitment of the government of South Sudan to
adapt a structured approach to guarantee the people of South Sudan quality
health care services in the application of human, financial, and material
resources in the health sector.

Recognized by various stakeholders as a major barrier of access to the basic

package for health and nutrition services (BPHNS) in South Sudan is the mal-
distribution and inadequacy in number, quality, and skill mix of the health
workers to deliver services where they are most needed.

Health care services in South Sudan are provided by medical doctors,

aneasthetist, midwives, clinical officers, nurses, community health workers
and health promotion education officers. Although there is an effort to
invest in pre-service education of all cadres in the health sector in South
Sudan, to address the shortage in the health workforce, the pre-services
route will take decades for the country to reach the desired threshold and
deliver quality health care services.

The South Sudan National Development Plan 2011 - 2013, the Health Sector
Development Plan 2012 - 2016, the revised Health Policy 2015 - 2025, the
Human Resources for Health Policy 2011 have all identified task shifting as
an important strategy to maximize the effectiveness of the few existing
health workers and improve health services delivery and utilisation in the
country. Task shifting have been informally used in South Sudan as a
strategy for providing care services in the absence of fully trained personnel
and its use though beneficial has been characterized by lack of systematic
and formally structured approach to ensure quality and improved health

Consultations with various stakeholders brought a common voice that

development of task shifting policy will promote rational distribution of task
amongst the few existing health workers, allow moving task where necessary
from highly qualified health personnel to those with shorter training and
fewer qualifications and make more efficient use of available health workers
to improve health service delivery to the population.
The task shifting policy was identified and provided for as a core strategy in
the national health policy 2015 - 2025, the national human resources for
health policy and strategic plan 2010- 2013 prioritizing task shifting around
reproductive, maternal, child health including emergency surgery for
obstetrics and gynaecology, HIV/AIDS, Malaria and TB care, mental health
including sexual gender based violence and ophthalmic care which are all in
line with the top 10 priority diseases and health challenges requiring priority
health actions in the republic of South Sudan.

The Content

The main emphasis of the task shifting policy in the Republic of South Sudan
is the setting up of the programme for clinical officers to be trained and
engaged on emergency obstetric and surgical care, nurses and midwives to
be trained and deployed for vacuum extraction, vacuum aspiration and
manual removal of placenta and community health workers trained and
engaged in giving some injectable drugs.

The policy promotes rational redistribution of task amongst existing health

workforce cadres allowing specific task to be moved from highly specialist
cadre level to lower cadre level where appropriate in order to make more
efficient use of the available health workers to promote access and improve
access to health services in the country. The redistribution of task has
prioritized four areas. 1) reproductive, maternal, newborn and child health
(RMNCH) including emergency surgery for obstetrics and gynaecology; 2)
HIV/AIDS, Malaria and Tuberculosis care; 3) mental health including sexual
gender based violence and 4) ophthalmic care. The cadres to be involved in
the task shifting programme are medical doctors, aneasthetist, Midwives,
Clinical officers, nurses, community health workers and health promotion
and education officers, shifting task performed at each level to the lower
The Actors

The actors involved in the formulation of the South Sudan Task Shifting
policy included government, international non-governmental organizations,
national non-governmental organizations, international organizations,
bilateral organizations and funding agencies. Those who were opposed to
the policy included the Doctors Council, the South Sudan Medical Council
and some national NGOs. According to the records obtained from the policy
document, it was silent on those who were neutral to the policy:

 The Government (Ministry of Health, Ministry of Education and Culture

and Ministry of Labour)
 International non-governmental organizations ( Jpeigo, Canada MNCH
programme, CUAMM)
 National non-governmental organisations
 International organisations (WHO, UNFPA)
 Bilateral organisations (USAID, SIDA, GAC, DFID, AusAid)
 Funding organisation (the Health Pool Fund)

Most of the stakeholders in the health sector have supported the

development and implementation of task shifting policy in the Republic of
South Sudan. However, there were also those stakeholders who were
opposed to it. These included

 Health workers themselves, although some health workers support the

policy as an opportunity for acquiring new skills and doing more for
the people in the country, others viewed it as creating more workload
to them and bringing stress to their work and overburdening them with
other peoples job.
 Some individuals in the political sector also opposed the policy for
example; the Cabinet minister of education and general instruction
who opposed the timing of the policy saying the country still does not
have adequate checks and balances to implement the policy. The
legislation of South Sudan still restricts certain cadres from performing
other cadres function and this will not benefit the policy
 The medical council of the republic of South Sudan that license
doctors and health workers to practice in the republic of South Sudan
was not convince with the programme of training in the country to
enable effective practices of task shifting.