Capacity Building in South Sudan: Juba Teaching Hospital College of Nursing and Midwifery,
February 2010
By Michael Lear, Director International Relations, Country Director, Sudan

Progress over the past three months towards the commencement of the first class of the Southern Sudan College of Nursing and Midwifery at the Juba Teaching hospital is worth noting. The coordinated efforts of all stakeholders under the direction of Ms. Bilha Achieng, UN Intern at the UNFPA have addressed a number of complex issues pertaining to the schools development and with favorable outcomes.

These issues include:

Candidate Interviews Curriculum Development Course Materials and Supplies School Block Upgrades and New Structures Teaching and Administrative Staff

It also bears mention that the consortium supporting the program has grown. We’d like to welcome The World Health Organization South Sudan, (WHO) and The Japanese International Cooperation Agency (JICA) to the group. Both organizations are making significant contributions to the successful establishment of the College of Nursing and Midwifery.

November was a busy month for the Ministry of Health offices of the Director Generals of Nursing and Midwifery and Human Resource Development as they handled the candidate interview and selection process. The office of the Director General Nursing and Midwifery short-listed 79 applicants for the Nursing and midwifery program from most of the 10 states in Southern Sudan. Below is the public announcement for candidates to apply.

The breakdown of representation by states is as follows:

Central Equatoria – 49 Eastern Equatoria – 13 Upper Nile – 11 Jonglei – 3 Warrap – 2 Western Equatoria – 1

There was no representation from Western Bahr el- Ghazal, Northern Bahr el-Ghazal, Unity and Lakes States. Since the interviews took place in 3 states the applicants from Jonglei, Warrap and Western Equatoria had to be flown into Juba for interviews for the sake of equal representation.

Further, there were significant differences in the number of applicants interviewed between the equatorial region and the rest of Southern Sudan mainly because of untimely coverage of advertisements in the ten states. Applicants were not able to arrive in time for the interviews in both Eastern Equatoria State and Upper Nile State.

An interview panel was formed to carry out the interviews and come up with criteria for selection of the students. The panel was comprised of members of the Ministry of Health, offices of the Directorates Nursing and Midwifery and Human Resource Development, also the Nursing School at the Juba Teaching Hospital.

The panel members included:

Victoria Abua - MOH, N & MW, Deputy Director for Continuous Education Samuel Maketh Lwal - MOH, HR, Deputy Director for Training Isdoro Thomas Lojek - Principal, Juba Nursing School Repent Khamis George - Tutor, Juba Nursing School

Interviews took place as follows:

1. Juba: December 2-4, 2009 at the Nursing School, Juba Teaching Hospital, Central Equatoria State
2. Torit on December12, 2009 at Torit Nursing School, East Equatoria State
3. Malakal on December 16, 2009 at The Nursing School, Malakal Teaching Hospital, Upper Nile State

The written portion of the interview consisted of 70 questions measuring the general knowledge of the Sciences, Mathematics, First Aid and HIV/AIDS. During the oral interviews, which involved 30 questions, some difficulties communicating in English were reported. The panel will however form criteria for the selection of the final 40 students that will take all the varying factors into consideration.

The panel has selected a total of 17 nurse and 8 midwife students. This was based on the performance of both oral and written interviews and exams respectively. While the general outcome of the interviews was commendable, the performance of women was reported as quite low and was indicative of the country’s 12% literacy rate for adult women. Another interview was conducted in early February in Juba to source especially midwife students however the results were unfavorable. Curriculum Development

The registered nursing curriculum for the diploma course in nursing for the three year period has been developed and approved. A midwifery curriculum has not yet been completed. The MOH has three options:

1. Improving on the current community midwifery curriculum,
2. Adopting diploma curricula from other countries, or
3. Following up on a curriculum developed in Kenya for Sudan by a team that included DG Dr. Samson Baba of the GoSS MOH.

MOH Nursing and Midwifery Director General, Mrs. Janet Michael will work together with the health office and (MOH) consultants who will be in Juba through March for the development of the midwifery curriculum. A midwifery specialist/advisor from UNFPA would also help in the development of the curriculum.

It was also suggested that both curricula include a foundation course of Mathematics, English and other courses during the first three months of the first year. This will also ensure continuity of learning as the diploma curriculum is being developed.

The government is taking measure to strengthen the education system in general to improve the quality of the candidate pool for health care other sector applicants for professional positions.

One of the primary concerns of the program development, in addition to the construction of the new library and teaching blocks has been the procurement of the educational materials and skills lab equipment that will bring South Sudan into the 21st century. Up until now they have been relying upon a limited number of recent course books but predominantly, decades old resources.

We are deeply grateful to The World Health Organization, Juba Sudan, and Director Mrs. Roya Sadrizadeh for their commitment to support the program. In addition to The WHO, support from Teaching at Low Cost (TALC) has also been secured.

We have commitments for the following materials.

• Anatomical models and charts
• Instruments for skills laboratory
• Nursing and Midwifery Books
• A heavy duty photocopy machine
• 6 desktop computers (for library)
• (3) Printers
• Over head projector 1 (one is already existing)
• 2 screens (for projectors)

Quotations on furniture and stationary are in the final stages.

The Japanese International Cooperation Agency, (JICA), who will be assisting with construction of education blocks, library and tutor residence, has also expressed a willingness to provide course materials i.e. computers.

Perhaps the greatest challenge the college has faced until now has been acquiring funding and construction expertise for the building of new school blocks and upgrading the existing blocks. Recently, Kiyotaka Tamari, Project Formulation Advisor at JICA, informed us that JICA had a budget line expansion for the improvement of training institutions in South Sudan and they would be willing to support the college. They will be providing their own consultant engineer team and carry out all necessary construction and renovations on the administrative block, library and tutor’s residence. Student Residence halls remain a long term goal for the program. Assessments will being next in March.

Public bid requests for upgrades to existing training blocks, funded by RMF, and made possible by a grant from World Children’s Fund (www.worldchildrensfund.net) have already been placed in the newspapers for transparency and quotations are being reviewed.

The project has been fortunate to secure 2 tutors for the period of training to start the program and the UNFPA is presently interviewing for additional tutors for the program, funded by RMF. The UNFPA will also be providing a IUNV project manager to support the administrative staff and the ongoing development of the program. St. Mary’s Hospital UK IOW has also been coordinating its volunteer staff to provide a stream of on-going nursing and midwifery tutors to the program once it is underway.

The GoSS Department of Human resource development and Juba Teaching Hospital will provide salary support for the new hires to their institutional staff such as administrative assistant, lab technician, accountant; and non-technical staff such as the watchmen and cleaners.

Moving a project of this magnitude forward can only be accomplished by teamwork and a clear vision of the project’s outcome and impact. We wish to thank World Children’s Fund for their vision to catalyze this project through their generous grant; GoSS MOH departments of Nursing, Midwifery and Human Resources as well as all partners of the consortium for their participation, commitment, time and dedication. Together, we are making a difference.

We’d also like to thank Bilha Achieng, our UN Intern, for signing on with Real Medicine Foundation to continue her work on the program. Welcome aboard, Bilha!

• The assignment of IUNV intern, Ms. Bilha Achieng as our in country coordinator for program activities.
• To date, over 80 student applications from around the country (all 10 states) have been submitted for review.
• Janet Michael, MOH and Vice Chancellor, Aggrey Abate of Juba University will meet to finalize the program accreditation status.
• Mrs. Petronella Wawa has been selected principal of the College.
• During his recent visit to Southern Sudan, UNFPA Regional Director from NY, Dr. Hafedh Chekir assured full support to get the needed human resources to initiate the program.
• RMF is providing funding for IUNV’s in collaboration with the UNFPA
• The WHO has agreed to contribute towards the provision of course materials and skills lab equipment – (budgeting to be determined – please see attached Midwifery equipment list provided by AMREF)
• Janet Michael met with JICA to discuss collaboration on building structures for the school.
• We’ve identified 3-4 potential school advisory board members.
• Attended the monthly Health Care Sector forum
• RMF participated in White House State Department debriefing with General (Ret) Scott Gration to better understand the implications of the CPA (Peace Agreement) and the pending referendum and upcoming election as they pertain to capacity building in Southern Sudan.

Southern Sudan College of Nursing and Midwifery, June 2009
Michael Lear, Director International Relations, Country Director, Sudan

Four years after the CPA in 2005, Southern Sudan remains void of any functional and accessible health care sector.  Largely due to the sheer lack of capacity building within the country, the absence of qualified professional health care staff at literally every level of the health care sector leaves the approximately 9.6 million Southern Sudanese at very high risk.

Internationally, nurses and midwives comprise approximately 70% of health care sector staff.  In Southern Sudan they are expected to comprise almost 90% and presently this tier is virtually non-existent, according to Mrs. Janet Michael, Ministry of Health, Director General, Nursing and Midwifery.

It is the intention of the consortium to provide a scalable working model for a Government Nursing and Midwifery college accredited by the Ministry of Higher Education and Juba University that offers a diploma of Registered Nursing and Midwifery Status and that may be extended to strategic locations within the country. The college will educate candidates from all ten states and will serve as the first college of its kind exclusively operated by Southern Sudan and in Southern Sudan educating professionals to serve the country population of 9.6 million.

For the first three years the school will accept applicants from all 10 states to optimize the distribution of newly qualified health care personnel.  Subsequent years will see satellite campuses in other states.  The program is designed to be a three-year diploma program, during which time students will serve as staff at the outlying primary health care clinics in Munuki, Nyakuron, and Kator as well as the Juba Teaching Hospital.   The immediate population in Juba and surrounding areas, estimated at 500,000, will be direct and immediate beneficiaries of this newly qualified health care.

Our objectives are to provide:

1. A curriculum recognized by all ministries associated with education in the GOSS
2. Leading edge skills lab and library for students
3. Improved clinical setting for student training
4. Highly qualified instructors and tutors for the duration of the three year program
5. An unprecedented model of health care sector capacity building for Southern Sudan
6. A sustainable solution to Southern Sudan’s Maternal and Infant Mortality Rate, the former of which is the highest in the world at 2,034/100,000.   Approximately 200,000 women die giving birth each year.
7. Highly qualified instructors and tutors for the duration of the three year program

RMF has met with key stakeholders within Southern Sudan including the Minister of Cabinet Affairs, Ministry of Health, Director General of Nursing and Midwifery, Director of the UNFPA in Southern Sudan, Minister of Human Resource Development, Dean of Apina Medical College, Malakal, as well as the Director General of the GOSS Juba Teaching Hospital and the Director of the Joint Donor Fund to approve the project.  All parties have enthusiastically aligned with the mission of long-term success of the college and have pledged their support.

Accomplishments:

1. Through these meetings with the Minister of Cabinet Affairs, we have helped secure land on the hospital grounds for the new structures needed to establish a fully functioning residential learning institution.  We are presently following the due process to formalize this.
2. We have also succeeded in getting the College onto the GOSS 2010 operating budget in general and on the 2010 Ministry of Human Resource Development, GOSS and Multi-Donor Fund Budget considerations.  Full funding is not guaranteed, however this inclusion in the county budget suggests the level of commitment within the GOSS administration towards the success of this program.
3. We have identified the expanded group of stakeholders, prepared a preliminary budget and have set a timetable for execution.  The UNFPA will act as implementing partner on the ground and utilize a UN volunteer Project Manager to ensure compliance, transparency and timely project execution.

Current Status/Actions:

The curriculum is presently in the approval process while we are obtaining estimates on structures, such as student residence, teacher’s residence, mess hall, skills lab, and library and cost estimates for student supplies, library materials, skills lab equipment, internet access for the hospital.  Concurrently we are in the process of recruitment of lead teachers and assistant tutors as well as student candidates.

Summary:

The timing of this partnership and its importance to the development of Southern Sudan’s Health Care Sector independence cannot be overstated.   Through the work of St. Mary’s Hospital, Isle of Wight UK to identify the need for such a program, coupled with initiation by RMF, WCF’s support has catalyzed the necessary momentum among critical stakeholders in the GOSS and primary international relief organizations to make this school a possibility and has ensured the best possible chance for Southern Sudan to provide a real solution to the wide range of health care challenges the country continues to face.

The enthusiasm alone within the Ministry of Health, Human Resource Development and not to mention in the executive branch of government, towards this long overdue, tangible solution was palpable during our visit.  Further, our three year college program as estimated will actually cost 35% less per year than the existing training and deliver a fully accredited registered nursing and midwifery program.

Reference Materials and Photos:

Leading stakeholders drafted a funding appeal letter for international circulation and the Juba based partners have met with UNMIS to request their full support in promoting the need to the international community through both internal UN and external channels:

Photos from our recent visit:

Touring the surrounding PHCCs, it does not take long to understand that these new structures are grossly understaffed and underutilized.  While the centers average about 70-80 patients a day, they do little in terms of absorbing the overflow at the Juba Teaching Hospital.  The primary reason for this is – no professional staff to hire.

Doug with Janet Michael, Goss MOH	Doug with Magda Armah, UNFPA

Visiting the Juba Teaching Hospital School of Nursing and Midwifery:

We intend to use the existing structures for the first term of the first year, all of which will require some upgrade.   The UNFPA is having drawings made up to get estimates for constructions costs of student residents, cafeteria, administrative offices, labs and classrooms, as well as an instructor’s residence.  They intend to hire a UN Volunteer project manager to oversee this construction project as well as other elements of the program implementation.

The Skills Lab:

Antiquated and void of nearly all equipment, the skills lab remains a significant component of the program requiring adequate funding to bring nurses into the 21st century.

The Library:

Also considered a core component of the program, has only three old computers for over 100 students and a medical text collection from as early as 1937. To assure that students obtain the best possible education available today, the library upgrade requires adequate funding.  Internet access will be provided to the hospital to facilitate web access for student, faculty and medical staff.

 

The Juba Teaching Hospital:

Of primary concern to the success of the program is ensuring that the clinical environment in which students will be trained is up to a progressive standard of management and operational protocol to complement the education they will be receiving.  To this end, a major parallel focus will be to upgrade the hospitals Health Management Information Systems, provide new equipment and support staff training, all of which require funding to improve.

Outpatient:

The Laboratory and Blood Bank

The laboratory is clean yet under equipped.   The blood bank pictured above right, a mere refrigerator, is the only clean blood supply for the approximately 500,000 residents of Juba and its surrounding communities.   Ms. Madga Armah, UNFPA asks the question, “Who gets the blood, a hemorrhaging mother or someone standing in line in the outpatient clinic which often totals in the hundreds by the early am?”

Maternity Visit:

The Wharton Group Arrives	Certified Nurses and Midwives

Magda Armah, UNFPA has been the single-handed effort to build a new emergency delivery room at the hospital and to get stores of emergency birth/delivery kits for distribution throughout the country. She also recently sponsored the first Midwifery Symposium May 13-17, 2009, which was endorsed personally by the Vice President, Dr. Riak Machar Teny and First Lady of Southern Sudan, Mrs. Rebecca Nyandeng De Mabior.   

The Health Management Information System:

The absence of a comprehensive patient data base management system stresses the decision making process about the efficacy of program implementation addressing infectious diseases of all kinds.   While the treatment records are well kept, efficiency is lacking along with the ability to generate informative reports to guide the hospital. 

The Juba Team (from L to R)

Dr. Louis Danga, Juba Teaching Hospital, Mrs. Janet Michael, GOSS MOH, Dr. Dario Lado, Director General, Juba Teaching Hospital, Dr. Dragudi Buwa, Director, UNFPA Southern Sudan, Ms. Magda Armah, UNFPA Project Specialist.

RMF Nutrition in Southern Sudan

Dr. Danga, Juba Teaching Hospital, sitting in the UNFPA conference room, received the latest research and documentaries available on nutrition and diseases of affluence (Heart Disease, Cancer and Diabetes - copies of Dr. T. Colin Campbell’s China Study (www.plantbasednutrition.org) and the Healing Cancer from the Inside and Eating DVD’s produced by Mike Anderson - www.ravediet.com)

In our discussion, he explained that already, in just a few years, the incidence of diabetes is skyrocketing.  Once the hospital is on line, we intend to provide staff at the Juba Teaching Hospital with access to Cornell University’s remote learning course on Plant Based Nutrition as we have done for our staff in Pakistan and Sri Lanka’s National Cancer Institute.

Appendix B Southern Sudan Campaign for Midwives:

Here is an excerpt from a radio station in Southern Sudan that covered Magda’s event, which speaks to the need of both adequately trained midwives and nurses.

INVESTING IN MIDWIVES
Susan Dokolo

JUBA, Miraya 13th May 09

Maternal mortality has become a serious global problem threatening mothers of developing countries such as the Sub-Saharan Africa, Latin America and Southern Asia.

In Sudan, household survey indicates that Southern Sudan has the highest maternal mortality rate in the world.

Dr Dragudi Buwa, Head of UNFPA Office Juba confirms in his speech:

"You might be pretty aware that the maternal health indicators for Southern Sudan are actually the poorest in the world and that for every 100,000 live births in Southern Sudan 2,054 of the mothers die".

To help reduce this high rate, on May 14th this year, the United Nations Population Fund (UNFPA) together with the International Confederation of Midwives (ICM) with support from the government of Southern Sudan launched a program in Juba called "investing in midwives and others with midwifery skills to accelerate progress towards Millennium Development Goal number four, five and six."

Millennium Development Goal five aims to reduce maternal mortality by 75 per cent.

"We are working for a mother and her child. We don't put money ahead. We want the two to be successful in our hands even if we have problems." 

Kolorinda Laku, Midwife

Addressing the crowd during the occasion, the Vice President of the government of Southern Sudan, Dr. Riak Machar Teny urged the citizens to stop harmful traditional practices that prevent women from safe delivery.

Dr. Machar said the government has the challenge to develop the profession of Midwifery and promised the Government support to the Ministry of Health.

"There is also a misunderstanding; even the midwives are having problems how to communicate with the society....... So these are challenges. She wants to improve on how to reduce the maternal death rates, but when she gets confronted, she can't communicate...... so the aspect of advocacy is very important. We should talk about it until our people can reduce maternal death rate, child death rate by improving or by training midwives," advised Dr. Riak.

An adviser from the International Confederation of Midwives (ICM) explained that her organization's vision is that every childbearing woman should have midwife access to herself and her newborn baby.

In a press conference prior to the occasion, Dr. Jamima Dennis said that the midwife is a key to reducing maternal mortality and infant mortality in a country.

Dr. Jamima, a PhD holder in the midwifery profession said that there is a need to educate midwifes and set regulations to support the work of midwives and advocate to the government to set up necessary structures.

‘We believe that the midwife is a very critical skilled birth attendant that every country in Sub-Saharan Africa, Asia and Latin America should promote and develop to be able to contribute towards making this change in our societies. We believe that a woman should not die because she wants to bring another life into being,” expressed Dr. Jamima.

Low morale

Midwives play key roles when it comes to caring for pregnant women, and therefore need to be encouraged to do the work.

Kolorinda Laku is a midwife working in Juba; she is amongst many other midwives who have worked in the profession for a very long time without any promotion.

Madam Kolorinda said she has worked for 11 years now but has not yet been upgraded. However, she still believes she has an important duty to perform.

"We are working for a mother and her child. We don't put money ahead. We want the two to be successful in our hands even if we have problems."

The Minister of Health in the Government of Southern Sudan, Dr. Joseph Monytueil said that to invest in midwives is investing in future generations.

He pledged his Ministry will increase the number of nurses and midwives. He also emphasized the importance of putting a healthy foundation for a health system.

Optimism

Meanwhile, the head of the United Nations Population Fund (UNFPA) Dr. Dragudi Buwa expressed hope that the launch of the program "investing in midwives", will remind the international agencies and Government of Southern Sudan what to do for the women in the region.

The UNFPA is one of the international organizations that have focused its programs on improving reproductive health.

Last year the organization in partnership with the Ministry of Health trained a total of 36 community midwives.

According to UNFPA, in order to reduce the maternal mortality rate, there is a need to have access to comprehensive primary health care including family planning, skill care for pregnant women and access to emergency intervention when complications arise.

The launch was attended by top officials from the Government of Southern Sudan, international organizations and a cross section of the community.

In February we’ll be visiting Juba, capital of Southern Sudan to meet with the Ministry of Health and UN agencies to discuss the placement of a Primary Health Care clinic in the region. In addition we will be discussing support for a Nurses and Midwifery training program for the Juba Teaching Hospital.

Currently Southern Sudan has the highest infant and maternal mortality rates in the country and a physician to patient ration of 1:100000 in most areas. A quick glance at the statistics paints a challenging situation for the people of Southern Sudan. Juba Teaching Hospital has approximately 5 trained nurses and only 2 certified midwives.

Numbers at a Glance:

• 2 % of boys & less than 1 % of girls complete primary education
• 7 % of teachers have had formal training
• 82 % of girls currently do not attend school
• Infant mortality: 150 per 1,000 live births
• Under-5 mortality: 250 per 1,000 live births
• Maternal mortality: 2037 per 100,000 live births – 10 times that of Europe.
• 45%of children suffer from physical stunting resulting from malnutrition.

Reference - SavetheChildren.org

Real Medicine’s clinic will address the following Priority Health Care needs identified by the UN:

• Malaria Prevention Support
• Mosquito Net Distribution
• Access to Clean Water
• Maternal Care and Education
• Nutrition
• HIV/AIDS education, prevention and treatment

Our clinic will also supply fresh drinking water and serve as a channel for UNICEF, The WFP and other international aid agencies to deliver their services to these destitute communities.

Our investment in nursing and midwifery education programs has the potential to increase the combined delivery capacity of their health care services in the immediate vicinity by over 900%, from 7 qualified personnel to over 60, and improve the qualified HC Practitioner to patient ratio to 1:17,000 from >1:100,000.