IMPLEMENTATION COMPLETION AND RESULTS REPORT (MDTF-UPHSD P120464, IDA TF096243) ON A GRANT TO THE GOVERNMENT OF SOUTH SUDAN FOR A

Transcription

1 Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized Document of The World Bank IMPLEMENTATION COMPLETION AND RESULTS REPORT (MDTF-UPHSD P120464, IDA TF096243) ON A GRANT TO THE GOVERNMENT OF SOUTH SUDAN FOR A Report No: ICR2670 MULTIDONOR TRUST FUND FOR SOUTHERN SUDAN (MDTF-SS) IN THE AMOUNT OF US$71.5 MILLION PROVIDING ADDITIONAL FINANCING TO SOUTH SUDAN UMBRELLA PROGRAMME FOR HEALTH SYSTEM DEVELOPMENT PHASE II Human Development Sector Health Nutrition and Population Country Department AFCE4 June 27, 2013

2 CURRENCY EQUIVALENTS Currency Unit US$ 1.00 = 0.65 SDR FISCAL YEAR 2012/2013 ABBREVIATIONS AND ACRONYMS ACT ACTs ANC ARI ART ARVs BPHS CBHC CEmONC CHD CHEWs CHWs CMOH CO CORPS CPA CPR DFID DOTS EHSP EMNOC EONC EPI GoSS HBC HCW HCWM HHP HIS HIV/AIDS HLSP HMIS Artemisinin-Combination Therapy Artemisinin-based Combination Therapies Antenatal Care Acute Respiratory Infection Anti Retro-Viral Treatment Anti Retro-Viral Drugs Basic Package of Primary Health Services Community Based Health Care Comprehensive Obstetric and Neonatal Care County Health Department Community Health Extension Workers Community Health Workers County Medical Officer of Health Clinical Officers Community s Own Resource Persons Comprehensive Peace Agreement Contraceptive Prevalence Rate UK Department for International Development Directly Observed Treatment, short-course Essential Health Service Package Emergency Maternal Neonatal and Obstetric Care Emergency Obstetric and Neonatal Care Expanded Program of Immunization Government of South Sudan Home Based Care Health Care Waste Health Care Waste Management Home Health Promoters Health Information Systems Human Immunodeficiency Virus -Acquired Immunodeficiency Syndrome Health and Life Sciences Partnership Health Management Information System

3 HMM HP HRH ICB IDPs IDSR IEC IECHC IFMIS IFR IMA IMCI IPT ITN JAM JICM LATH LLINs M&E MA MCH MDGs MDTF MENCD MIS MMR MoFEP MOH MoU MPHS NAR NCB NGO NIDs NPA NTDs OPCS ORT PA PAA PAC Home Based Management of Malaria Health Policy Human Resources for Health International Competitive Bidding Internally Displaced Populations Integrated Diseases Surveillance and Response Information, Education and Communication Integrated Essential Child Health Care Integrated Financial Management Information Systems Interim un-audited Financial Report Interchurch Medical Assistance Integrated Management of Childhood Illnesses Intermittent Preventive Treatment Insecticide Treated Nets Joint Assessment Mission Joint Interagency Coordinating Mechanism Liverpool Associates in Tropical Health Long-Lasting Insecticidal Nets Monitoring and Evaluation Monitoring Agent Maternal and Child Health Millennium Development Goals Multi Donor Trust Fund Management of Endemic and Neglected Communicable Diseases Malaria Indicator Survey Maternal Mortality Ratio Ministry of Finance & Economic Planning Ministry of Health Memorandum of Understanding Minimum Package of Health Services Net Attendance Rate National Competitive Bidding Non- Governmental Organizations National Immunization Days Norwegian Peoples Aid Neglected Tropical Diseases Operations Policy and Country Services Oral Re-hydration Therapy Procurement Agent Project Accounting Agent Post Abortion Care

4 PDU PFMU PHC PIM PMTC PRIMA PSC PSI RPF SBD SHA SHHS S-MoH SPLM SOEs SWAP TB TBA ToR UN UNDP UNFPA UNICEF UPHSD USAID VCT VMWs WFP WHO Project Disbursement Unit Project Financial Management Unit Primary Health Care Project Implementation Manual Preventing Mother-to-Child Transmission Portfolio Risk Management Project Steering Committee Population Services International Resettlement Policy Framework Standard Bidding Document State Health Assembly Sudan Household Health Survey State Ministries of Health Sudan People s Liberation Movement State of Expenditures Sector-Wide Approach Tuberculosis Traditional Birth Attendance Terms of Reference United Nations United Nations Development Programme United Nations Fund for Population Activities United Nations Children's Fund South Sudan Umbrella Program for Health System Development United States Agency for International Development Voluntary Counseling and Testing Village Midwives World Food Programme World Health Organization Vice President: Makhtar Diop Country Director: Bella Bird Sector Manager: Olusoji O. Adeyi Project Team Leader: Mohamed Ali Kamil ICR Team Leader: Noel Chisaka

5 THE REPUBLIC OF SOUTH SUDAN SOUTH SUDAN UMBRELLA PROGRAM FOR HEALTH SYSTEM DEVELOPMENT PHASE II CONTENTS Data Sheet A. Basic Information.. i B. Key Dates..i C. Ratings Summary.. i D. Sector and Theme Codes..ii E. Bank Staff.ii F. Results Framework Analysis ii G. Ratings of Project Performance in ISRs... v H. Restructuring...v I. Disbursement Graph.v 1. Project Context, Development Objectives and Design Key Factors Affecting Implementation and Outcomes Assessment of Outcomes Assessment of Risk to Development Outcome Assessment of Bank and Borrower Performance Lessons Learned Comments on Issues Raised by Borrower/Implementing Agencies/Partners...34 Annex 1. Project Costs and Financing..36 Annex 2. Outputs by Component..37 Annex 3. Economic and Financial Analysis.51 Annex 4. Bank Lending and Implementation Support/Supervision Processes.54 Annex 5. Beneficiary Survey Results 55 Annex 6. Stakeholder Workshop Report and Results...55 Annex 7. Summary of Borrower's ICR and/or Comments on Draft ICR..56 Annex 8. Comments of Cofinanciers and Other Partners/Stakeholders 67 Annex 9. List of Supporting Documents...68 MAP.. 69

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7 A. Basic Information Country: South Sudan Project Name: Southern Sudan Umbrella Program for Health System Development Project ID: P L/C/TF Number(s): TF ICR Date: 06/27/2013 ICR Type: Core ICR Government of Lending Instrument: ERL Grantee: Southern Sudan, Ministry of Health Original Total Commitment: USD 63.00M Disbursed Amount: USD 71.30M Revised Amount: USD 71.30M Environmental Category: C Implementing Agencies: GOSS MINISTRY OF HEALTH Cofinanciers and Other External Partners: B. Key Dates Process Date Process Original Date Revised / Actual Date(s) Concept Review: 12/04/2009 Effectiveness: Appraisal: Restructuring(s): Approval: 03/05/2010 Mid-term Review: Closing: 06/30/ /31/2012 C. Ratings Summary C.1 Performance Rating by ICR Outcomes: Risk to Development Outcome: Bank Performance: Grantee Performance: Satisfactory Moderate Satisfactory Satisfactory C.2 Detailed Ratings of Bank and Borrower Performance (by ICR) Bank Ratings Borrower Ratings Quality at Entry: Satisfactory Government: Satisfactory Quality of Supervision: Satisfactory Implementing Agency/Agencies: i Satisfactory

8 Overall Bank Performance: Satisfactory Overall Borrower Performance: Satisfactory C.3 Quality at Entry and Implementation Performance Indicators Implementation QAG Assessments Indicators Performance (if any) Potential Problem Project at any time No (Yes/No): Problem Project at any No time (Yes/No): DO rating before Closing/Inactive status: Satisfactory Quality at Entry (QEA): None Quality of Supervision (QSA): None Rating D. Sector and Theme Codes Original Actual Sector Code (as % of total Bank financing) Health Public administration- Health Theme Code (as % of total Bank financing) Health system performance E. Bank Staff Positions At ICR At Approval Vice President: Makhtar Diop Obiageli Katryn Ezekwesili Country Director: Bella Deborah Mary Bird Laurence C. Clarke Sector Manager: Olusoji O. Adeyi Eva Jarawan Project Team Leader: Mohamed Ali Kamil Mohamed Ali Kamil ICR Team Leader: Noel Chisaka ICR Primary Author: Noel Chisaka F. Results Framework Analysis Project Development Objectives (from Project Appraisal Document) The project's development objective is to: (i) improve the delivery of the Basic Package of Health Services (BPHS) in four states (Upper Nile, Jongeli, Central Equatoria, and Eastern Equatoria); and (ii) strengthen key stewardship functions of the MOH, including monitoring. ii

9 Revised Project Development Objectives (as approved by original approving authority) Project Development Objective was not revised (a) PDO Indicator(s) Indicator Baseline Value Original Target Values (from approval documents) Indicator 1 : Births attendance in a facility. Value quantitative or Qualitative) Formally Revised Target Values Actual Value Achieved at Completion or Target Years Date achieved 12/14/ /27/ /30/2012 Comments (incl. % Target Not attained. However, good progress made. Baseline data from 2010 Sudan HH survey. Percentage achievement 85%. Source HMIS and achievement) Lead Agencies Reports. Health facilities submitting new monthly reports within one month of the Indicator 2 : reporting month to the county health. Value quantitative or Qualitative) Date achieved 12/11/ /27/ /30/2012 Comments (incl. % achievement) Target attained and exceeded. Baseline data an estimate. Percentage attainment 105.4%. Source: HMIS and Lead Agencies Reports. Indicator 3 : Children Immunized. Value quantitative or Qualitative) Date achieved 12/14/ /27/ /30/2012 Comments Target Attained. Baseline data from 2010 Sudan HH survey. Percentage (incl. % attainment 100%. Source: HMIS and Lead Agencies Reports. achievement) Indicator 4 : Long Lasting Insecticide Nets purchased and or distributed. Value quantitative or Qualitative) Date achieved 12/14/ /27/ /30/2012 Comments (incl. % Target attained and exceeded. Baseline data from 2010 Sudan HH survey. Percentage achievement 151.6%. Source: HMIS and Lead Agencies achievement) Reports. iii

10 (b) Intermediate Outcome Indicator(s) Original Target Formally Actual Value Indicator Baseline Value Values (from Revised Achieved at approval Target Completion or documents) Values Target Years Indicator 1 : Health facilities with at least one structured supervision visit per quarter. Value (quantitative or Qualitative) Date achieved 03/30/ /27/ /30/2012 Comments Target technically attained. Structured supervision using the supervisory (incl. % checklist was introduced by the project. Level of achievement 91.1%. achievement) Source HMIS and Lead Agencies reports. Indicator 2 : Value (quantitative or Qualitative) Health facilities having agreed 10 essential drugs at the time of the supervision Date achieved 11/12/ /27/ /30/2012 Comments (incl. % Target attained and exceeded. Initial baseline an estimate. Percentage achievement 107.7%. Source: Health facility survey of 2011 in two achievement) project supported States. Indicator 3 : New acceptors of modern contraceptive methods Value (quantitative or Qualitative) Date achieved 12/11/ /27/ /30/2012 Target not attained. Baseline survey from 2006 Sudan household survey. Comments Source: HMIS and lead agencies completion report. LQAS survey 2011 (incl. % reported 6.8% of women using modern contraceptives nationwide. achievement) Percentage achievement 50%. Pregnant women receiving antenatal care during a visit to a health Indicator 4 : provider Value (quantitative or Qualitative) Date achieved 12/04/ /27/ /30/2012 Comments (incl. % Target attained and exceeded. Baseline data is 2006 Sudan HHS. Percentage achievement 102%. Source HMIS and Lead Agencies achievement) completion reports. Indicator 5 : Outpatients visits per capita per year Value (quantitative iv

11 or Qualitative) Date achieved 12/11/ /27/ /30/2012 Comments (incl. % Target attained and exceeded. Baseline survey from LA in first quarter of implementation. Data only available for children under five. Percentage achievement) achievement 120%. Source HMIS and LA completion reports. Primary Health Care units with at least one male and female trained health Indicator 6 : worker (CHW or Higer) Value (quantitative or Qualitative) Date achieved 12/11/ /27/ /30/2012 Target attained and exceeded. Baseline from survey conducted by LA in Comments first quarter of project implementation. Health facility survey of 2011 (incl. % showed at least 59% of facilities had at least 2 or more nurses. Percentage achievement) attainment of target 327%. G. Ratings of Project Performance in ISRs No. Date ISR Archived DO IP Actual Disbursements (USD millions) 1 06/11/2010 Moderately Satisfactory Satisfactory /26/2011 Moderately Satisfactory Satisfactory /27/2011 Satisfactory Satisfactory /25/2012 Satisfactory Satisfactory /26/2012 Satisfactory Satisfactory H. Restructuring (if any) Not Applicable v

12 I. Disbursement Profile vi

13 1. Project Context, Development Objectives and Design 1.1 Context at Appraisal A. Country and sector issues 1. The Republic of South Sudan covers a geographical area of approximately 640,000 square kilometers. The population is estimated at 8,260,490 million 1 with a density of 15 people per square kilometer. More than 90% of the population lives in rural areas. The average annual population growth rate is 2.2%. Females constitute 52% of the population while males account for 48%. The total fertility rate is estimated at 6.7, while the average life expectancy at birth for both sexes is 42 years South Sudan suffered decades of conflict with massive internal and external population displacement, widespread insecurity, and lack of public funding. South Sudan was, and still is, characterized by high prevalence of poverty, inadequate access to basic services, inadequate access to economic opportunities, high mortality and morbidity rates and food insecurity. The health care system as well as the health status of the people of South Sudan suffered greatly during this period. Overall infrastructure was destroyed, roads were inaccessible and the entire education system was barely functional. This was and still is a major bottleneck with regards to national capacity building efforts. 3. In January 2005, the Comprehensive Peace Agreement (CPA) was signed between the Government of the Republic of the Sudan and the Sudan People's Liberation Movement (SPLM). The CPA marked the end of more than 20 years of civil unrest and ushered in a new dawn for laying the foundation for peace. It provided a framework and agenda for conflict resolution, power sharing and development. 4. The Joint Assessment Mission (JAM), of March 2005, comprising the Sudan People's Liberation Movement (SPLM), the Government of Sudan, the World Bank, and the United Nations (UN), prepared the Framework for Sustained Peace, Development and Poverty Reduction to establish the financial requirements, as envisaged in the Peace Agreement, for reconstruction and development of South Sudan. In addition to the humanitarian aid and the UN and bilateral presence, the Government of South Sudan (GoSS) anticipated significant resources resulting from: 1) the Comprehensive Peace Agreement, which includes a wealth sharing protocol intended to transfer substantial amounts of oil and non-oil revenues to the SPLM; and 2) the Multi Donor Trust Fund (MDTF) to be administered by the World Bank using Bank procedures, into which donors agreed to contribute funds. The Bank committed at least 1% of US$ million received for the period of the MDTF. The figure and chart below shows the different MDTF donors and their funding proportions Census, Southern Sudan Centre for Statistics & Evaluation (SSCSE) 2 GOSS. Ministry of Health. Health Sector Development Plan Revised and final draft. March

14 5. Under the Multi-Donor Trust Fund (MDTF), an Umbrella program to provide financial and technical support to carry out the Ministry of Health's (MoH) sector development program was developed and has been effective since July 28, 2006 (see Phases of MDTF-UPHSDP). The program was based on the JAM's recommendations and on the draft GoSS Health Policy and has provided the framework for strengthening the sector's managerial capacities, developing essential health care delivery systems, and increasing the population s access to basic health services. The Basic Package of Health Services (BPHS) of the MoH GoSS provides the key elements of services to be developed and provided in a manner that focuses on epidemiological priorities and intended performance targets as recommended by the respective Directorates of the Ministry in pursuit of the Global Millennium Development Goals and commitment to other specific Global Health Goals. Figure 1: Donor pledges and cummulative receipts Egypt World Bank Donor Spain Finland Canada EC Netherlands Amount US$m Cumulative receipts Combined pledges Source: MDTF-SS Administrator Chart 1: Proportional funding of the MDTF by Donor Source: MDTF-SS administrator 2

15 6. Progress on strategy formulation in the health sector: The MOH made progress on formulating a strategy for the sector and establishing a consensus. The accomplishments were: (i) development and launch of the Health Policy for the Government of Southern Sudan in December 2007; (ii) building partnerships with international (mostly NGOs) and local (mostly faith-based) implementing partners after the signing of the CPA; (iii) strong government willingness to adopt implementation mechanisms, particularly in the area of contracting, which were designed to overcome existing capacity constraints; and (iv) developing a consensus on the need for decentralizing governmental responsibilities and health services management. Another important accomplishment of the GOSS-MOH was the focus on developing Primary Health Care (PHC) as the cornerstone of the new health policy. The policy instrument underlying this consensus was the Basic Package of Health Services (BPHS). Even though the Basic Package of Health Services (BPHS) becomes more comprehensive with each revision, the underlying message that remained was that of high impact interventions that needed to be implemented on a priority basis. 7. Health Sector Financing: The GoSS/MDTF provided the main health sector financing mechanism with a resource criterion pegged on two-to-one during Phase I 3 for the domestic government budget and international donor funding, respectively. Reviews of public expenditures and budgets show that the GoSS allocated 7.9% of its budget (US$ 110 million) to health in 2006, gradually dropping to US$82.5 million (5.4% of the national budget) in 2007 and, US$70.5 million, or 4.2% of the national budget in 2008 and in Similarly, development assistance to the health sector has dropped from US$214.8 million in 2009 to US$169 million in In per capita terms, GoSS health spending stood at US$ 7 in 2008, well below her neighbors Kenya (US$28), Tanzania (US$ 12), Uganda (US$ 10) and Zambia US$ 18. This was far below the WHO recommended level of US$34 per capita to provide for minimum basic services and below commitments by African governments in Abuja to spend 15% of the total budget on health. The reductions in health spending during the period were largely attributed to volatility of oil revenues as the main source of domestic revenue, and Ministry of Finance inability to release money in a timely manner in the previous years. Table 1 and Figure 1 below highlights the proportion of health financing as a percentage of total of annual government funding for the period Table 1: Budget to Health Sector (in SDG million) Allocation Budget % of total budget allocated to Health Source: Approved Budget, the Government of Southern Sudan (GOSS), Ministry of Finance and Economic Planning, Juba, Expenditures financed by GOSS revenues, December, The MDTF UPHSDP was to have had three phases but Phase III was consolidated into Phase II due to financial challenges from the GOSS. 4. Republic of South Sudan, Ministry of Health, Health Sector Development Plan,

16 Figure 2: Trends in Health sector Budget: Trends in Health Sector Budget 250 5% 200 SDG (m) 4% 150 3% 100 2% 50 1% National budget Out turn Health budget as% of National budget 0% Source: Health Policy for the Government of Southern Sudan, Health Status: South Sudan continued to have poor health indicators and equally poor access to health 5 services which remained limited and inequitably located. (Table 2 below). Estimates for maternal mortality (2,054 per 100,000 live births) were the highest in the world and the coverage of preventive services such as immunization among the lowest. Malnutrition remained widespread with tropical diseases making a large proportion of the total burden of disease. Infectious disease epidemics continued to remain common and HIV prevalence estimates from location-specific surveys range from 0 to 8% among adults. The annual incidence of tuberculosis in South Sudan estimated at 325 per 100,000 was among the highest rates in the world. Table 2: Indicators Health Status Southern Sudan; compared with average of the region Middle East and North Africa (MENA 6 ): Indicator Regional Indicator Key SSHHS SSHHS level averages Maternal Mortality Rate 2, Deaths per 100,000 live births TB annual incidence Per Infant Mortality Rate Deaths per 1000 live births 5. The availability of health services facilities remained minimal. Coupled with many years of war, there was very little construction of new facilities or rehabilitation of old infrastructure and consequently infrastructure remained poor and inadequate, greatly affecting access. 6. South Sudan was at the time epidemiologically mapped to MENA. 7. Still for No new data on Maternal mortality in 2010 SSHHS 4

17 U5 Mortality Rate Deaths per 1000 live births Vitamin A supplementation Proportion of children under five who get Vitamin A supplementation. TB immunization coverage Proportion of infants with TB vaccination Measles Immunization coverage Proportion of infants who had measles vaccination Availability of Treated Proportion of households mosquito nets Treatment with any antimalarial Use of contraception among married or in union with at least one LLIN Proportion of children who had any antimalarial drug for fever Use of contraceptives among married couples or those in union Total Fertility Rate Births per women First Antenatal visit % Visit during pregnancy Institutional deliveries Deliveries attended at HFs Skilled Birth Attendance All deliveries attended by skilled HRH Contraceptives Prevalence Rate 3% 4 (all methods) 56 Use of contraceptives among CBA women DTP3 coverage ( routine) % of children vaccinated Access to health care (%) 0.2 (<25%) NA Visit per person/year Source: SSHHS, 2006 and World Children s Status report UNICEF * Institutional deliveries conducted at HFs also by non-professional staff and SSHHS Health Facilities: There are in total 1,487 health facilities in the 10 States. Of these 1,147 are functional, while 340 are non-functional. Of the functional ones, 3 are Teaching Hospitals, 7 State Hospitals, 27 County Hospitals, 284 Primary Health Care Centers, 792 Primary Health Care Units, 10 Private facilities, 14 specialized hospitals/clinics and 10 police and military health facilities. The non-functional health facilities include 2 State Hospitals, 1 County Hospital, 30 PHCCs, 302 PHCUs, 4 Private facilities and 1 Specialized Hospital/Clinic. Regarding the state of infrastructure in these health facilities, 376 (26%) are in good condition, 347 (23%) require minor renovation, 274 (18%) require major renovation and 490 (33%) need complete replacement. Furthermore, these facilities lack medical equipment, transport and communication, water and power supplies. 10. Access to health facilities: It is estimated that 44% of the population are settled within a 5 kilometer radius of a functional health facility (HFM 2011) 8. The per capita Out Patient Department utilization rate is estimated at 0.2 visits per annum. A combination of factors lead to the low utilization rates: lack of qualified staff; inadequate 8 Coverage estimates for 10 States that have been surveyed by the Health Facility Mapping (HFM)

18 equipment and supplies in County and State hospitals; long distances to health facilities; poor roads and transport; limited/no ambulance service; dysfunctional referral system; cultural and financial barriers. Access to known, cost-effective, life-saving maternal and child health interventions, for instance bed nets, water-guard and immunization, is still low in South Sudan. 11. Primary health Services (PHC): PHC delivery at the County level is catered around 1377 PHCUs and 270 PHCCs. Provision and quality of health services are very low with estimated 35% of health facilities providing immunization, less than 20% providing laboratory services for common tests and over 50% have regular drug stockouts. Facility utilization rate is lower than 0.2 contacts per person per year. Utilization of maternal and reproductive health services is low. Just 48% of pregnant women attend one or more Ante Natal Care (ANC) visits of which only 26% have delivered by skilled health personnel whereas the rest is provided by non-health personnel such as CHWs. Deliveries assisted by skilled birth attendants is just 10%. Prevalence rates of modern contraceptives are less than 3%. Access to Comprehensive Emergency Obstetric and Neonatal Care (CEmONC) in hospitals is very low. Overall 20% of health facilities at the primary level are not operative mainly due to a deficit in HRH. Particularly remote areas show over 40% non-functionality of primary health facilities. In addition, health facilities mainly suffer from inadequate and dilapidated infrastructure and lack of equipment and supplies. Health services are provided by lower staff cadres that have not received adequate professional schooling or any further training. Supervision by the SMoH and CHD is often inadequate. Table 3 below shows the distribution of facilities in South Sudan. As can be seen, the actual number of facilities in Equatoria is more than the number of facilities in other States showing the unequal distribution of facilities. Table 3: Distribution of health facilities by type and State 9 State Teaching State County PHCC PHCU Private Special Others Total Hosp. Hosp. Hosp. Wings Hosp. Upper Nile Unity N. B. E. Ghazal W. B. E. Ghazal Lakes C. Equatoria E. Equatoria W. Equatoria - - Jonglei - Warrap TOTAL , Source: Health Facility Mapping MoH-GoSS Health Service Delivery: Like in many post-conflict settings, the organization of health services in South Sudan was and mostly still is a patchwork of efforts that was not 9 As of Variance between these total and those in text reflect the non-inclusion of Jonglei and Western Equatoria 6

19 having a substantial effect on the population as a whole. The whole country was sub served by a network of un-coordinated NGOs whose link with Central and State MoH was at best minimal. This created a serious challenge on monitoring implementation and coordinating the various players on the ground. Work by the Ministry of Finance (MOF) indicated that 27% of the counties (21 counties) did not receive external financing for primary health care (PHC). Most of the funding to counties was directed to a few of the payams (districts or local government areas equivalent) was provided as support for vertical programs. In addition, financing for PHC exhibited significant inequities. The amount of money available for PHC ranged from $0.94 to $9.02 per capita per year. The health management information system (HMIS) was not functional. There were no systematic health facility surveys except for a facility mapping exercise the development of which was initiated under the phase 1 and completed under Phase 2 of Umbrella Program for Health System Development. 13. Human Resources for Health (HRH): There is a huge deficit in Human Resources for Health (HRH) with the health workforce skewed to a poorly trained lowlevel professional and auxiliary staff and an absolute shortage of higher-professional staff such as clinicians, midwives, medical officers, nurses, pharmaceutical technicians, laboratory technicians and health administrative cadres. It is estimated that just 10% of the staffing norms are filled by appropriately trained health workers 11. In addition, the capacity of health training institutions is limited. Only 23 of the 36 pre-service health training schools are functional with training mostly for low professional cadres. The table below highlights the HRH situation in the country. Table 4: HRH in South Sudan State Doctor Nurs MW CO CHW Phar Lab. Dental Theat. EPI Others Total e m Tech Attend Upper Nile ,221 Unity , ,590 N. B. E Ghazal W. B. E Ghazal Lakes C. Equatoria ,924 E. Equatoria W. Equatoria - Jonglei - Warrap TOTAL 189 1, , ,668 Source: Government of South Sudan Ministry of Health. Health Strategic Plan ( ) 14. Support to the health sector: During the period of the war and even after the Comprehensive Peace Agreement, health services were fragmented among many actors, including over 100 NGOs which were supported by multilateral and bilateral agencies. In the three years that followed the Joint Assessment Mission of 2005, in addition to the 11.The GOSS, MoH Strategic Plan

20 GOSS budget, three principal financing channels came on board to support the health sector: (i) the GoSS/MDTF Umbrella Program for Health Systems Development (UPHSD); (ii) the UN and its partners Work Plan; and (iii) bilateral donor mechanisms, including humanitarian programs, with some donors contributing through more than one channel. Among bilateral agencies, USAID supported an integrated health sector development project, building parts of the health system in 12 (of a reported 79) counties. The Joint Donor Team through the Basic Services Fund (BSF) supported 43 counties. 15. Rationale for Bank involvement: Following the CPA and JAM of 2005, it became important that the Bank play a significant role in the administration of developmental support given its comparative advantage in post conflict areas. In addition, the Bank has been involved as Trustee in administering a large number of trust funds. The Bank under the context of the MDTF UPHDSP was uniquely positioned not only to administer the trust fund, but also to bring its comparative advantage in systems development, monitoring and evaluation, financial management and procurement. In Phase I, the GOSS-MOH made considerable headway in formulating policy and in decentralizing decision-making. However, effective stewardship and efficient use of the large amount of resources coming into the sector needed to be strengthened considerably. This required the MOH to further build its capacity to effectively monitor and evaluate health sector performance and efficiently coordinate the activities of its many implementing partners. The Bank was well positioned to support the MOH given its experience in other post-conflict areas. The Bank as part of the donor coordinating committee was leading the work on overall system strengthening and health financing. 1.2 Original Project Development Objectives (PDO) and Key Indicators 16. The project's development objective was to: (i) improve the delivery of the Basic Package of Health Services (BPHS) in four states (Upper Nile, Jonglei, Central Equatoria, and Eastern Equatoria); and (ii) strengthen key stewardship functions of the MOH, including monitoring. The project consisted of the following two components: Component 1: Development of key stewardship functions I. Strengthening the coordination and management capacity of MOH; II. Development of monitoring and evaluation capacity, including the measurement of health sector performance; III. Strengthening pharmaceutical management, supply, and distribution system. Component 2: Expansion of delivery of basic health services IV. Expansion of the coverage of basic health service delivery (provision of basic package of health services in Upper Nile, Jongeli, Central Equatoria, Eastern Equatoria, including further development of human resources) 8

21 17. Project Development Objective indicators were: 1. Percentage of births attended in a health facility. 2. Percentage of children 12 to 23 months old who received measles vaccine before the age of 12 months. 3. Percentage of health facilities submitting new HMIS monthly reports within one month of the reporting month. 4. Percentage of children under 5 sleeping under ITN the night before survey. 1.3 Revised PDO (as approved by original approving authority) and Key Indicators, and reasons/justification 18. PDO was never revised during the lifetime of the project 1.4 Main Beneficiaries 19. The project beneficiaries were the populations served in the project States with a combined population of 4,734,400 (52% of country s population) for all interventions outlined in the PDO. However, the procurement of pharmaceuticals benefited the entire country population as the UPHSD was the designated entity for nationwide procurement of all pharmaceuticals. The project preferentially benefited children and women for the delivery of basic health care package that looked at specific maternal and child survival interventions. In addition, the project benefited the MOH and State MOH and their counties in policy formulation, strengthening of capacity in policy implementation, capacity building in human resources and monitoring and evaluation through the design, development and implementation of the HMIS. The project also strengthened interconnectivity between the Country Health Departments (CHD), State Ministries of Health and the Central Ministry of Health which had far reaching benefits. 1.5 Original Components Component 1: Development of key stewardship functions: Component 1 had three sub components: Total cost US$ 35, 5 million. Subcomponent 1.1: Strengthening the coordination and management capacity of MoH: Total cost US$ 1, 7 million. 20. Under this sub component, Phase II continued to support n GoSS-MOH to enhance the capacity of the MOH to coordinate the health sector and enable it to manage grants from diverse sources. The management team comprised four competitively selected national consultants two public health consultants, one financial management specialist and one procurement specialist. Their tasks included: (i) coordinating the country-wide provision of the BPHS to fill gaps in service delivery and avoid duplication; (ii) ensure that non-state actors (NGOs, private firms) follow MOH guidelines and strategies (e.g. implementation of new HMIS); (iii) carry out the recruitment of NGOs with MOH-GoSS and selected donors funds; (iv) manage the 9

22 contracts of NGOs, including regular field supervision; (v) monitor and evaluate NGO performance; (vi) oversee the management of funds from the MDTF, GAVI, Global Fund etc.; and (vii) assist in developing the capacity of the MOH to work effectively with NGOs and FBOs for the future partnerships with the private sector in health, utilizing domestic resources. To support the management team s activity, Phase II of the UPHSD provided the team with the budget for salaries, equipment, operating costs, and transportation. Subcomponent 1.2: Development of monitoring and evaluation capacity. Total cost US$ 3, 2 million. 21. Under this sub component, Phase II of the UPHSD provided support for data collection and analysis with technical assistance provided through a contract with Liverpool Associates in Tropical Health (LATH) financed from phase I. Phase II supported: (i) The design, conduct, and analysis of country-wide health facility surveys. The surveys examined quality of care, availability of drugs, personnel, and equipment, and implementation of the high impact interventions of the BPHS; (ii) Obtaining community-based information through a national health household survey; (iii) Development of a standard LQAS (lot quality assurance sampling) survey protocol that can be implemented by NGO partners to provide rapid household information on key coverage indicators at county and state level; (iv) Development, field-testing, and implementation of a quantitative supervisory checklist (QSC) that will facilitate and strengthen supervision of PHC facilities; (v) Development of an HMIS database to be used at county, state, and national levels; (vi) Strengthening the MOH M&E department through the provision of furniture and equipment and recruitment of two local consultants; and (vii) Rolling out the implementation of the revised HMIS formats through the implementing agencies (lead agencies and other NGOs) across all of the 10 states. Subcomponent 1.3: Strengthening pharmaceutical management, supply and distribution system: Total cost US$ 30, 6 million. 22. Under this sub component, Phase II saw the development of pharmaceutical management, supply, and distribution capacity within the MoH. It continued to take advantage of the ongoing contract with Euro health which was extended from Phase 1. Component 2: Expansion of delivery of Basic Package of Health Service. Total cost US$ 27, 5 million. Subcomponent 2.1: Expansion of the basic health service delivery in four states (Upper Nile, Jonglei, Central Equatoria, and Eastern Equatoria), including further development of human resources: Total cost US$12, 7 million. 23. Under this sub component, Phase II, the Lead Agencies (LA s) (IMA World Health and Norwegian Peoples Aid) working in 4 states had their contracts extended until the end of the project. The lead agency contracts were amended to: (i) make them more 10

23 results focused and ensure greater concentration on actually improving service delivery as well as strengthening capacity in a meaningful and measurable way; (ii) increase the flexibility provided to the LA s so they can effectively respond to challenging circumstances and fill financing gaps; (iii) facilitate procurement activities by LAs by making more use of post-review procedures and taking full advantage of the prior-review threshold; and (iv) reduce the focus on subjective deliverables such as the quality of work plans. Implementation of activities not completed in Phase I but funded under Phase II: Total cost: US$ 14, 8 million. 24. This sub-component included those activities that were not completed in Phase I due to lack of funds mostly and late implementation and finalization of contract by GoSS MOH. These were brought forward and funded in the Phase II budget. The activities included the following: i) MoH institutional capacity strengthening contract with Liverpool Associate in Tropical Health (LATH); ii) Lead Agency contract for Eastern Equatoria state, Health and Life Sciences Partnership (HLSP); iii) State MoHs V-SAT installation contract, UNOPS and; iv) Pharmaceutical management and capacity building, Eurohealth. The detailed costing is shown in the tables below. 25. Project costs by component: Financing of UPHSD Phase II should be viewed in the context of the overall design and financing of the different phases of the project. In the 2006 proposal, the total cost of UPHSD was US$225 million, which was divided over three phases (I-III) of implementation. Donors were to finance US$75 million and the GOSS would finance US$150 million in line with commitment to a two-to-one ratio of domestic-to-international funding for MDTF programs. The tables below show the original and revised phased allocation of the funds. The three-year-uphsd was originally scheduled to be implemented from April 2006 December 2008 but had to be extended to a more realistic time frame of July 2006 June The estimated cost of Phase I was $60 million, of which the donors were to provide $20 million against GOSS s $40 million. However, due to the financial crises and austerity measures, the GOSS was not able to put more than $28.0 million and donors financed GOSS s part for the rest of phase I and all of phase II. $14.8 million of Phase I was financed from Phase II. Table 5: Original and revised program costs by phase and source of financing (USD million) Period MDTF GoSS Total Original Phase I Apr Dec Phase II Jan-Dec Phase III Jan-Dec Total Revised Phase I July June Phase II Nov 2009-Jun

24 Total Source: adapted from country project document Table 6: Summary Program costs by component for Phase 2 (US$ million) (USD million) Amount % of total Outstanding commitment from Phase I (see Table below) Pharmaceuticals (LIB, ICB) Distribution (LIB, ICB) Continuation of 4 lead agencies M&E Management team GoSS HA Training of health personnel Total Phase II budget Additional Financing ( Procurement of Pharmaceuticals) 7.0 Additional Financing (Contingent Funds and ARVs) 1.5 Grand Total 71.5 Source: adapted from country project document Table 7: Details on outstanding commitment from phase I financed in Phase II USD million Amount MoH institutional capacity strengthening contract, Liverpool Associate in Tropical Health (LATH) 5.3 Lead Agency contract for Eastern Equatoria state, HLSP 4.1 State MoHs V-SAT installation contract, UNOPS 2.5 Pharmaceutical management/capacity building Eurohealth 2.5 Emergency pharmaceuticals transportation from state capitals to counties 0.4 Total outstanding commitment from phase I 14.8 Source: adapted from country project document 1.6 Revised Components 26. The original components were not revised. 1.7 Other significant changes 27. Design, Scope and Scale: No changes in design were made from the project design of Phase I. However, a number of activities that were scheduled to be implemented in Phase 1 were funded and implemented in phase II. These activities are highlighted in table 3. The scale of the UPHSD was to have covered all the 10 States. 12

25 However due to the GoSS inability to meet its obligations, donor funding for both Phase II and Phase III 12 was moved to support implementation of Phase II. This reduced the number of States for Phase II to four (Eastern and Central Equatoria, Jonglei and Upper Nile). The lack of financing to meet the earlier plan affected the overall scope of the MDTF UPHSDP by limiting actual implementation to the four States mentioned earlier. However, this did not impact the range of activities to be implemented. 28. Implementation arrangements and schedule: The implementation arrangements of UPHSD Phase II took advantage of pre-existing contracts (such as for the lead agencies, pharmaceutical supply and distribution, and capacity strengthening in the MOH and following closely the implementation of Phase I). The schedule of implementation was designed to last from June 30, 2010 to June , but this was extended by six months to December 30, 2012 to ensure that there was no gap in the delivery of the BPHS, while the next phase of Bank support became effective (Health Rapid Results Project). 2. Key Factors Affecting Implementation and Outcomes 2.1 Project Preparation, Design and Quality at Entry 29. Project preparation: The project was prepared as part of the overall MDTF UPHSD. There was high stakeholder participation right from the development of Phase I. Government, Bilaterals, Multilaterals and NGOs all worked together in line with the spirit of JAM recommendations in the development of the project proposal. The overall development period was a joint and consensus effort of getting the health sector transit from humanitarian support to health systems development. Hence, even though there was no formal quality at entry review, this can be said to have been satisfactory given the high level partner participation and review. 30. Design: The design of the second phase was consistent with the priorities identified in the new health policy of South Sudan, with a greater focus on results and improved coordination of activities in order to facilitate a more coherent sector-wide approach. Implementation challenges encountered in Phase I helped inform the design of Phase II. The Phase II of the UPHSD was implemented in four States Jonglei, Upper Nile, Central and Eastern Equatoria, with the objective of implementing the basic health care package, strengthening infrastructure and human resource base, and improving the availability of pharmaceuticals in Primary Health Care Centers (PHCC) and Units. The lead agencies recruited under Phase I to strengthen service delivery had their contracts extended until the end of phase II except for the HLSP whose contract was not renewed and reassigned to Norwegian peoples Aid (NPA). Similarly, technical assistance on pharmaceutical management, procurement, financial management, planning and monitoring and evaluation was extended to the end of Phase II. Overall, there was no change in implementation arrangements. The continuation of these contracts from Phase I 12. In the original planning, the MDTF-UPHSD was supposed to have been implemented in three phases. However, due to financial challenges, Government could not meet its obligations and hence Phases II and II were fused. 13

26 had a significant impact on the level of implementation for Phase II. The challenges and delays of Phase I were not encountered and the project moved to implementation immediately. This can be seen from that fact that all activities for Phase II were implemented including the remaining Phase I activities. 31. Project Organization and Management: The program continued to operate within the framework of the structure and management determined by the GOSS. Under the arrangement, the GOSS MOFEP had overall responsibility for procurement and financial management, and continued to build the capacity of the MOH at all levels. A management team within the GOSS-MOH played a key role in coordinating and tracking implementation of the project s activities. The MOH-GOSS continued to be the grant recipient. Within the MOH, the Senior Management Board acted as the Project Steering Committee with overall responsibility for program implementation. The Executive Board comprised of the Under Secretary, the Directors General, and Directors directly managed the program with the assistance from the Management Team established during Phase II. The Management Team collaborated with the directorates to ensure the availability of necessary technical information and provided project financial and administrative information to the Executive Board. 32. MOH and Partners: The MOH established the Health and Nutrition Consultative Group (HNCG) to coordinate the activities of development partners such as donors, UN agencies and NGOs. The project contributed by financing: (i) quarterly supervision and review of program and project implementation; (ii) annual planning and budgeting to ensure effective and flexible use of resources to fill gaps and implement new priorities, at national, state, and county levels. In addition, the UPHSD provided the framework for the MOH health sector development plans, to which other partners (such as USAID, DFID, WHO, UNICEF, UNFPA) continue to contribute. Phase II focused on strengthening effective coordination of partners and the stewardship role of the MOH, building towards a future sector-wide approach. Ultimately, the MOH continued to take the responsibility to ensure that activities were not duplicated among the various supporting mechanisms with initiatives supported by other partners complementing the UPHSD by either focusing on different activities or geographical coverage. Overall, the GoSS was fully committed to implementation but challenges in resource availability and inadequate human resources were a major drawback. 33. Lessons from Other Post-Conflict Settings: The experience of developing health systems in other post-conflict settings suggested that success required: (i) a clear and understandable strategy with explicitly enunciated priorities that stakeholders buy in to; (ii) a focus on achieving tangible results in a reasonable time frame as judged by a few specific and measurable indicators of success; (iii) actual collection of data by which to assess progress; (iv) that the ministry of health invests sufficient time and resources in coordinating the delivery of services (particularly geographical coordination) rather than focusing exclusively on delivering services itself; and (v) that the ministry of health take on a stewardship role rather than try to exert its influence through command and control mechanisms. Excessive centralization of management decision-making tends not to work 14

27 well in post-conflict situations, particularly when infrastructure has been destroyed and political considerations require significant decentralization. 34. MDTF financing provided an opportunity to apply these lessons effectively in South Sudan. During Phase I, the GOSS-MOH made considerable headway in formulating policy and in decentralizing decision-making. However, effective stewardship over the sector and efficient use of the large amount of resources coming into the sector needed to be strengthened considerably and required MOH to further build its capacity to: (i) effectively monitor and evaluate health sector performance overall and of its implementing partners in particular; (ii) efficiently coordinate the activities of its many implementing partners; (iii) fill gaps in service delivery by quickly mobilizing the resources required to implement the high impact interventions of the BPHS. Phase II of the UPHSD aimed to help MOH to play key stewardship functions thereby increasing the effectiveness of other investments being made in the health sector. 35. Risks and mitigating measures: 1. High expectations from the population and partners. For the population, this was mitigated through building support for expanding basic service delivery and highimpact health interventions. For the partners, the UPHSD supported country dialogue and coordination with other sectors and key ministries, including assisting the MOH s capacity building for coordination at the central, state and country levels. 2. Project scope and complexities of implementation. Was mitigated through phased implementation (especially the components to develop public health administration and health infrastructure/equipment) and geographical targeting and the use of Lead Agencies. 3. Inadequate skilled human resources: Insufficient and mostly unqualified human resources to manage health systems development coupled with inadequate salaries was a challenge mitigated through increased skills training and use of incentives in the delivery of basic health care package as well as subcontracts to NGOs to implement specific activities. 4. Rapid expansion of health services remained a major bottleneck but was mitigated by mobilizing workers from the community and those demobilized from the SPLM including retired civil servants. 5. Weak procurement and fiduciary capacity: This was mitigated through the recruitment of both Financial and Procurement Specialists who sat at the Ministry of Health and whose roles in addition to ensuring adherence of Bank processes and procedures was to ensure that appropriate capacity building and knowledge transfer to MOH Staff. 6. Inadequate capacity in monitoring and supervision of the project: The recruitment of a Monitoring Agent ensured that implementation progress, fiduciary and procurement processes were adequately monitored ad supervised in a timely and effective manner. 7. Donor relation complexities: This was mitigated through interagency donor coordinating meetings and monthly MOH and Donor meetings. 15

28 2.2 Implementation 36. The project was not restructured nor was it at risk at any point. There was no mid-term review as the project only had a two year time line. The project had two rounds additional financing; 1. USD$7.0 million for the purchase of pharmaceuticals following the designation of the UPHSD as the overall entity for national drug procurement including other medical products, and 2. US$1.5 million for the procurement of anti-retroviral medicines; as well as for continued support to counties previously supported by USAID in Jonglei to ensure continued implementation of the BPHS after the USAID contract ended and responsibility transferred to NPA. 2.3 Monitoring and Evaluation (M&E) Design, Implementation and Utilization 37. The Directorate of Research, Planning and Health System Development in the MOH was responsible for program monitoring and reporting on performance. Technical support was provided through a contract with LATH. The results framework for Phase II was in line with overall MOH M&E framework focusing on outputs and outcomes rather than inputs. Data was collected through a HMIS developed through the support of the project and now being used by all states of South Sudan, a health facility survey and a household survey using the LQAS methodology. GoSS MOH Directorate of Research and Planning was and remains responsible for the implementation of HMIS, development and implementation of a quantitative supervisory checklist, and carrying out surveys (health facility survey and LQAS). The lead agencies recruited for the provision of BPHS were in charge of implementation of HMIS in the respective health facilities that they supported. 38. As reflected from the results matrix, significant progress was made in both data collection and data utilization. During the ICR mission to the counties of Juba in Central Equatoria and Torit in Eastern Equatoria, the level of data management and utilization was evidenced by disease trend charts in measles, BCG and DPT vaccination, malaria visits and TB reporting. This was reiterated as the norm in other counties that were under other Lead Agencies. Reports from the Lead Agencies clearly show the advanced level data of collection and utilization at source. Monitoring missions were held on a quarterly basis and contributed to project implementation. It should be pointed out that the availability of the TTL who was resident in South Sudan provided an increased measure of proactive follow up and greatly strengthened the frequency and quality of monitoring and supervision support visits. 39. Another aspect that was strengthened was the implementation of surveys. As was noted earlier, data for decision making at project inception was scanty and this led to setting of targets based on surrounding counties and regional level data. The 2006 South Sudan Household Survey (SHHS) was old and the project contributed to implementation of surveys to improve data availability. 16

29 2.4 Safeguard and Fiduciary Compliance 40. Environmental and social safeguards: A draft Environmental and Social Assessment Framework for MDTF Investments in South Sudan was finalized by the Directorate of Environment in the Ministry of Housing, Physical Planning and Environment and shared with all major GOSS sectors. Based on this Framework, the Ministry drafted an Environmental and Social Screening Checklist. The checklist identified issues and mitigation measures with regard to environmental management and social safeguards requirements during implementation of the investments. As UPHSD only did minor rehabilitation of existing functioning health facilities in the four States and no new construction, no safeguard issues were raised. Environmental issues were addressed through the existing Environmental and Social Management Framework that provided guidelines for environmental site selection, design and construction, and procedures for ensuring compliance. In addition, a Medical Waste Management Plan was prepared and was implemented in the four states (Upper Nile, Jonglei, Central Equatoria and Eastern Equatoria) through Lead Agencies. The implementation progress of the plan was under the Department of Environmental Health in the MoH. No issues in the implementation of the medical waste management plan were encountered during the project period as centers supported by the project constructed incinerators that were used to dispose of medical waste. 41. Fiduciary compliance and expenditure: The World Bank contracted Price Waterhouse Coopers (PwC) Africa Associates Ltd as the Monitoring Agent (MA) for the MDTF-SS. The MA assisted the World Bank fulfill its fiduciary, management, evaluation, and reporting obligations with respect to procurement and financial management, as well as monitoring and evaluation of results for the purpose of accountability and transparency. 13 Projects/programs financed through the MDTF-SS were subject to a financial audit on an annual basis. The MoFEP contracted an External Audit Agent to carry out the functions of an external auditor of the MDTF-SS projects. The table below shows the commitments, disbursements and utilization of the UPHSD Phase II resources by close of project. Project ratings in ISR for Implementation Progress were satisfactory throughout project life; MS for first two and satisfactory for the last three ISRs for development objective. (Trend of disbursements in data sheet). Table 8: Commitments and Disbursements by close of project Project UPHSD Commitments (US$ m) - Signed Grant Agreements Disbursements (US$ m) To Project Accounts Actual expenditure (US$ m) Dnr RSS Total Dnr RSS Total D RSS Total Dnr RS S Unexpended funds (US$ m) % Utilisa tion Tota l 13. The MA s role was to monitor expenditures related to the activities financed under the Grant. It had the following responsibilities: 1). Monitoring the procurement of goods, works and services; 2). Monitoring progress of implementation of activities and other items; 3). Screening and recommending withdrawal applications for IDA s approval and payment; 4). monitoring all expenditures financed under the Grant, and 5). screening the financial management capacity of the Recipient so as to ensure that the proceeds of the Grant are disbursed only for the intended purposes and according to applicable IDA procedures 17

30 Phase II % Source: Draft Monitoring Agent report. Dnr-Donor, RSS, - Republic of South Sudan, 42. Procurement: Goods procured under phase II were IT equipment, essential drug kits for additional 21 months and office equipment for the Management Unit. GoSS also used the Bank s standard evaluation forms. Goods procured from United Nations agencies such as United Nations Children s Fund (UNICEF), United Nations Fund for Population Administration (UNFPA), or the United Nations Office for Project Services (UNOPS) were in accordance with the provision of paragraph 3.9 of the Guidelines, subject to the Bank s prior review. All Good and Services procurement were done according to the World Bank s guidelines. Procurement monitoring was done every six months. 43. Given the measures taken by the GoSS MoFEP vis-à-vis the procurement of monitoring agents, contracting of an external audit firm and recruitment of a PFMU within the MoFEP, the project did not have any qualified audits. Reports and other stipulated financial requirements such as interim financial reports and financial annual reports were delivered on time. By the close of project, the project had been fully committed and disbursed as shown in Table 4 above (details in annex 2). 44. The project was in compliance with all legal covenants. 2.5 Post-completion Operation/Next Phase 45. Sustainability: The GOSS has developed the South Sudan (SS) Development Plan as well as the Health Sector Development Plan (HSDP) which has requested donors to align, harmonize and coordinate their financial and technical support to the implementation of the HSDP at State and County level. It is important to note that as part of sustainability MDTF-SS was GoSS led and driven, there was high community participation and use of NGOs to implement projects. The three major donors of the HSDP (WB, DFID and USAID) have continued to support the sector as described below. 46. Following GoSS and partners agreement on the division of support to states by the various partners, the Bank has been designated to support two Northern, and most challenging, States of Jonglei and Upper Nile, and does so through the US$28 million Health Rapid Results Project whose main development objectives are: (i) to improve the delivery of high impact primary health care services in Jonglei and Upper Nile; and (ii) to strengthen coordination and monitoring and evaluation capacities of the Ministry of Health. The project was approved in April 2012; became effective in August 2012 and will close in October USAID supports Central Equatoria and Western Equatoria States while the other six States will be supported through the Health Pooled Fund (led by UK DfID and partners). Following the adoption of the new arrangement for supporting the sector, discussions were held to ensure that health service delivery was not interrupted with the closure of the ongoing support (MDTF, SHTPII and BSF). This last point is essentially critical as evidence on the ground is showing the negative impact of 18

31 rapid deployment of new implementation arrangements coupled with changes in local NGOs. This has led to challenges in meeting the logistic needs of facilities as the new lead implementing agencies are still becoming operational and so not able to meet the needs of the affected health facilities and communities, i.e., drug distributions and operational costs for PHCC and PHCU are being affected negatively as resources allocated from the County are minimal. 47. It will be important to point out here that the designation of different partners to provide total State support could also be a challenge and could hinder implementation if the health system based approach and the procurement and contracting mechanisms already established within UPHSDP Phase II are not continued. Already some of the challenges noticed above are a result of discontinuation of the work of some Lead Agencies on the ground. In addition, the role of State MOH will have to be especially strengthened to ensure that overall health implementation is done with State leadership for continuity and sustained capacity strengthening. 3. Assessment of Outcomes 3.1 Relevance of Objectives, Design and Implementation 48. Rating: Substantial for overall relevance of MDTF-UPHSDP Phase II. The objectives were (and remain) highly relevant to the existing political orientations and technical considerations and are in synch with the current health agenda. 1) Relevance of PDO: The relevance of the PDO of the MDTF UPHSD was in line with the JAM recommendations and the overall direction of the GOSS in ensuring that MOH was taking the lead and prioritizing health interventions in line with meeting the MDGs. The focus towards MDG attainment is evident across all the MDTF support projects in all sectors. The relevance of the PDO remains high at the time of the ICR. 2) Design: The design of the second phase was consistent with the priorities identified in the new health policy of South Sudan, with a greater focus on results and improved coordination of activities so as to facilitate a more coherent sectorwide approach. The design of the project also contributed to other higher level objectives such as good governance and equity where the GoSS had stronger stewardship over the health sector to help improve equity and ensure that all the people of South Sudan have access to at least basic health services and poverty alleviation through strengthening the delivery of preventive, promotive, and curative services which will mitigate the worst aspects of poverty and help prevent families from becoming destitute. 3) Bank Assistance Strategy: Lastly, the Project was in line with the World Bank Africa Strategy for Health that focuses on attainment of MDGs and poverty reduction and the country development strategy on health; and one that regards the health system as the cornerstone of sustainable delivery of health services. 19

32 The project was being implemented taking cognizance of Phase I lessons and using Phase I arrangements. This drastically reduced time lag in procurement and initiation of delivery of services on the ground. 3.2 Achievement of Project Development Objectives 49. Attainment of PDOs: The UPHSDP Phase II by and large achieved its development objectives. The project was implemented within the time frame with an extension of six months to ensure that the delivery of the basic package of health services was not interrupted. All the components of the project were implemented fully albeit with some challenges mostly due to ongoing security issues and inadequate human resource capacity on the ground. The use of contracted lead implementing agencies and their supporting NGOs was especially useful in the attainment of results. The fact that the Lead Agencies were carried over from Phase I meant no time was wasted in recruitment at the start of the project and therefore, they were operational right from the start of the project. The implementation of planned activities was done in a timely manner and undoubtedly contributed to the achievement of expected outputs. A summary of implementation by PDO is provided below. PDO 1: Improve the delivery of the Basic Package of Health Services (BPHS) in four states (Upper Nile, Jonglei, Central Equatoria, and Eastern Equatoria): 50. Expansion of delivery of Basic Health Services: The purpose of this PDO was to strengthen the delivery and expansion of coverage of a basic package of health services in Upper Nile, Jonglei, Central Equatoria and Eastern Equatoria and the development of human resources. This was done through the implementation of high impact interventions. As part of improving coverage and quality of service, Lead Agencies were allowed to incentivize the implementation of activities leading to the attainment of this PDO. 51. The project supported the improvement of access to high impact interventions through a fixed strategy (routine delivery of service in health facilities) and outreach activities. Priority was given to interventions known as most effective and providing the best value for money. These interventions are child immunization, treatment of major child killers (diarrhea, pneumonia, malaria, etc.), Vitamin A and LLINs distribution, maternal care, etc. The achievement of results for these interventions within a very short period of time (32 months) is seen through data as follows: 52. The utilization and coverage of high impact interventions increased significantly from Quarter to Quarter : The number of children under 5 treated in facilities increased from 29,121 to 205,181; the number of children under 12 months who received DPT3 vaccination increased from 14,022 to 44,815; and the number of pregnant women receiving antenatal care during a visit to a health provider increased from 4,913 to 20,175. The number of under-5 consultations increased from 20,690 in Q to 39,954 in Q During the same period, there was an increase in number of women attending antenatal consultations (52152 vs 589) number of deliveries occurring at health facilities (1,501 vs 551 ) and number of children under 12 months who received DPT3 20

33 vaccine (5,352 vs 2,020). Even though these significant achievements could be attributed to improvements in the reporting system, the 80 health facilities in Upper Nile who were reporting consistently over the same 18 months showed significant improvements in service delivery. The final status of health coverage for the high impact interventions is contained in the data sheet. 53. A detailed analysis of the attainment of each PDO indicator is described below. 1. PDO Indicator 1: Birth attendance in health facility: 85 % of target reached. The proportion of pregnant women who delivered in a health facility increased from 10% at baseline 2009 to 15.3% in Although this achievement is less than the agreed end of project target (18%), the overall observed progress should be taken in the context of a country where the availability of health services providing skilled delivery was extremely limited. In 2010, only 125 health centers out of 787 functioning health centers were able to provide skilled delivery. During the project life, this number increased consistently and reached 457 in June 2012 and consequently, the number of pregnant women who have delivered in a health facility increased from 17,851 in 2010 to 28,944 in High levels of insecurity and the nomadic nature of the population in the northern states could have had an impact on fully reaching the target. 2. PDO Indicator II: Children immunized: 100% of Target reached. The number of children under 12 months of age who received DPT3 vaccine and a Measles vaccine has increased from 34,286 (baseline 2009) to 179,260 for DPT3 in 2012 and from 54,553 (baseline 2009) to 180,462 (2012). This substantial increase is a result of improved availability and access to routine immunization services; the number of health centers providing immunization services increased from 184 in 2010 to 388 in June 2012 in addition to the dry season campaign supported by the project which aimed at improving access and coverage of basic services such as immunization, vitamin A supplementation, and insecticide treated bed nets for malaria prevention. 3. PDO Indicator III: Health facilities submitting new HMIS monthly reports within one month of the reporting month to the county health department: Target surpassed. At the launch of the project, HMIS was essentially not in existence in the country, there were various reporting tools and channels, and the MOH was not systematically receiving data from implementing agencies which were reporting to their respective donors. The project supported the development of HMIS tools, capacity building and ensured that reports were delivered from the participating health facilities. The proportion of health facilities submitting their monthly HMIS report on time increased from 5% baseline-2009 to 68.5% in June 2012, even surpassing the MDTF target of 35%. The HMIS now forms the basis for all reporting in all ten states and is used by all actors supporting the states. 4. PDO Indicator IV: Long-lasting insecticide-treated malaria nets purchased and/or distributed: Target surpassed. The project was not intended to procure 21

34 bed nets which was planned and funded under the Global Fund. The objective of the project was to ensure the distribution of the bed nets for pregnant women and children under-five. During the project s life, 287,234 long-lasting insecticidetreated malaria nets were distributed through the routine health service and the dry season campaign supported by the project. This met and exceeded target of 189,378 LLINs procured /distributed set for UPHSD Phase II. Table 8 highlights the various achievements by indicator category. PDO II: Strengthen key stewardship functions of the MOH, including monitoring and evaluation. 54. The project had three sub-components supporting this particular PDO. The three subcomponents were: (i) Strengthening the coordination and management capacity of MOH; (ii) Development of monitoring and evaluation capacity, including the measurement of health sector performance; and (iii) Strengthening pharmaceutical management, supply, and distribution system. 55. Strengthening the coordination and management capacity of MOH: The coordination and management capacities of the Ministry of Health at the central and state level were strengthened through the setting-up of a functional project Management Team with the objective of coordinating and monitoring the delivery of health services not only in the project supported states but throughout the country. Monthly coordination meetings were conducted with the involvement of the MOH staff, lead agencies team, NGOs providing services, the World Bank and other development partners. The purpose of these meetings was to identify obstacles to the implementation of the project with a focus on delivery of health services and to find appropriate solutions. 56. The capacity of County Health Departments (CHDs) was strengthened through better staffing, equipment (provision of internet connection, transport means), and operating costs to carry out regular supervision. Within the overall context of strengthening the MOH capacities, the project supported the provision of technical expertise to the MOH to implement the following activities: (i) identification of strengths and weaknesses of the MOH as it sought to oversee the management of the health system, (ii) revision of the existing infrastructure needs and definition of new roles and responsibilities which clarified lines of authority and decision making; (iii) reviewing and updating of the Health Sector Policy and development of a 5 year Health Sector Development Plan which was published in The project was instrumental in the engagement of IFC/Health Initiative for Africa in South Sudan which looks at policy frame work development and support for private sector in health. The table below provides an example of the level of capacity strengthening of CHD in Upper Nile. (See details in Annex 2). 22

35 Table 10: Number of structures renovated County Facility Facility Intervention Notes Akobo CHD office Construction Completed Q Bor CHD office 2 PHCCs Bor Hospital Compound Construction Renovation Construction: 2 latrine/shower blocks Completed Q Completed Q Completed Q Pibor CHD office Construction Completed Q Pochalla VCT center TB Laboratory unit Construction Construction Completed Q Completed Q Twic East 3 PHCCs Renovation Completed Wuror VCT center Construction Completed Q Source: Upper Nile Cumulative Rehabilitation, End Evaluation Report (EER), The project contributed to the development of a government concept note to introduce PPPs in the health sector. It supported the conduct of two studies: one to assess the existing legal framework and the other on the feasibility of an integrated pharmaceutical supply chain through PPP. One of the ongoing challenges within capacity building was availability of personnel to be trained or those with adequate skill to be further developed. This is a larger challenge in the Northern regions and less so in Central Equatoria. 58. Development of monitoring and evaluation capacity, including the measurement of health sector performance: The project supported the development of an M&E system in the country. The MOH did not have any operational M&E system and the only credible available data at the launch of the project was the report from the 2006 Household Survey. The project supported 2 population-based surveys, a health facility survey, developed and implemented the routine HMIS with the introduction of the District Health Management Information System. This has improved the reporting from facilities. The project was instrumental in ensuring the availability of credible data which has contributed to enhanced decision making and informed planning in the sector. Table 11: Firms and costs used in the strengthening of HMIS and DHIS: Firm Amount MOH institutional capacity strengthening contract, Liverpool Associates in Tropical Health (LATH) 5.3 Lead Agency contract for Eastern Equatoria state, HLSP transferred to NPA 4.1 State MOH s V-SAT installation contract, UNOPS 2.5 Source: adapted from country project document 59. Strengthening pharmaceutical management, supply, and distribution system: The Umbrella Program for Health System Development was designated as the preferable source of essential drugs procurement. Following this agreement, the project supported the provision of drugs for the entire country. A total of US$ 38 million was used for procurement of medicines and other pharmaceuticals out of which US$ 35.1 million was 23

36 invested in the procurement and distribution of drugs for more than 1200 health facilities covering the needs of 10 million individuals. The Health Facility Survey (2011) and subsequent surveys and supervision revealed that availability of drugs is comparable to other countries with an established health system. Euro Health was also engaged for capacity building and pharmaceutical management as per table below. Table 12: Pharmaceutical firm for capacity building and amount used. Firm Amount in millions US$ Pharmaceutical management/capacity building Eurohealth 2.5 Source: adapted from country project document 60. Training: 6 Laboratory technicians were trained at Malakal Teaching Hospital while 5 Emergency Obstetric Care (EmOC) laboratories were equipped and supplied. 76 Front line workers were trained in Maternal Neonatal Child Survival interventions and referral to EmOC centres with over 4000 persons were reached in EmOC outreach campaigns. The five EmOC centers have been functional since June 2012 and the preliminary results (August-October 2012) show an increase of ANC attendance (994) compared to the same period of 2011 (427). Major partners for this component outside MOH and UPHSD were USAID, Great Lake University in Kisumu (Kenya), Massachusetts General Hospital and UNFPA. Table below highlights the training outcomes in Upper Nile State (See detail in Annex 2). Table 13: Cumulative Training Activities in Upper Nile and level of Staff trained by facility Date Training Group Subject CHD/SM OH NGO IMA PHCC PHCU No. trained 10-Jan GoSS/IMA BPHS and EPI x x Aug GoSS/IMA Program Coordination/Micro-planning x x Aug CHASE Management x Sep HISP ICT Training (6 days) x x Sep HISP Register and Report Training (2 days) x x Sep HISP DHIS training (4 days) x x Oct IMA DHIS for Management x x 6 10-Nov ETC Health Sector Coordination x x Dec CHAS Training of HHP (health promoters) x x Jan HISP ICT Training (6 days) x 5 11-Jan HISP Register and Report Training (2 days) x x 150 Jan-11 HISP DHIS training (4 days) x 2 11-Mar IMA Refresher HMIS 2 11-Mar IMA/MGH Training of Trainers for MNCH (Juba) x x x Apr IMA/MGH Front Line Training MNCS x x May IMA/MGH Front Line Training MNCS x x 30 24

37 11- May IMA State Health Summit x x x Jun IMA/MGH Front Line Training MNCS x x x x x 8 11-Jun HISP/IMA Refresher HMIS x x x Jun IMA Basic computer training x 5 11-Jul ROSS HMIS Master training in Juba x x 2 11-Jul FLHW Increased utilization of FP & STI tools x 8 11-Jul FLHW Follow up training in Renk x x x Oct IMA, CHD Basic Computer skills and DHIS training x Nov TBA, MWs Front Line Training MNCS x Dec CHD, SMOH DHIS data quality and use of info for action x Dec TBA, MWs Front Line Training MNCS x Jan SMOH DSC Launching Workshop x x x Feb TBA, MWs Front Line Training MNCS in Maiwut (5 days) x Mar TBA, MWs Front Line Training MNCS in Longechuk (5 days) x Mar TBA, MWs Front Line Training MNCS in Maban (5 days) x Mar CHD/SMOH Voluntary Testing & Counseling (VCT) 21 days x x May CHD/SMOH/ NGO 2 nd Health Summit x x x Jun CHD/SMOH Training of Lab Technicians in Blood Safety & Basic Microscopy x 6 12-Jun CHD/SMOH Training of Health Workers in Basic Emergency Obstetric & Neonatal Care (EmOC) x Dec IMA EPI Micro planning x Dec IMA DHIS training (4 days) x 13 1,03 5 Source: Upper Nile cumulative training End Evaluation Report (EER) 2012 This level of training was conducted across all the States and in all the Counties that were being supported by the project. 61. Intermediate Outcome Indicators (IOI)s: The project saw a progressive improvement in the attainment of IOIs throughout the lifetime of the project. Structured supervision with the use of supervisory check list was introduced. Health facilities with at least 10 essential drugs exceeded the set target of 65%. The health service has seen an increase in number of pregnant women who receive antenatal care at health facilities and the target has been surpassed (102% achieved). Overall, outpatients visits per capita have also increased during the project exceeding the target by at least 20 percentage points. Especially noteworthy is the progress in health facilities with at least 25

38 one trained health worker which exceeded the target by 327%. (See detail in Results Framework) 62. The table below provides a summary of the indicator attainment by type of indicator Table 14: Attainment of targets by indicator type Number Attained Not attained Over 90% Comment progress PDO indicators (Great progress - 0 PDO attained 85%) Intermediate Outcome (Modest progress Indicators 50% Source: Results Framework 1 IOI mostly attained 63. Issues with data sources: A number of data sources are used to measure progress in this ICR. These include data generated through developed HMIS and District Management Information System, household and health facility surveys and the LQAS survey. It has to be appreciated that as part of improving data availability and utilization within the span of the project time, there will be limitations in the comparability of these data. Whereas HHS and HFS are mostly comparable over time due to uniform use of similar tools, LQAS can be used as an additional source on how well an intervention is doing over a given threshold. However, all survey methods are useful in defining how well interventions have been attained. It should also be pointed out that during project development some indicators were designated as percentages. For a project of two years duration, the issue of appropriate denominators becomes rather challenging in an environment where denominators might change as more accurate data and estimates become available. 3.3 Efficiency 64. Rated Substantial for the reasons described below. 1. Net present value: The Umbrella Program for Health System Development (UPHSD) Phase II financial investment for a total amount of US$71, 5 million was a small contribution compared to $100 million per annum coming into the South Sudan health sector during the period of project implementation. However, it was able to make a very significant difference in health services and delivery of care in the project States. The level of capacity strengthening in terms of human resources and infrastructure development was high. The States where the project was implemented showed improved delivery of service, policy coordination and increased coverage of high impact interventions. 2. Cost effectiveness: The cost of delivery of health care through a system approach and strengthening of coordination was found to be cost effective. As explained in the economic analysis (annex 3), the cost per total DALYs averted is equal to USD 496. Taking the per capita GDP of South Sudan as USD 1546, the monetary value of DALYs averted is equal to USD 175,532,840. The present value of benefit is far 26

39 greater than the present value of the costs incurred. The effectiveness or cost benefit ratio of the project (56,365,286.47/175,532,840) is Furthermore, close monitoring of project implementation enhanced efficiency and contributed to better harmonization with other donors in the sector thereby reducing duplication and ensuring effective use of resources. 3. Financial Rate of Return: The implementation of UPHSD Phase II was designed in the context of improving the efficiency and effectiveness of health service delivery as the country transitioned from humanitarian delivery of health service. The financial rate of return in a post conflict situation where delivery of health services is done by an uncoordinated mix of NGOs is very minimal and might not provide value for money. As the country grows, the availability of NGOs might become complementary rather than the mainstay for health delivery. Hence, the strengthening of capacity and improved coordination for the different players at different levels, national, State and County provides the opportunity for streamlining the developmental agenda and maximizing on the financial rate of return. In addition, the investment in delivery of the Basic Package of Health Services translates into high rate of return for children and pregnant women in the medium to the long term. 3.4 Justification of Overall Outcome Rating 65. Rating: Satisfactory. Implementation of the MDTF UPHSD contributed greatly to the success and strengthening of health service delivery in the project States. There was substantive improvement in all the PDO indicators and Intermediate outcome indicators. Evidence on the ground shows improved level of infrastructure, increased number of staff developed as part of capacity strengthening and strengthened delivery of the Basic Health Services Package. The development and strengthening of HMIS through the DHMIS and supportive supervision has resulted in successful information management. All these are indicative of good project performance. Therefore, in view of substantial rating for relevance, substantial rating for attainment of PDO/Implementation progress (efficacy), substantial rating for efficiency, the overall project outcome rating is rated as Satisfactory. 3.5 Overarching Themes, Other Outcomes and Impacts (a) Poverty Impacts, Gender Aspects, and Social Development: 66. The project focused on equity and gender by making priority service delivery to the most vulnerable through the delivery of the high impact interventions in the Basic Health Services Package. High impact interventions were prioritized to maternal and child survival thereby helping contribute to improving the very poor health indicators. The ICR mission to the States PHCCs and PHCUs noted the satisfaction of the health workers as regards the UPHSD, especially for supporting maternal health interventions such as advocacy for health facility delivery, provision of ANC and the implementation of community child campaigns for EPI. The availability of the UPHSD also provided the much need operational costs that allowed the facilities to conduct community monitoring, thereby taking health services as close to the people as possible. Morbidity reduction in 27

40 the health of women and children contributes to reduction in poverty, as women s contribution to household income has been shown to be more towards social development and poverty reduction including improvement of child survival interventions. (b) Institutional Change/Strengthening 67. The MDTF UPHSD was designed as per recommendation of the JAM to transition the country from delivery of health care through humanitarian support to delivery of health care through a health system strengthening approach. Results from the implementation of the UPHSD at central level have clearly shown the improved capacity and strengthening of the MOH. The GoSS has gradually taken overall coordination of health, and development policies and across its implementation units, increasing the functionality and supervisory roles of MOH. This has helped strengthen coordination of the health partnership at central level. The States are also leveraging the efforts of the Central level in taking leadership. An example from Eastern Equatoria shows that all partners and NGOs now have a consolidated monthly presentation that follows the work plan of the State MOH. The partners contribute their quarterly achievements to MoH and the Ministry then presents the overall report on behalf of all other stakeholders. 68. The development of the HMIS and use of supervisory checklist has strengthened the collection and use of information at all levels. Human resources for health, however, remain a challenge. This is not due to the lack of capacity building, but rather as a consequence of the long period of war which resulted in destruction of schools and the opportunity for education in the general population. However, the project has mitigated this situation through on the job training of CHW, county nurses, and traditional birth attendants to support delivery at health facilities. Plans for roll out of higher training are ongoing at Central and State levels. Those nurses, clinical officers and few doctors that are available are continuously taken by NGOs who pay better salaries, leaving the MoH with a shortage of appropriately qualified human capacities. 69. It should be highlighted that the project was instrumental in moving the health systems delivery in South Sudan closer to a systems approach. Following the war and CPA, the level of infrastructure development and human resource capacity was practically negligible. The development of the HMIS and DHIS, strengthening of county health departments in the areas under the project, human resource capacity development across all levels, and provision of commodities across the country all highlight the added value that the project contributed to improving the level of service delivery in South Sudan. Without the project, this level of development towards a system based health system could not have been realized as the humanitarian mode of health delivery could have continued. This is not to say the aim of developing health systems for South Sudan has been reached, but rather to point to the fact that the project helped jump start the process and now has to be supported by all stakeholders for success under the leadership of the GoSS MOH. 28

41 (c) Other Unintended Outcomes and Impacts (positive or negative) 70. The following can be said to be the unintended positive outcomes: 1. That the success of any program requires appropriate capacities at all levels to ensure adequate stewardship, coordination and supervision especially where the country s implementation of health service delivery is still reliant on NGOs. 2. That strengthening of polices leads to better coordination of implementing agents on the ground. 3. The government has agreed with donors and partners in health for comprehensive states support as opposed to piecemeal support by different NGOs in each State. 71. A negative unintended outcome lies with the different NGOs who were formerly supporting the MOH who may not fully support the enhanced coordination and strategy direction shift from the humanitarian mode of operation to an increasingly confident stewardship role from both the Central and State governments. There will be a need to manage this more carefully to leverage resources and capacities available from this group of stakeholders. 3.6 Summary of Findings of Beneficiary Survey and/or Stakeholder Workshops 72. There was no beneficiary survey undertaken. However, during the ICR mission, beneficiaries opinions were obtained as part of understanding the impact of the project on the ground. Beneficiaries expressed a high level appreciation of the services being offered in facilities. They considered that activities covering ANC and community outreach were successful and that they should continue. They were especially pleased with the availability of drugs during the project implementation period. Challenges identified included lack of coordinated takeover between the new and the old Lead Agencies as part of the agreement for overall states support. This resulted in inadequate resources for operations and some shortages of drugs due to difficulties in distribution. 4. Assessment of Risk to Development Outcome: 73. Rating: Substantial. The MDTF UPHSD was implemented in a very challenging environment. Immediately post war, with minimal infrastructure, few and inadequate human resources, poor access to facilities, continued high insecurity and a highly expectant population. All these attributes rendered the implementation of a health program in a system wide approach extremely challenging. However, the mitigation measures that were put in place such as the renewal of contracts for lead implementing agencies, and monitoring agents ensured that the project remained on track as planned. In addition, the recruitment of consultants for financial management and procurement all reduced the risk in dealing with financial arrangements and procurement processes using Bank procedures. All these were part of lessons leant in implementing Phase I and contributed to reducing the risk to development outcome in a post conflict environment. However, the fact that the project still remained part of the broader system where these 29

42 inadequacies were prevalent resulted in a high level of risk throughout the implementation period. 74. The results of this project have been satisfactory over the two years of its implementation. However, sustainability of these results will depend on the continued commitment of all partners and GOSS. The new arrangement of health service delivery will need to take into account the lessons of both Phases I and II to ensure sustainability of the system developmental approach. Indeed the new Bank supported project, the Health Rapid Results Project, which is being implemented by the MOH in a similar manner to the UMPHSD Phase II, will contribute to sustainability in Upper Nile and Jonglei but this will need to be replicated across all other States if any meaningful impact is to be attained. The Ministry of Health will continue to have personnel challenges and as such it will still rely on external support; however, the Ministry will need to be in charge of coordination and provision of overall States level guidance on policy. 5. Assessment of Bank and Borrower Performance 5.1 Bank Performance 75. (a) Bank Performance in Ensuring Quality at Entry: There was no quality at entry assessment. The design ensured extensive collaboration between the different MDTF donors and Government. The project was designed within the framework of the JAM recommendations and the Bank was tasked with administering the MDTF. The recruitment of the Lead Agents ensured that the issues of low capacity at national and state levels were addressed. In addition, the Lead Agents contributed to the transfer of capacities through training and on the job support. The recruitment of financial management and procurement specialists located in the Ministry of Health resulted in timely implementation of activities and compliance with fiduciary requirements. 76. (b) Quality of Supervision: The country had no substantive M&E capacity and had only conducted one household survey in The supervisory role of the Bank was carried out with the additional support of the Monitoring Agent Price Waterhouse Coopers. The Bank contributed to the development of the M&E system and the operationalization of the Health Management Information System and the strengthening of the District Health Information System. Through the project, the Bank conducted quarterly supervisory missions which fed into technical areas for improved implementation of the project. The presence of the TTL who was stationed in Juba strengthened this component. The Bank and MA were proactive and diligent in providing supervision on the ground. 77. Through the Bank supported supervision, the project was able to conduct two household and facility based surveys and two lot quality assurance sampling surveys. The development of the HMIS resulted in the strengthened district health management system that contributed to a wealth of information at central level enhancing decision making. Even though Government was involved in the planning and discussions in field 30

43 supervisions, at times the M&E unit at the MOH was not fully involved in the actual supervisory missions Fiduciary supervision was strengthened and supervision of the financial specialist and the Project Financial Management Unit (PFMU) in the MoH was enhanced by the Monitoring Agent. There were no delays in reporting of Interim Financial Reports and annual audits. All financial covenants were complied with. Safeguard monitoring was carried out as per recommendations from the medical waste management framework. As part of carrying out the recommendations, facilities renovated under the project had incinerators installed to deal with medical waste disposal. In view of the efforts of the Bank team, monitoring agent and support from MOH, Bank rating for Supervision is Satisfactory. 79. However, there were limited skills transferred due to unavailability of appropriately trained staff in MOH. This is an issue that Government will need to take up for the immediate short and medium term as it has the capacity to impact negatively on sustainability. However, even with this challenge of inadequate skills transfer through the Bank s support, the performance of the available staff was greatly improved. Bank Performance is rated Satisfactory. 80. (c) Justification of Rating for Overall Bank Performance. Given the satisfactory rating for Bank performance in ensuring quality at entry and satisfactory rating for Bank supervision, including fiduciary aspects and safeguards, the overall Bank performance is rated Satisfactory. 5.2 Borrower Performance 81. (a) Government Performance: Rating: Satisfactory. A management team within the GOSS-MOH played a key role in coordinating and tracking implementation of the project s activities. The MOH-GOSS continued to be the grant recipient. The GOSS MOFEP had overall responsibility for procurement and financial management. Within the MoH, the Executive Board which was the Project Steering Committee had overall responsibility for program implementation. The Management Team collaborated with the directorates to ensure the availability of necessary technical information and provided appropriate logistical and technical support. In this regard, Government provided the playing field for the implementation of the MDTF-UPHSD Phase II which included coordination, and policy development. Quarterly coordinating meetings were held between the management team and the MDTF UPHSD partners and these looked at resource management and implementation. Review of outcomes fed into improving the implementation on the ground. 82. (b) Implementing Agency or Lead Agencies Performance is rated Satisfactory. Lead Agents were responsible for implementing component two on the expansion of delivery of basic health services. Initially, three agencies were recruited. 14. Comments from GOSS, MOH, Director- Monitoring and Evaluation. 31

44 However, the performance of one agency was not satisfactory to the MOH and was replaced by the Norwegian Peoples Aid (NPA). The two Lead Agencies, Norwegian Peoples Aid (NPA) and IMA World Health were each responsible for two States: Upper Nile and Jonglei for IMA, and Central and Eastern Equatoria for NPA. The Ministry of Health pursued a two-track strategy, balancing development of core capacities of the health system and immediate delivery of essential services to a significant proportion of the population. The TOR of the two LAs were identical and reflected on GoSS's health sector objectives that intended to: 1) develop core institutional capacities of the public health administration; 2) implement a phased infrastructure and equipment investment plan; 3) invest in human resources for health; 4) develop the pharmaceutical management, supply, and distribution system; 5) expand the coverage of health service delivery and support selected high-impact health interventions; and 6) strengthen capacities to monitor and evaluate project results and sector performance. The Lead Agents were able to work directly or through contracted NGOs. They conducted both system health system related activities and the delivery of high impact interventions. The summary below shows achievements in the various components. 1. Supply of pharmaceuticals : 1. Medical supplies were procured and distributed to 47 hospitals; 250 primary health care centres (PHCCs); and 1000 primary health care units (PHCUs). Covering a period of 18 months and valued at US$ 24.3m. 2. Capacity building: health facilities rehabilitated; MoH and County Health Departments (CHDs) staff trained in Basic Primary Health Services (BPHS); 3. CHDs equipped with furniture, EPI, data processing and communication equipment and transport means; 4. PHCCs and PHCUs management committees formed and trained; 5. Health Management Information System established for monitoring and reporting tools developed and used. 3. Basic package of health services: 1. Provision of Basic Package of Health Services in four states, namely Central Equatoria, Eastern Equatoria, Upper Nile and Jonglei through contracted NGOs focusing in high impact interventions ( See detailed description in Annex 2) 4. Supply of ARVs to health facilities in South Sudan 83. (c) Justification of Rating for Overall Borrower Performance. In view of the level of effort of GOSS given the circumstances of South Sudan at the beginning of Phase I in moving to a systems wide approach for the delivery of health, the coverage and implementation success of the Lead Agents, the Borrower performance is rated Satisfactory. 32

45 6. Lessons Learned 84. The following are the lessons that can be drawn from the implementation of the MDTF- UPHSD Phase II. 1. Long term sustainability, overall stewardship and coordination: Sustainability of project gains requires both government commitment and partnership support to ensure that health systems are strengthened as the country moves from humanitarian service delivery to systems oriented approach. The new donor mechanism for working at the state level needs to be strengthened to mitigate the negative effects of change (lack of continuity). This has to have strong coordination from both Central and State governments to ensure government policy is articulated and systems development and capacity building meets the needs of the government. Policy direction and coordination from central level is critical for streamlined and uniform policy management. There is need for the central government to strengthen its role as the driver of policy at State level and the current examples of central level led monitoring and supportive supervisory roles should be strengthened. 2. Scarcity of human resources, capacity building and skills transfer: In post conflict situations, challenges in human resources availability, skill set mix as well as challenges associated with implementation with scarce human resource capacity are inevitable; the use of partners to support government to deliver service may not support government develop its systems unless the Government provides strong leadership. However, it should be taken as an opportunity of continued strengthening of systems for sustained delivery of health service. The unavailability of appropriate qualified personnel in post conflict creates a need for a sustained effort by both Central and State governments to develop innovative policies that would attract capacity to underserved areas. 3. Supply of Pharmaceuticals: Central distribution of pharmaceuticals in post conflict situations is as difficult as it is challenging. In South Sudan, given the poor infrastructure, poor road network and difficult geographical terrain, contracting out improved commodity availability in facilities helped create confidence in the population to seek services at facilities. This approach is especially useful for the immediate short to the medium term. However, for the long term, there is a strong need for a more robust distribution mechanism and strengthening of the logistics management information systems. 4. Monitoring and Evaluation including Data Management: At the beginning of Phase II, there was little data available for use in decision making. The implementation of Phase II saw a number of surveys being conducted, such as South Sudan Household survey, Health Facility Surveys, and Lot Quality Assurance Sampling Surveys. These surveys contributed to improvement in overall availability of data for decision making. The development of HMIS and implementation of the DHIS helped strengthen overall information management 33

46 as evidenced by the number of facilities and counties reporting data back to central level by the end of the project. Hence, in post conflict situations, specific health surveys are a priority in helping provide the data required for immediate health decisions but should be taken as a complement to the overall strengthening of health information management. 5. Challenges in sustaining a Health System Approach: Development of Health systems may not be the preferred approach for international aid agencies and NGOs working in a post conflict situation as results of such investments are mostly long term and not immediate. Hence, a project approach may be the preferred approach to show results. This requires a careful balance between strengthening the system and continuously improving the system over time. Both the Health Rapid Results Project and the new donor matrix should support the objectives of Health System Strengthening by ensuring that overall leadership, from both the Central and State governments continue to support critical components of the system. 7. Comments on Issues Raised by Grantee/Implementing Agencies/Donors 85. (a) Grantee/Implementing Agencies: 1. Government Comments can be summarized as follows: The MDTF-UPHSD was the core bearer of health systems development in health. It came at a time when all infrastructure was destroyed as a result of prolonged war with resultant poor development of all sectors especially so in health. Service delivery at the time was highly fragmented being delivered by local and international NGOs. The UPHSD provided government with the opportunity to bring order to the sector and transform from humanitarian based service delivery to a systems based delivery which was more sustainable and development oriented. Despite the numerous challenges on the ground (inadequate infrastructure, poor human resource base, lack of M&E capacity, inadequate drug supply, poor road network and above all persistent insecurities), the project was able to step up and provide valuable support in all these areas. Under the new Project, the Government felt that renewed attention needs to be given to capacity building to ensure the longterm sustainability of health sector investments in the country. 2. Combined Comments from NPA and IMA: The two lead agencies felt that the MDTF - UPHSD was a very good vehicle to promote health system development. They observed that the project was able to meet both short term goals (implementation of BPHS) and medium to long term goals of strengthening the MoH at both central and State levels. The development of County Health Department and the strengthening of the HMIS, and improved supply of pharmaceutical at facilities were really remarkable. 34

47 86. (b) Comments from Co-financiers/Donors 1. DFID: Noted that there was need to look at the MDTF as a comprehensive project and not to focus on health only. They noted that the procurement of pharmaceuticals was well done and contributed to increasing the availability of essential drugs in the facilities. The issue of systems versus humanitarian support in the current environment was challenging as most parts of the country still need direct NGO interventions. 2. WHO: highlighted the challenges associated with developing sustainable health service delivery in post conflict environment associated with scarcity of human personnel, adverse terrain and impassible roads. In addition, WHO noted the continued security issues in the country which impacted on sustained system delivery. 3. UNICEF: Noted the challenges facing South Sudan described a two pronged dichotomy. One of inadequate human resources and the other of increased decentralization. However, UNICEF noted that the MDTF was instrumental in supporting the development of systems. UNICEF also noted the need for both the Bank and itself to be more engaged in issues of comparative advantage such as nutrition. 4. Comments from Joint Donor Coordinating Agency: The coordinator of Donor Aid expressed her appreciation of the MDTF UPHSD. The UPHSD was the only health initiative that was helping South Sudan develop health systems and very vital in assisting the Government transit from humanitarian service delivery to System wide service delivery. The coordinator noted the level of capacity building at development levels and the coordination policies that MoH was advocating as part of the project outcomes. 87. (c) Other partners and stakeholders 88. None. No comments received. However, comments incorporated from discussion with Lead implementing agent. Lead agents subcontracted some of the work to NGOs and these were under direct supervision of the LA to ensure TOR were implemented a in a timely manner. 35

48 Annex 1. Project Costs and Financing (a) Project Cost by Component (in USD Million equivalent) Actual/Latest Appraisal Estimate Components Estimate (USD (USD millions) millions) Component 1: Development of key stewardship functions Percentage of Appraisal Subcomponent 1.1 Strengthening the coordination and management capacity of MoH Sub-total Sub component 1.2: Development of monitoring and evaluation capacity Sub-total Subcomponent 1.3: Pharmaceutical system capacity and supply Sub total Component 2: Expansion of delivery of basic health services Subcomponent 2.1: Expansion of the basic health services delivery in four states (Upper Nile, Jonglei, Central Equatoria, Eastern Equatoria) Sub total Outstanding commitment from Phase I Sub-total Total Baseline Cost Physical Contingencies Price Contingencies Total Project Costs % Project Preparation Costs Total Financing Required % 0.00 (b) Financing Source of Funds Type of Cofinancing Appraisal Estimate (USD millions) Actual/Latest Estimate Percentage of (USD Appraisal millions) Trust Funds Multi-donor Trust Fund for South , Sudan 36

49 Annex 2. Outputs by Component 1. The overall goal of the BPHS project was to assist the State Ministry of Health in delivering the Basic Package of Health Services through county health departments (CHDs) and health facilities (HFs) to the population of four states supported by the project while strengthening the overall network of health services (HSS). To achieve this goal, the project aimed to substantially improve the quality, accessibility, and sustainability of the selected basic preventive and curative services, and to reinforce the capacity of local health personnel in planning, coordinating, and managing primary health care activities. The discussion for this section will be done by components and will aim at highlighting the implementation of each component taking into account the situation on the ground. COMPONENT 1: DELIVERY OF CORE HEALTH SYSTEM 2. This was implemented at National and State levels. The component was designed to strengthen governance/coordination/management, monitoring and evaluation (Health Management Information System - HMIS) and also contribute to human resource capacity building. As infrastructure was utterly destroyed during the course of the war, one of the major responsibilities of the project was to contribute to infrastructure rehabilitation and equipping of facilities providing the BPHS. 3. At national level, staff capacity building was strengthened through the recruitment of technical specialists in financial and procurement management. These officers were stationed in the MoH and worked as part of the MOH team providing on the ground supports and direct knowledge transfer were feasible. Notable success in this area was achieved; 1). The development of policies and establishment of coordinating meeting between MOH and the partners, the renovation of buildings to accommodate the MoH, capacity building in form of the strengthening of supervisory roles from the MoH. However, this remained challenging as the States felt that Central level was not doing a lot to ensure coordinated actions and implementation of polices at State level. The reporting to central level from the States was also increased (table on indicators of success). Furthermore, monitoring and evaluation through the implementation of surveys was strengthened via contracting of LATH. LATH worked with GOSS in developing and conducting the survey. However, due to reasons already alluded to, the level of knowledge transfer and actual capacity building in implementing LQAS survey was minimal. 4. At State level, these activities were part of the overall TOR for the LA. The LA or contracted NGO provided capacity building and coordinating roles were even more pronounced as this is where actual implementation was done. The States MoH offices were all renovated and the country health departments (CHD) under the four States were all strengthened in capacity building, office renovation and equipment provision as well as all counties were strengthened in HMIS and collected data from PHCC and PHCU and aggregated at CHD level. LAs were able to partner with Health Information System Program (HISP) to support HMIS roll out. Across All States, HMIS roll out can be said 37

50 to have been significantly developed and rolled out as exemplified by end of project surveys which show at least 60% of facilities reporting on the HMIS. As part of strengthened supervision, the GOSS developed the integrated supervisory checklist which has become a very useful tool for supervision as well as on the job training. This has been rolled out from national to State, to CHD to PHCC and PHCU (See table on capacity strengthening) Table 15: Capacity building in the Jonglei State supported by the MDTF UPHSDP Phase II: ACTIVITIES Health system strengthening Intermediary outcomes/outputs indicators FORMULA Target at the end of the project % Achieved during performing period No. of county health department supported by LA or sub-contractors All Counties 6 100% No. of county health departments adequately equipped (office, transportation, communication) All Counties 6 100% No. of county health departments with core staffs required in the GoSS guideline All Counties 6 100% No. and type (PHCU, PHCC, CH) of health facilities supported by LA or subcontractors No. of Health facilities submitting their HMIS report to the county on time per county No. of County Health Department submitting their HMIS report to the state on time % of health Facility having 10 essentials drugs at the time of the supervision**** % of health facilities with structured supervision visit within a month before the latest supervisory visit (using quantified supervisory checklist [QSC]) All Health Facilities All Health Facilities % % All Counties 6 100% All Health Facilities % % COMPONENT 2: DELIVERY OF THE BASIC PACKAGE OF HEALTH SERVICES 5. The components of the BPHS were defined by the Government of South Sudan (GoSS) and include access to Health Care, family planning and services, antenatal care, intra-partum Care, essential newborn care services, immunization, clinic IMCI, Community -IMCI, malaria treatment and Prevention, TB detection, HIV/AIDS and blood safety, nutrition and micronutrients and mental health and disability. Basic 38

51 Package of Health Services delivery had two objectives namely; 1). Improving the delivery of the basic package of health services (BPHS), especially for the poor and under served communities with initial focus on the high impact health interventions; as part of objective one of the BPHS, facility renovation and reconstruction was a critical component in the delivery of BPHS. As earlier stated, the overall infrastructure within the States was destroyed or was very inadequate quality. Hence, renovations and reconstruction become vital to effectively deliver services.2). Strengthening key stewardship functions of the Ministry of Health (MOH) at state, county, health facility and community levels, with an initial focus on coordination of BPHS activities, supervision of PHC, monitoring and evaluation, and strengthening the technical knowledge of the health workers. 6. This component was delivered by the two Lead Agencies; IMA World Health and NPA. The LA instituted the use of incentives for performance in the implementation of the BPHS as well as subcontracted to NGO for effective implementation in some counties. The agencies worked closely with GoSS-MOH and the four States under the project, i.e. State Ministry of Health (SMOH), local primary health care clinics (PHCCs) and primary health care units (PHCUs), and various non-government organizations (NGOs) to achieve project goals. The results are drawn from the 2011 LQAS and relate them to the project areas. However it should be noted that the LQAS was not specific for the four states but rather country wide and hence the results will highlight the progress being made from almost nothing at the time of the CPA and the JAM. The details of achievements by component are described below. 7. Objective 1: Improving the delivery of the basic package of health services (BPHS), especially for the poor and under served communities with initial focus on the high impact health interventions; 8. Maternal Health: South Sudan has one of the highest Maternal Mortality Rates (MMR) in the World, estimated at 2054/100,000 live births 15. Although close to 46.7% 16 of pregnant women attend at least one ANC visit, only 14.7% of deliveries are attended by skilled health professionals. Institutional deliveries account for just 12.3% of births, while the contraceptive prevalence rate is 4.7%. The caesarean section rate, a good indicator of access to Comprehensive Emergency Obstetric & Neonatal Care (CEmONC), is only 0.5% 17 of the population served in the three teaching hospitals (Juba, Malakal and Wau) Sudan Household Health Survey Sudan Household Health Survey 17. Report of Strengthening of Hospital Management in South Sudan, caesarian section rate in the 3 Teaching Hospitals was 0.5%. SHHS 2010 also confirms the same figure of 0.5%. 39

52 Figure 4: Reproductive Health Indicators from LQAS Health survey 2011: Source: Health LQAS Most of the deliveries are predominantly still done at home (78.7%) compared to 16.2 % of institutional deliveries. Skilled attendants at deliveries account for only 22.1%. Given the proportion of ANC attendance, malaria prevention in pregnant women for two doses of SP remains low at 23.7%. 10. Contraception Prevalence Rate: This remains low but is well over the project target of 1.5. The unmet need for contraception is clearly very high. 40

53 Figure 5: Contraceptive prevalence Health LQAS Source: LQAS Health survey Child Health: Infant Mortality Rate (IMR) and Under-five Mortality Rate (UMR) at onset were high at 102 per 1000 live births and 135 per 1000 live births, respectively. The EPI program had 13.8% of children less than 12 months having received DPT3 18 and just 1.8% children under-five years of age fully immunized. 22.7% 19 of children with diarrhea received oral rehydration therapy and only 35.1% of children with suspected pneumonia are taken to an appropriate healthcare provider or health facility. Figure 6: EPI and Vitamin A coverage Indicators: Health LQAS UNICEF 2009 and SHHS SHHS

54 Source: LQAS Health Survey 2011 The LQAS results show low coverage in all EPI indicators Malaria: Malaria accounts for almost a quarter (24.7%) 20 of all diagnoses reported by health facilities in South Sudan. The 2009 South Sudan Malaria Indicator Survey (SSMIS) showed that 35% of children below 5 years had suffered from a fever within the two weeks preceding the survey and 12% of children with fever were treated with an appropriate anti-malarial medicine within 24 hours of the onset of fever. 60% 21 of households have one or more insecticide-treated nets. Figure 7: Integrated management of childhood illness: Source: LQAS Health Survey UNICEF SSMIS

55 Figure 8: Indicators of malaria prevention: 13. As can be seen the house hold coverage of at least one net is lower that the project coverage of 60% with the proportion of children under five sleeping under the net at 31.2%. Given that malaria accounts for at least 24% of all childhood morbidity; there is clearly a great need to mitigate this challenging I coverage. However, this is a great improvement from near zero at the beginning of the project Neglected Tropical Diseases: Neglected Tropical Diseases (NTDs) are endemic in South Sudan and account for a considerable proportion of the disease burden. The major NTDs include leishmaniasis, trypanosomaisis, onchocerciasis and schistosomiasis. 15. Tuberculosis: The annual incidence of all forms of TB is estimated at 140 per 100,000 population (79/100,000 are smear positive cases), while TB specific mortality is estimated at 65 per 100,000 population. The treatment success rate for smear positive pulmonary TB was 79% in HIV/AIDS Prevalence: The prevalence of HIV/AIDS in South Sudan is estimated at 3% 22, with the epidemic considered to be generalized, albeit some areas are described as hot spots. There are 17 HIV treatment centers in South Sudan taking care of about 8,000 clients (about 5% are children) with close to 2,500 on Antiretroviral Therapy (ART). The HIV program has established 55 Prevention of Mother to Child Transmission (PMTCT) and over 105 HIV Testing and Counseling (HTC) sites that are integrated into existing health care structures Antenatal Care Surveillance Report 43

56 Figure 9: HIV indicators LQAS health survey 17. Even though the prevalence of HIV might be described as low, the actually knowledge on HIV for prevention and treatment countrywide is low. There is a huge need to support overall prevention methods to not only increase knowledge awareness but also to improve the rate of voluntary testing and counseling. 18. Objective 2: Strengthening key stewardship functions of the Ministry of Health (MOH) at state, county, health facility and community levels, with an initial focus on coordination of BPHS activities, supervision of PHC, monitoring and evaluation, and strengthening the technical knowledge of the health workers. 19. Brief Summary on the Implementation and achievements of BPHS by NPA: The BPHS project was implemented in Eastern Equatoria state in January The contract for the implementation of the project was awarded to HLSP, who were the lead agency (LA). However, the contract initially awarded to HLSP was terminated after two (2) years of the project implementation, because the lead agency did not have a competent team of permanent staff to implement the project. Through single sourcing, NPA was mandated to take over in February Targets and achievements: From February 2011 to May 2012, NPA was able to accomplish the activities below: 44

57 21. Accomplished activities 23 : 1. Built office space for staff at Budi and Lopa 2. Renovation of county facilities 3. Provided each county with a hard top vehicle for supervision, delivering of drugs and a sometimes as an ambulance and for outreach programs 4. Supplied 15 motorbikes to the 15 PHCCs for supervision and carrying of the vaccines and a further 8 motorbikes for the CHD. 5. Supplied 91 bicycles to 91 PHCUs for creation of awareness 6. Installed in each county HF radio communication and each car with mounted radio 7. Supplied each county with VSAT equipment (8 panels and 8 batteries) 8. Supplied 1 laptop and desktop for CHD offices 9. Capacity building in computer, financial management, leadership and data filling in registers 10. Distribution of registers 11. Supported the acceleration campaigns for immunization in 7 counties except Kapoeta East 12. Distribution of drugs to counties on quarterly (3 months) basis 13. Procured beds and other equipment yet to be distributed to PHCCs and PHCUs 14. Funded coordination meetings at county level 15. Constructed a drug store and an office for the SMPH at Torit. 22. Achievement of the intended objectives: The project had 13 indicators to measure success. Table 15 below summarizes our evaluation of the indicators that focus on the high impact interventions. Table 16: Project performance against set indicator targets Indicator Baseline Target Achievement % children 12 to 23 months old who received 67.5% 85% DPT3/measles vaccine before the age of 12 months % of children under 5 sleeping under and ITN the 9.4% 35% night before the survey 27% Vitamin A coverage among children % 80% months, % receiving it in the last 6 months 82% Antenatal care from skilled providers % among 27.5% 40% women giving birth in the last 2 years 27% Skilled birth attendance in a health facility 15.2% 25% - Family planning Contraceptive prevalence rate for modern methods 1.6% 7% 2% Treatment of diarrhea, ARI, malaria outpatient 63% 23. NPA/MDTF BPHS End Project Evaluation Survey conducted in June

58 visits among below 5 per capita Underweight (Weight for age < 2SD NA TBD - HMIS strengthening - % of health facilities NA 60% submitting new, standardized HMIS monthly - reports within one month of the reporting month Strengthening supervision - % of health facilities with structured supervision visit within a month NA (likely 50% before the supervisory visit using quantified supervisory checklist (QSC) 0%) 100% Staffing - % of PHCUs with at least one male and NA 60% female trained health worker (CHW or higher) - Drug supply - % of facilities having 10 essential NA 80% drugs at the time of supervisory visit 93% Knowledge of health workers in managing NA 40% important ailments as judged by clinical vignettes 95% Source: NPA/MDTF BPHS End Project Evaluation Survey conducted in June 2012 Brief Summary on the Implementation and achievements of BPHS by IMA World Health: 23. From 2008 to 2012, IMA World Health served as the lead agency (LA) BPHS in both Upper Nile and Jonglei States, South Sudan s two largest states. The original threeyear timeframe (January 2009 to December 2011) was extended recognition of initial funding delays and other challenges, with activities ultimately extended through December BPHS project was to assist the State Ministry of Health in delivering the Basic Package of Health Services through county health departments (CHDs) and health facilities (HFs) to the population through improving the quality, accessibility, and sustainability of the selected basic preventive and curative services, and to reinforce the capacity of local health personnel in planning, coordinating, and managing primary health care activities. IMA World Health worked closely with GoSS-MOH, the State Ministry of Health (SMOH), local primary health care clinics (PHCCs) and primary health care units (PHCUs), and various non-government organizations (NGOs) to achieve project goals. 24. Key successes included: 1. Significant capacity building of the County Health Departments through continual training and engagement, provision of essential equipment and supplies, technical assistance, and more 2. Introduction of Performance-Based Contracting, which incentivized health workers and CHD staff to reduce staff turnover and improve timely reporting 3. Implementation of successful, multi-focal Dry Season Campaigns, which in 2012 alone administered over 400,000 vaccines in both states 4. Establishment and support of a Statewide HMIS System with one of the best reporting records in the country. 46

59 Table 17: Comparative analysis of overall achievements Population target Jonglei CUMULATIV E 2010/2011 Upper Nile CUMULATIV E 2010/2011 INDICATORS Comments No. of doses administered to children Attained 40,923 80,946 44,887 under 12 months by DPT3 No. of doses administered to children Attained 40, ,722 70,117 under 12 months by measles No. of <5 treated in facilities 204, , ,822 Attained No/ proportion of <5 treated for Malaria 193, ,428 No/ Proportion of <5 treated for Diarrhea in facilities 114,754 68,734 No./ Proportion of <5 treated for ARI in facilities 81,790 55,290 No. of children who receive Vitamin A Routine 40,923 55,722 32,354 No. of Mosquito net distributed to under 5 204,616 18,200 30,497 No. of severe malnutrition under 5 19,319 11,927 No. Moderate malnutrition under 5 25,096 20,164 No. of newly registered pregnant women attending ANC 40,923 41,814 39,591 No. of Mosquito net distributed to pregnant mothers 40,923 23,613 26,293 No. of women delivered in the health facilities 40,923 19,451 11,424 No. of mothers screened during the postpartum period 40,923 10,777 6,766 No. of newly enrolled women for FP services (contraception) 255,771 8,041 4,366 Source: Jonglei and Upper Nile End Evaluation Report Monitoring and Evaluation: HMIS was introduced and the lead agencies ware responsible to supported by LATH and Boston Massachusetts group in addition. To overcome challenges, pay incentives for reporting were worked into the project plan to promote timely and accurate data collection. HMIS officers for at state level were brought on board strengthen the HMIS at the State level. Thanks to these solutions, the project noticed considerable improvement in reporting coverage from CHDs and health facilities. The project provided laptops, DHIS and antivirus software, flash drives, and other essential equipment necessary for successful and timely reporting the project introduced Introducing the MOH Priority Indicator List for use by all CHDs and facilities. This was a single form covering all health facility information, with World Bank reporting requirements included. Over 90% overall attainment Not attained Attained Not attained Not attained Not attained Not attained 47

60 Systematizing the approach to data collection to include other donors and NGOs Cascading the new forms and definitions from the county level to facilities Introducing data quality checks for all CHDs and systems to capture mistakes, from the facility level upwards. Figure 10: Supervision of Health facilities Source: Health facility survey LQAS 2011 (UPBPHSD) 26. A progressive improvement of reporting over time is seen as is the number of facilities reporting supervisory visits at 83%. Please take note that the two sets of data one in the results framework and the other in the LQAS survey are not comparable as one is through HMIS and the other through sample based survey. However both do indicate increased facility data reporting. Graph 2: Evolution of reporting rate over 15 months for Jonglei Sourse: Jonglei End Evaluation Report 27. Drugs and Pharmaceutical Management: The project was the principle vehicle for the procurement of all medicines and other pharmaceutical products. A total sum of US$ 38 million was used for medicines. The project also supported the distribution from 48