Annual Report 2012 World Health Organization Country Office of South Sudan
2 Foreword by Head of WHO South Sudan Office One and half year on after Independence, South Sudan continued facing deteriorating humanitarian and health conditions. The humanitarian situation in South Sudan was somewhat unstable during the period in focus as aerial bombardments continued in some parts of the states bordering with Sudan, however as the year came to an end the rates had somewhat reduced. As a result of the isolated bombings, a considerable number of persons were wounded and lives lost while a big number of others displaced. The influx of refugees from South Kordofan and the Blue Nile as well as the high numbers of returnees from Sudan was also seen during the year. Inter-tribal clashes continued in some states between Rebel Militia Groups (RMGs) and the Sudan People s Liberation Army (SPLA) in Upper Nile state. While in Jonglei state, Inter-tribal clashes in some states between the Rebel Militia Groups (RMGs) and the Sudan People s Liberation Army (SPLA) in Upper Nile state continued. Amidst all the reported tensions with others leading to mass casualties requiring medical care and support, WHO maintained its support by providing leadership to health partners (UN agencies, NGOs, Civil societies and MOH) in emergency and crisis preparedness at the national and sub national levels. Technical and financial support was provided to the Government of the Republic of South Sudan (RSS) and the states to implement key focused life saving health interventions while advocating for more attention and funding for the country. Together with the MoH/RSS, the organization participated in several Joint health Assessments in states affected by different emergencies. The main achievements registered by the WHO Country Office (WCO) in 2012 in support of the country s efforts included; The development and Launch of the Health Sector Development Plan, the construction of maternity wing in Bor State hospital to improve access to maternal services in the state, increased and timely delivery of humanitarian health assistance to the vulnerable populations like, refugees, returnees and the injured. Disease surveillance and response was also improved during this period especially in Guinea worm, Acute Flaccid Paralysis (AFP), measles and other communicable diseases. In this period, mass drug administration happened in areas endemic of Onchocerciasis and coordination and partnership enhanced through the health cluster approach. The WCO continued to provide leadership by supporting the ministry of health and other partners with protocols in HIV and TB to ensure standards are adhered to at all levels. The country office played an important role in strengthening surveillance and emergency response at the state levels through capacity building interventions. This resulted in improved implementation and coordination of humanitarian emergency health programs at the state levels.
3 In 2013, WHO will continue to focus on technical support and capacity building of the Ministry of Health at all levels as demonstrated in our ability to control many outbreaks in the country through prompt and timely investigations of all suspected cases and immediate measures instituted. I am pleased to share with you the first Annual Report for WHO South Sudan Country Office, outlining our major achievements for 2012. Am grateful to the WCO team for their dedicated professionalism in supporting their counter parts at the Ministry of Health, and for the close working relations with health cluster and other development partners. This helped WCO to better align and harmonize her programmes in the country for the benefit of the people of South Sudan. As WCO, we count on your support, collaboration and partnership as we move the country forward. Dr Abdi Aden Mohamed Head of Office World Health Organization, South Sudan
4 Acknowledgment The success of the World Health Organization in South Sudan and its contributions towards the health of the people of the Republic of South Sudan were made possible through huge contributions and support from key partners within and outside the health sector in the country. We would like to acknowledge the immense support of the Ministry of Health, Republic of South Sudan and the State Ministries of Health for their committed leadership and support that enabled WCO contribute to the achievements outlined in this report. We would like to acknowledge the immense contribution and support of the development and humanitarian partners, these include; CHF, Bill Gate, CIDA, Carter Centre, Danish government, ECHO, Finland, Germany, KNCV, MDTF, PATH, Roll Back Malaria, Rotary International,, SPAIN, GAVI, UNAIDS, UNDP, CERF, CDC, DFID, GTZ and USAID who provided the much needed funds and moral support that significantly contributed to the effective execution of our responsibilities. Others donors that supported WCO in kind were; Norvatis and Sanafoi. We also acknowledge the support and cooperation of the, H4+ partners, UN Country Team, and all health cluster partners without whom, we could not have achieved our objectives in South Sudan. WCO is grateful to Dr Ala Alwan, WHO Regional Director for the Eastern Mediterranean and the entire team at the Regional Office and Headquarters for the technical and financial assistance and essential guidance in effectively discharging the WCO responsibilities. We also would like to thank all other ministries that worked in close collaboration with the WCO to enable us achieve our objectives. We would like to thank Dr Abdi Aden Mohamed, the Head of the WHO South Sudan Office for his leadership and all staff of the country office for their professionalism and dedication that successfully enabled the execution of the WCO annual work plan. Special thanks to Ms Pauline for the editorial work, design and layout of this report.
5 Table of content Introduction Executive summary i. The South Sudan Context ii. Current situation Chapter One. Coordination and Partnership Chapter Two. Health systems strengthening i. Health systems development and strengthening ii. Health Promotion Chapter Three. Communicable diseases prevention and Control i. Integrated Disease Surveillance and Response (CSR) ii. Expanded Programme on Immunization/Polio Eradication initiative iii. HIV/AIDS iv. Tuberculosis Control v. Guinea Worm Eradication vi. Onchocerciasis control Chapter Four. Emergency preparedness and response Chapter Five. Maternal Health Chapter Six. Communication, Advocacy, Resource mobilization and Utilization Chapter Seven. Administration and Management
6 Abbreviations and Acronyms ACSI Accelerated Child Survival Initiative MDR-TB Multi Drug Resistant -TB AFP Acute Flaccid Paralysis MDTF Multi-Donor Trust Fund ANC Antenatal Clinic MISC Miscellaneous APOC The African Programme for Onchocerciasis Control MNTE Maternal and Neonatal Tetanus Eradication ART Antiretroviral Treatment MOH FP Ministry of Health Focal Person ARVs Antiretroviral Medicine MoH Ministry of Health AWD Acute Watery Diarrhea NGDO Non Government Development Organizations CAP Consolidated Appeal Process NGOs Non Government Organizations CAR Central African Republic NIDs National Immunization Days CDC Centre for Disease Control NTLBP National TB/Leprosy/Buruli Ulcer Control Program (NTLBP) CDDs Community Drug Distributors OI s Opportunistic Infections CDTI Community-Directed Ivermectin Treatment OV Onchocerca Volvulus CEmONC Comprehensive emergency obstetric and newborn care PATH Program for Appropriate Technology in Health CEQ Central Equatoria State PEI Polio Eradication Initiative CERF Central Emergency Reserve Fund PHCC Primary Health Care Centers CHF Common Humanitarian Fund PHCU Primary Health Care Units CIDA Canadian International Development Assistance PMT Program Management Team cmyp Country Mid-Year Plan PMTCT Prevention of Mother to Child Transmission of HIV CPT Co-trimoxazole preventive therapy. RC Regional Coordinator s CSR Communicable Disease Surveillance and Response REC Reaching Every County CTRL Central TB Reference Laboratory RMG Rebel Militia Groups DFID Department for International Development RSS Republic of South Sudan DOTS Directly Observed Treatment - Short course snid sub-national Immunization Days chemotherapy DRC Democratic Republic of Congo SPLA South Sudan People s Liberation Army ECHO European Commission Humanitarian Aids Office SSDP South Sudan Development Plan EEQ Eastern Equatoria State SSGWEP South Sudan Guinea worm Eradication programme EMRO Eastern Mediterranean Regional Office SSHS South Sudan Household Survey EPI Expanded Programme on Immunization SSOTF South Sudan Onchocerciasis Taskforce EWARN Early Warning and response Network TB Tuberculosis FLHF Front Line Health Facilities TFM Transitional Funding Mechanism GAVI Global Alliance for Vaccine Initiative TOR Terms of reference GHWA Global Health Work Force Alliance TWG Technical Working Group GTWG Gender Technical Working Group UN United National GTZ Deutsche Gesellschaft FÜR Technische UNAIDS Joint United Nations Programme on HIV/AIDS Zusammenarbeit GWEP Guinea worm Eradication programme UNDAF United Nations Development Assistance Framework HDPs Health Development Partners UNDP United Nations Development Programme HEP Health Education and Promotion UNHCR United Nations High Commission for Refugees HF High Frequency UNHWP United Nations Humanitarian Work plan HIS Health information System USAID United States Aid for International Development HIV Human Immune Deficiency Virus USG United States Government HMIS Health Management Information System VCT Voluntary Counselling and Testing HRH Human Resources for Health VPD vaccine-preventable diseases HSS Health system Strengthening VSAT Very Small Amateur Terminal HTC HIV-counselling-and-testing WB World Bank IDSR Integrated Disease Surveillance and Response WCO WHO Country Office INGOs International Non Government Organizations WEQ Western Equatoria State ITNs Insecticide Treated Nets WHO World Health Organization IPT Intermittent Presumptive Treatment KNCV Koninklijke Nederlandse Centrale Vereniging M&E Monitoring and Evaluation MCH Maternal and Child Health MCNH Maternal Child neonatal Health
7 Executive summary In 2012, the WHO country office (WCO) provided technical and financial support to the Government of the Republic of South Sudan in line with the Health Sector Development Plan (HSDP).This report highlights major achievements recorded in the areas of Coordination, Partnership, Advocacy, Resource mobilization, Health systems strengthening, maternal and child health, Communicable disease surveillance and response, prevention of HIV/AIDS, Tuberculosis, Malaria, Guinea worm, Onchocerciaisis and Emergency preparedness and response. One area where WHO South Sudan greatly played a big role was in supporting the emergency response to many emergencies in the country, among them; response to an estimated 250,000 returnees, over 200,000 people affected by floods in 46 counties, and over 180,000 refugees in Upper Nile and Unity states, conflicts due to militia attacks and inter tribal conflicts. Other areas that WHO greatly supported during this period was strengthening disease surveillance and response in all the states, four National Immunization Days (NIDs) particularly polio vaccination campaigns and Mass measles campaigns were conducted. Focus was also put on supporting the Ministry of Health to strengthen the Health Promotion and Education unit, Health Systems, HIV, TB, Guinea worm eradication programme, Onchocerciasis and the Health Cluster. WHO also played a crucial role in prevention and control of diseases by focusing on coordination and capacity building to achieve strategic results, this was mainly seen in the areas of Communicable disease surveillance and response, Guinea worm, TB, HIV and other neglected tropical disease like Kala azar, sleeping sickness and onchocerciasis. No wild polio virus was detected in the country for the past 32 month since June 2009. This achievement was made possible through significant support to surveillance, routine immunization and campaigns. Finally the WCO made significant efforts in contributing to maternal and child health by supporting the construction of new maternity wards in Bor state hospital, Jonglei state and by strengthening advocacy, and partnerships, capacity building at the state hospital levels in the area of maternal and child health.
Photo credit: WHO/P Ajello 8 Current situation ii) The Current Situation The health situation across South Sudan remains fragile. There are high risks of diseases, floods and drought, low access to safe drinking water, food insecurity, poor sanitation and low literacy rates. Environmental factors contribute to the spread of diseases such as water and vector-borne diseases like diarrheal, dysentery, hepatitis, malaria and dengue fever. Both health and nutrition rates are much lower A mother and her 2 malnourished children waiting for treatment at Malakal State hospital than averages in neighbouring east and central African countries, and within South Sudan there are significant urban/rural, state, gender and socioeconomic disparities. Health infrastructure in many states were abandoned or destroyed by decades of conflict. For a population estimated at 8.2 million, there are just 220 doctors 1. Government expenditure on health has risen in the last two years but is still well below the global recommendation of $37 2. In South Sudan, only 25 percent of the population is estimated to use any kind of health facility during their lifetime. Although some progress has been made in the area of immunization, the proportion of fully immunized children still remains very low. Half of all the children do not attend school. Eighty-five per cent of the South Sudanese population is illiterate (92% of women). South Sudan also has the highest maternal mortality rate in the world with more than 2,054 out of every 100,000 live births mainly due to inadequate access to primary and curative health services and low demand for and awareness of preventive services. Despite efforts to train midwives, skilled attendance at births has remained very low compared to the neighbouring countries 3. Under 5 mortality is 135 out of every 1,000 live births. South Sudan s epidemiological profile is dominated by communicable diseases. Frequent outbreaks of acute watery diarrheal, kala azar, measles, malaria and cutaneous anthrax were reported in the last biennium. Nonetheless, all outbreaks were detected on time due to the improved surveillance system and comprehensive responses conducted. Poor sanitation and quality of drinking water following flooding, remains a challenge and leave open the potential for serious outbreaks during the rainy season. An outbreak of kala azar that started in late 2009 is still ongoing affecting over 17,000 people with 550 deaths. Disease outbreaks remained a major challenge in the 2012-2013 biennium. Malaria is a big risk and tuberculosis is on the rise. The risk of polio importation increases with cross-border population movements. Although HIV prevalence in South Sudan is at a low level compared to countries of southern and eastern Africa, it is the highest in the Middle East and North Africa. According to a recent report by the Joint UN Programme on HIV/AIDS (UNAIDS) and the World Health Organization (WHO), the estimated HIV prevalence among 15-24 year old women is 3 percent, but the distribution of HIV prevalence various from region to region with the equatorial region having the highest rates. Reference 1. GoSS/WHO/AMREF (African Medical and Research Foundation) survey conducted in July 2006. 2. The Commission of Macroeconomic and Health, a WHO publication, states that $37 is the recommended per capita spend. 3. 1999 SMS and 2006 SHHS
Photo credit: WHO 9 Summary of 2012 achievements Chapter One. Coordination and Partnership The WCO plays a very crucial role in different partnerships and coordination mechanisms including formal events in support of the government s efforts for better alignment and harmonization of health in the country. Heads of UN agencies in an assessment mission to Abyei South Sudan, among was the WHO head of Country Office, Dr Abdi Aden Mohamed Key Achievements The WCO continued to participate in and conduct activities that contributed to strengthening of leadership and governance in the health sector in South Sudan. As an important input for partnership, WCO participated in the signing of the United Nations Development Assistance Framework (UNDAF) outcome document between the Government of the Republic of South Sudan and United Nations. To strengthen the UNDAF, the WCO participated in the monthly United Nations Program Management Team (PMT) meetings. Major outcomes of WHO inputs in the PMT included; revision of the health indicators for the monitoring and evaluation framework of the United Nations Development Framework (UNDAF); drafting of the health section of outcome three of UNDAF midterm review report. Preparation of WHO data to be inputted on to the PMT web based 4Ws matrix (who is doing what where and when) to promote transparency and information sharing was also done. The WCO also proactively participated in the South Sudan investment summit during which a presentation on sustainable health investment in South Sudan was presented by the organization. In addition, the WCO participated in the Health Development Partners (HDPs) monthly meetings convened by the Joint Donor Team. Major outcomes of the HDP dialogue during the year included; development of the health sector aid financing plan, which outlines the major donor priorities and how the aid architecture is harmonized and aligned with national priorities; re-alignment of donor support to meet shortfalls in
10 government allocations to the health sector following the austerity measures; mobilisation of additional funding for drugs to cater for the anticipated shortage following the end of the drug funding from the Multi-donor trust fund (MDTF); geographical division of labour by the three primary health care services delivery mechanisms; Health Pooled Fund, USAID and WB to cater for the entire country equitably by January 2013. The WCO further supported the re-establishment of the H4+ (UNICEF, UNAIDS, UNFPA, WHO and WB) forum, a coordination mechanism for Maternal Child and Newborn Health (MCHN) actions among the UN agencies. The H4+ convenes monthly coordination meetings that bring together all heads of the 5 agencies and their technical teams. Separate regular Technical Working Group meetings of these agencies were also organized. The chair and secretariat for the H4+ forum is held on a rotational basis-a responsibility that WHO held 4 times during the year. Major outcomes of the H4+ work during the year included: the development of the H4+ position paper on Maternity Waiting Homes which will be piloted in Bor hospital, Jonglei State; redefinition & establishment of the H4+ advisory role to the Ministry of Health senior management; review of options for strengthening coordination within the health sector; drafting of the H4+ position paper on Community health workers/community midwifes; and the development of a framework for collaboration and joint programming on MCNH by H4+ members. To support the UN efforts in mainstreaming gender in all programs, WCO participated in the UN Gender Technical Working Group (GTWG) meetings which explored how UN agencies should mainstream gender in all programs. As a result, Terms of Reference (TOR) and work plan for the GTWG was developed and implementation modalities discussed.
Photo credit: WHO 11 Chapter Two. Health Systems Strengthening South Sudan s efforts in strengthening the health systems and services focuses on six building blocks of the health system, which include; health service delivery, health workforce, health information systems, access to essential medicines, health systems financing and leadership and governance, all these led to coordinated and concerted efforts in coordination of the health system. In strengthening the health systems, WHO worked closely with health authorities and partners at various levels of the health system, in line with the health sector strategic development plan in an effort to strengthen the system. During the year, the WCO focused on activities aimed at improving coordination of Human Resources for Health [HRH] interventions and development of a HRH policy and strategy, development of policies and strategies and strengthening of the health information system. Key Achievements Human Resources for Health The Minister of Health, Dr Michael Hussein Milly officially opening Human Resources for Health consultation meeting in Juba. Seated next to him is Dr Abdi Aden Mohamed, Head of Office, WHO South Sudan WHO supported and collaborated with the Ministry of Health Focal Point [MOH FP] for HRH and the HRH committee secretariat [JICA] to convene and participate in the monthly HRH technical working group [TWG] meetings. Major outcomes of the HRH TWG work during the year included; the harmonization and centralization of the admission process to all Health Training institutions in a bid to realize equitable consideration for applicants from all States in the country; establishment of a sub working group to explore options for establishing a national examination board for the health training institutions; and exploration of ways to harmonize the salary structure of NGOs to ensure uniform pay for all cadres across NGOs. In collaboration with the Global Health Work Force Alliance, WCO supported the development of the national HRH policy and Strategy, albeit during the validation processes the need to broaden its scope arose, this is currently being undertaken. In
12 recognition of the support rendered by the GHWA towards the development of the HRH policy and strategy, WCO supported the Ministry of Health attend and deliver a gratitude speech at the launch of the second GHWA strategy in Geneva during the World Health Assembly. WCO also supported the Directorate of Training and Professional Development of the Ministry of Health to carry out the evaluation of candidates for selection to health training institutions for the 2012/13 intake. This exercise involved conducting of interviews in each of the 10 States and the final evaluation and selection exercise in Juba. Development of Policies and Strategies WCO supported the Ministry of Health to finalize and launch the Health Sector Development Plan 2012-2016. This document provides the overall framework for service delivery and investments in the health sector in South Sudan over the next five years. The WCO deployed a consultant who led the process of developing an operational plan for the Health Sector Development Plan, however due to institutional limitations the exercise was rolled out to some departments of the MOH and State MOH. WCO supported the Ministry of Health develop the ministerial policy statement and work plan for 2012-2016. This document outlines the key priorities of the new Minister of Health over the medium term in view of the austerity measures. The proposed restructuring of the central MOH contained in this document is undergoing review by the Council of Ministers. In response to the Regional Coordinator s (RC) request, the WCO developed a paper on Health Systems Strengthening baseline and priorities for South Sudan. The WCO adapted strategy options from the RC position paper ensuring their relevance and suitability in addressing the HSS challenges and priorities in South Sudan as well as priorities set out in the national Health Sector Development Plan. Dialogue between the WCO and EMRO identified the following areas in which the later would support WCO and MOH to operationalize: health coordination, HIS strengthening and Health commodities security.
13 Strategic Information The WCO, participated in the monthly Monitoring and Evaluation (M&E) Technical Working Group meetings convened by the central MOH department of M&E. Key outcomes of these meetings included; development of the first ever annual HMIS report for South Sudan; reviewed the performance of the HMIS by State; developed strategies for improving institutionalization of the use of information for decision making at all levels; developed terms of reference for conducting a health information system strengthening strategy based on the health metrics network framework. Production and distribution of HMIS tools as well as; completeness and timeliness of reporting remain a critical challenge. Health Promotion At the WCO, Health promotion activities aim at promoting health and development, prevention and reduction of risk factors for health conditions and diseases. During this period, the WCO focused on health promotion was mainly on; Providing technical and financial assistance to strengthen the health promotion section at the national and the states levels. This was aimed at enabling the national level team ensure a well coordinated implementation of health promotion activities across all programme areas. Key Achievements The organization continued supporting the MoH with health education and promotion (HEP) message validation. Ten meetings were held during the year and Terms of Reference for the Communication Technical Group, an advisory group to the MoH on Behaviour Change Communication submitted to the Director General for Public and Community Health for validation. Technical support was also provided to the ministry of health to review Knowledge, attitude and practices tools to be used for an upcoming Knowledge Attitude and Practice survey on Maternal and Child health in the country. The tools have been finalized and await the commencement of the study by UNICEF. The WCO in collaboration with the Ministry of Health and UNICEF conducted a media orientation for journalist in South Sudan to create awareness of the polio programme. And updates on the status of polio shared with the media to enhance their reporting
Photo credit: WHO 14 during campaigns. In addition, Information, Education and Communication materials were printed and electronic media programmes like radio talk shows, spot messages and jingles also run to strengthen the campaigns. To strengthen health education and promotion activities at the national level, WHO supported the Ministry with the development and designing of health education messages for Yellow fever, Hepatitis E, meningitis and Polio. These were distributed to state health authorities in high risk states. Chapter Three. Communicable Disease Prevention and Control Integrated Disease Surveillance and Response (CSR), Expanded Programme on Immunization/Polio Eradication Initiative, HIV/AIDS, Tuberculosis, Guinea worm and Onchocerciasis. 3.1 Integrated Disease Surveillance and Response (IDSR) The humanitarian situation in South Sudan deteriorated in the past two years with more vulnerable people requiring emergency humanitarian assistance. Communicable diseases remained the leading cause of mortality and morbidity in 2012. The risk of major epidemics increased with massive population movement in South Sudan due to lack of safe drinking water, poor sanitation and hygiene, overcrowding, malnutrition, poor health services, inadequate vaccination coverage and low immunity to vaccine preventable diseases. A team from WHO EMRO conducting validation exercise for Kala azar in Old Fangak health facility Communicable disease morbidity and mortality burden can be minimized through effective epidemic preparedness and response capacity and disease surveillance system. In the last five years, WCO supported the expansion of integrated disease surveillance at all levels and strengthened the human and institutional capacities to control the threat of communicable diseases and reduce the excess morbidity and mortality. Recognizing the threat of communicable diseases, the MoH-RSS developed Integrated Disease Surveillance and Response (IDSR) strategy and five years plan of action to expand and promote integration of disease surveillance activities in all the states and counties with
15 effective community based disease surveillance network. The year 2012 was the third year of implementation of the five year Integrated Disease Surveillance and Response (IDSR) plan. Although there was marked improvement of surveillance capacity since the introduction of IDSR, South Sudan experienced a number of epidemics during this period, among them; measles, Kala azar, malaria, hepatitis E, cutaneous anthrax and others. Nonetheless, the impact of these outbreaks was not as severe as they were in previous outbreaks of 2006-2007 and the morbidity and mortality associated with the above outbreaks were very minimal due to improved surveillance capacity to detect, verify, report and respond to potential outbreaks. The objective of the Communicable Disease Surveillance and Response program in South Sudan is to; strengthen and sustain technical and management capacity of health authorities in epidemiological surveillance, outbreak investigation, and coordination of outbreak response; enhance surveillance, response to and preparedness for disease outbreaks and pandemics, through the expansion and implementation of integrated disease surveillance and response system (IDSR); and strengthen laboratory services for epidemic prone diseases through capacity building of personnel and provision of supplies and equipment. Key Achievements WCO supported; Sixty (60) in-service trainings to enhance knowledge and skills of frontline health workers, surveillance officers, laboratory technicians, data managers and malaria coordinators on integrated disease surveillance, case management of epidemic prone diseases, monitoring and evaluation of disease surveillance and data management using DHIS software. The comprehensive training needs assessment exercise and subsequent development of new training curriculum and plans for integrated disease surveillance and response in South Sudan. A systematic in-depth assessment of early warning and response network for South Sudan was conducted as part of the global effort to evaluate performance of the EWARN system within the regular IDSR system.
Photo credit: WHO 16 The production and distribution of technical guidelines, fact sheets and reporting tools in the following areas was done in 2012: 5,000 copies of cholera, Meningitis, Hepatitis E and VHF epidemic preparedness and response plans. 2,000 copies of IDSR training package and technical guidelines. 1,000 copies of outbreak investigation and response guidelines. 30,000 copies of IDSR reporting tools and registers including outpatient register, weekly and monthly forms, supervision visit registers, case based investigation, case definition banners and many more reporting forms. 10,000 fact sheets for meningitis, yellow fever, cholera, hepatitis E, cutaneous anthrax, measles and others. Six hundred and forty three (643) outbreak alerts were investigated by state rapid response teams, and over 478 specimens collected and transported to Nairobi for confirmation. Of these outbreak alerts, measles, hepatitis E, cutaneous Anthrax, kala azar and malaria were confirmed and responded to in timely manner, and procurement and installation of laboratory equipments to strengthen the national public health and reference laboratory in Juba done. In addition, the WCO supported; WHO team conduct a training of health workers in maban county on the Intergrated Disease sureviallnce and Response The monthly support supervision and monitoring with feedback was given to all the 80 counties and 10 states, and 75% of all planned supervision visits were conducted by surveillance officers. WHO supported national and state reference laboratories to improve their capacity to respond to epidemic outbreaks of communicable diseases through trainings, provision of lab supplies/equipment and technical guidelines. The completeness of weekly surveillance reporting by counties and states to the central level slightly improved to 55% in 2012 as compared to 48% in 2011. Efforts by health authorities to improve communication and transportation in peripheral facilities was done by procuring and installing 30 Cadon High Frequency radio and the provision of 30 motorcycles and 400 bicycles to trained surveillance focal points and Polio field supervisors.
17 Together with MoH-RSS, WCO supported the integration and collaboration process of all vertical surveillance programs like, AFP and Guinea worm into IDSR system, thereby strengthening IDSR to detect early warning signals of impending outbreaks and help initiate an effective response in a timely manner. Data management for disease surveillance was also improved and the weekly bulletin for disease surveillance data shared regularly with health authorities, partners and EMRO. Lessons learnt The WCO worked with key donors and the Ministry of Health to strengthen the capacity of state and county health authorities. Collaboration and involvement of health cluster partners in the implementation of integrated disease surveillance strategy contributed to the achievement of expanding the IDSR strategy to all the states and counties. Strong cooperation with government and health partners needs to be secured in order to strengthen surveillance and outbreak investigation and response for communicable diseases in South Sudan. The lack of local reference laboratory capacity delays outbreak diagnosis and response. Challenges The operating environment in South Sudan has become more expensive and difficult in the region due to poor infrastructure, shortage of fuel, high food prices, limited availability of transport, and high living expenses. High staff turnover at the health facilities, county and state levels which negatively impacted on the continuity of health services and surveillance activities. Retention of qualified and highly trained health personnel was very challenging due to delayed salaries coupled with availability of highly paid employment opportunities with the UN, INGOs and other NGOs. The ongoing austerity measures imposed by the government have severely impacted on service delivery and staff motivation;
18 Overall weaknesses within the health system at state and county levels remained a major obstacle to the successful expansion and implementation of IDSR in South Sudan. Shortage or high turnover of state and county surveillance officers negatively impacted the performance of surveillance system and other health programmes. Logistical difficulties due to poor roads, insecurity, bad communication and weak infrastructure delayed outbreak investigation and response. Way forward WCO shall; In collaboration with other partners strengthen the health system and infrastructure at state and county level to take full ownership and support the implementation of IDSR system. Maintain the international epidemiologists deployed in key states in order to provide technical support to State Ministries of Health and County Health Departments. Advocate for regular salary payment to all health workers and surveillance officers in order to ensure service continuity. Ensure timely investigation and response to all outbreak alerts in high risk areas and strengthen the epidemic preparedness and response capacity and coordination activities at all levels. Increase timeliness and completeness of reporting from health facilities, county and states in collaboration with state and county health authorities and partners. 3.2 Expanded Programme on Immunization/Polio Eradication Initiative As of December 2012, South Sudan went for more than three consecutive years without a wild polio virus being reported and all surveillance indicators were at optimal level. Despite the multiplicity of challenges faced during the year, both natural and manmade, the country continued towards achieving the polio eradication target. In accordance to WHO's Executive Board resolution, declaring the completion of polio eradication a "programmatic emergency for global public health and to respond swiftly
19 and timely, an emergency approach to polio eradication was adopted and the Emergency Standard Operating Procedures (SOPs) for the country activated. Polio eradication is the foremost priority of the country and the program is performing under the direct supervision and support of the Regional office for Eastern Mediterranean. Improving routine immunization services and coverage continues to be a cornerstone strategy for polio eradication. Despite significant resources and investment, routine immunization coverage remains sub-optimal at the county level with large gaps at subnational levels in the high-risk counties of the country. At least 40% of polio field staff time is contributed to immunization system strengthening. This includes surveillance support to vaccine-preventable diseases (VPD), measles and implementation of the Reach Every County (REC) approach (e.g. district micro-planning) and assessing cold chain facilities. The vaccination status of Acute Flaccid Paralysis (AFP) cases is used to identify areas of sub-optimal performance of routine immunization programs. Key Achievements Graph one showing the DPT coverage from 2010 to November-2012. WHO country office, consistently managed to attain over 60% DPT-3 coverage in the last two consecutive years with 73% coverage in 2012. Graph one shows the DPT coverage from 2010 to November 2012 and DPT-3 Coverage (2008 2012). WCO provided technical support to the Ministry of Health in finalizing the comprehensive multi year plan (2012 2016) & the application to GAVI board for the introduction of pentavalent vaccine in South Sudan. It is worth mentioning that WCO provided financial support for the hiring of an expert to cost the five year plan for the EPI program (cmyp). The WCO continued to support advocacy efforts by ensuring frequent communication between the central level and state level, through daily reminders and regular visits. All polio eradication advocacy strategies are complemented with advocacy for routine immunization.
20 During the year, four rounds of polio campaigns were conducted with a primary focus on high-risk geographic areas and/or under-served populations. Other vaccination activities conducted included; measles campaigns and vaccination week used to deliver additional doses of OPV to help boost population immunity. In addition, the country conducted one sub-national Immunization Days (snid) in Western Equatoria in response to a vaccine derived polio virus isolated. During the campaign a high percentage of mobile and under-served subpopulations were reached with OPV. Table 1 shows results of the four rounds of campaigns in 2012. Table 1 shows results of the four rounds in 2012. Table 2 shows results of the MNTE campaign in 2012. In 2012, the WCO in collaboration with the MoH, UNICEF and UNFPA commenced the implementation of the Maternal Neonatal Tetanus Eradication campaign in the Equatoria regions of; Central, Eastern and Western. This was successful, though with minimal turnout resulting into achievement of less than the global target of 85%. Table 2 shows results of the first phase of the campaign in the three states of the Equatoria zones. During the year, the overall AFP surveillance activity was enhanced to high level of sensitivity. The WCO did this by focusing on active case search, investigation and collection of samples from all suspected AFP cases and their contact. Collection of samples from healthy children in silent counties was also done. Key AFP surveillance indicators (non-polio AFP rate and percent of adequate stools) in South Sudan meet international certification standards across all states. However, county data analysis highlighted gaps, particularly in counties with difficult terrain and insecurity. The data
Photo credit: WHO 21 generated was used to address gaps that supported the maintenance of an effective AFP surveillance throughout the country. With the support of WCO, a total of 321 AFP cases were detected with a Non Polio AFP rate of 3.94% and stool adequacy increase of 95% far above the target of 80%. In addition there was an immense improvement in the immunity gaps of children 6-59months. The immunity profile of children under five increased from 76% in 2011 to 81% as at the end of December 2012. A WHO staff takes samples of measles from a child in Lakes state Measles Case Based Surveillance The WCO strengthened the measles case based surveillance activities in various capacities as a means of creating sensitivity and making it more robust in timely investigation of cases. For instance technical support was provided to Eastern Equatoria Kapeota County to investigate rumours of measles outbreak. During this period, a total of 2,048 suspected measles cases were reported. With the robust strategy in place approximately 13% of reported cases were investigated within 48 hours of notification. In addition, the country office provided capacity building for front line health workers in the detection and investigation of measles cases. On job training was provided for staff and opportunity of training during the National Immunization Days used to coach front line staff on measles case base surveillance. The laboratory in Juba is the main source of specimen analysis for measles specimen. Following its reactivation, the WCO supported the training of 2 technicians in Kenya Nairobi to enable them have hands on experience in the Laboratory work. This enabled measles and rubella serological testing at the hospital with a quality assurance measure put in place to minimize errors.
22 Table 3 shows performance indicators The Roll-over of measles follow-up campaign which began in mid 2011 was completed in the 10 States during the year under review. Final results from the 10 states showed that a total of 1,708,418 children aged 6-59 months were vaccinated (Admin data) against the disease. During the same period, a number of outbreak response activities were conducted in areas reporting high numbers of cases. These included but were not limited to Western Equatoria, Warrap and Eastern Equatoria. Capacity building of staff is very critical for the success of the Polio eradication. With this in mind, the WCO provided support to the states during the NIDs to train over 20,000 volunteers and staffs in routine surveillance, Supplementary Immunization activities and REC approach. Challenges Humanitarian crises due to tribal and border conflicts in some areas resulted in restricted movements and low supervision. The escalating living costs posed a huge burden on the program, raising the costs of fuel and transportation. The rapid turnover of staff poses a challenge especially as some organization use high salaries to lure experienced staff. Persistent lack of both accountability and ownership of the program from the health officials at different levels especially at the state and county levels continue to hinder the success of the program.
23 Way forward Intensify AFP surveillance activities in all Payams and bomas to ensure early detection and circulation of the wild polio virus for onward investigation as this is the only way to ensure and sustain gains made so far. In addition trainings will be conducted to strengthen surveillance. Support supervision on the implementation of Reaching Every County (REC) approaches (Routine EPI) while focusing on training of health workers, outreach and mobile services, mapping hard to reach populations and social mobilization at all levels will be done. In order to maintain South Sudan s polio free status, the WCO will continue conducting supplementary immunization activities, routine immunization, strengthening AFP and other Vaccine preventable diseases (VPDs) surveillance. WCO will also strengthen routine EPI services as part of the Accelerated Child Survival Initiative (ACSI). Interventions within the initiative will include micronutrient supplementation, de-worming, prevention of malaria using Insecticide Treated Nets (ITNs) and intermittent presumptive treatment (IPT) of malaria, health education and ANC services. The WCO will conduct EPI review meetings to evaluate Measles Mortality Reduction in South Sudan. This would be followed by training in the same areas to improve performance in the field, and stool sample survey from community children in salient counties will continue. Conduct quarterly desk reviews to monitor sub national surveillance performance and rapidly implement field-level reviews in areas with major performance gaps, and Strengthen measles surveillance system and intensify response mechanisms against the surge of measles outbreaks through the implementation of national follow up immunization campaigns. 3.3 HIV/AIDS South Sudan is regarded a country with a low generalized HIV epidemic. This is based on HIV annual program data and surveillance trends of the 2009 and 2012 South Sudan antenatal (ANC) clinic sentinel surveillance studies, which estimated the HIV prevalence among pregnant women in South Sudan at 3.0% and 2.6% respectively. The country has significant geographical variation between sentinel sites with the lowest and highest prevallance, ranging from 0% to 15.5%.
Photo credit: WHO 24 The 2009 ANC sentinel surveillance indicated that HIV prevalence rates are highest in states in the south (Western, Central and Eastern Equatoria states) bordering Uganda, Democratic Republic of Congo (DRC) and Central African Republic (CAR). This geographic heterogeneity of the epidemic is taken into consideration in planning HIV prevention, care and treatment interventions. UNAIDS estimates indicate that 16,000 new HIV infections were acquired in 2012, contributing to an estimated total of 150,000 people living with HIV by 2012 in the country. The number of newly infected people continues to rise mainly due to slow progress in implementing interventions for HIV prevention and suboptimal access to HIV treatment. Access to HIV testing and counselling among the general population, pregnant women and special populations is low, this was mainly due to a reduction in funding in 2012. The South Sudan Household Survey (SSHS) 2010 estimates knowledge of HIV status at only 4%, while coverage of HIV testing and counselling among pregnant women according to program data does not exceed 20%. It is important to note that the low access to HIV testing escalates HIV treatment crisis. In South Sudan, WCO plays a crucial role in providing support for the delivery of Antiretroviral Treatment (ART) and HIV care services to People Living with HIV/AIDS at ART sites. Other than this, WHO supports advocacy and policy formulations at the highest level, planning and resource mobilization, capacity building and quality assurance, monitoring and surveillance of HIV care/art patient, Blood safety and Universal safety precautions and strengthening linkages with TB, child health and reproductive health through planning, guideline development, training and service delivery. Key Achievements Health providers learn how analyze data from registers at HIV clinic in Yei As of the end of 2012, the total number of eligible adults and children enrolled on ART was 4,629. The number of Person Living with HIV receiving cotrimoxazole by the end of this reporting period was 9,880. By the end of 2012, the programme had enrolled a total of 9,880 Persons Living with HIV/AIDs and OI s on prophylaxis (Cotrimoxazole).
25 Challenges HIV-counselling-and-testing (HTC) rates remained low, with weak linkages between HIV testing and treatment services, compounded by a disconnect between the location of HIV-testing and HIV-treatment services. Sustained scale up of HIV services with better outcomes involves integration with other health sector interventions including TB, MCNH, blood safety and support services such as drug supply and HMIS. There was limited availability of ART service-delivery sites (n=22); physical access issues, such as poor roads, flooding, high transportation costs, and security problems in some areas of the country and sub-optimal identification of eligible patients by CD4 and clinical criteria leading to low ART coverage. Health workers providing services at ART facilities faced a lot of community pressure to enroll other members of the community into care and treatment. The absence of alternative sources of funding made it impossible to provide sufficient ARV drugs, OI medicines and commodities for new patients. This represents a large and immediate programmatic gap. In order to ensure adequate continuity of prevention, treatment and care, eligible Persons Living with HIV (PLHIV) must have access to ART: in the absence of ART, the success of the current HIV testing and counselling programmes in the context of VCT, PMTCT and TB programmes may be reversed. One of the biggest challenges the HIV-treatment programme faced in South Sudan was the low retention rates. According to the Ministry of Health (MOH), 12 month ART retention rate is 70.8% (2012). The quality and follow-up of ART services was affected by a range of factors, including: accessibility and distance to ART facilities and the associated travel costs; inadequate adherence counselling and ART monitoring due to inadequate staffing, training and inadequate laboratory support; problems with referral of patients, including inadequate monitoring of patient migration from one site to the other; lack of home-based care and support groups. Delayed financial disbursements led to interruption of services and loss of staff to support implementation. Weak leadership and commitment was observed in some areas and inadequately of qualified staff to provide services. Low levels of children and infants accessing ART and care was at only less than 3%. The country does not have facilities (equipment) to make infant diagnosis.
Photo credit: WHO 26 Way forward WCO will continue working in collaboration with the MOH and other partners including, UNDP, other UN partners and USG to ensure commitment and investment in combating HIV in the country. WCO will work with partners to strengthen linkages and integration of HIV, support updating and development of treatment protocols, tools and guidelines, conduct refresher training for Health Care Providers (HCP), introduce Quality improvement programs in HIV treatment, continue forecasting and quantification of HIV medicines and commodities. Sustained access to HIV services also needs strengthening for the delivery systems to become more integrated thus fostering a continuum of chronic HIV care. 3.4 Tuberculosis Control Tuberculosis (TB) is a priority disease for the WCO in South Sudan and among the major causes of mortality and morbidity in the country. The first National Strategic Plan for TB Control (2009-2013) was developed in 2009 and again revised soon after independence in line with the new Ministry of Health (MoH) Health Sector Development Plan (2011 2015). Tuberculosis control in the country is coordinated by the National TB/Leprosy/Buruli Ulcer Control Program (NTLBP) formed in 2006 at the central level and later in 2010 expanded to the state level through the appointment of 10 State TB coordinators. The tuberculosis control coordination structures in 79 counties have not yet been established. WHO team check deworming tables during the National Immunization Days in Eastern Eqautoria state The number of health facilities providing TB services including diagnostic and treatment centers increased from 32 in 2006 to 65 in 2012. TB services are provided for by the government in collaboration with Non Governmental Organizations (NGOs), following a 3 tier system of Hospitals, Primary Health Care Centers (PHCC) and Primary Health Care Units (PHCU). NGOs play an important role in TB control in South Sudan.
27 There is no specific data for the TB burden in South Sudan in terms of incidence and mortality. However, the average notification of TB cases in South Sudan increased steadily from 53/100,000 in 2008 to 85/100, 0000 in 2011. Female to Male notification ratio was at 1:1.5. Key Achievements WCO provided financial support to CUAMM (DOCTORS WITH AFRICA) to deliver TB services in Greater Mundri County, Western Equatoria State. WCO distributed various TB IEC (information, education and communication) materials to TB facilities in six states (Jonglei, Central Equatoria, Eastern Equatoria, Western Equatoria, Lakes and Upper Nile) to support and promote health education. One thousand (1000) brochures and 300 posters were distributed to the six states. In collaboration with the NTLBP, WCO trained 54 health workers on recording and reporting tools and basic aspects of monitoring and evaluation (M&E). Seventeen (17) health workers were from Western Equatoria State, 18 from Central Equatoria State and 19 from Eastern Equatoria State. The objective of this training was to improve knowledge of the health workers in completing accurate records, basic analysis of reports and monitoring and evaluation. In addition, 20 health workers from Eastern Equatoria State were trained on TB/HIV collaborative activities with a focus on Cotrimoxazole preventive therapy (CPT). As part of the capacity building strategy to strengthen the NTLBP, WHO trained two staff at the Regional MDR-TB training in Cairo, Egypt. WHO further supported the MOH with the development of Patient-Centred Treatment (PCT) guidelines, aimed at increasing the patient access to treatment so as to improve treatment outcome. WCO supported the development of MDR-TB guidelines and training materials meant to strengthen programmatic management of Drug Resistant TB and training of health workers respectively. Two thousand copies of MDR-TB guidelines were printed and distributed to various states. WCO also supported and participated in the commemoration of World TB Day, held for the first time in Torit, the state capital of Eastern Equatoria. WCO supported the NTLBP in the development and successful submission of Transitional Funding Mechanism (TFM) for the TB program. The TFM is to support the
28 continuity of TB services in South Sudan following the expiry of Global Fund TB Round 7 grant. Challenges Low Directly Observed Treatments - Short course chemotherapy (DOTS) coverage. TB services are provided in only 6% (65 out of 1147) of functional health facilities and these are unevenly distributed with high defaulter rate. Lack of TB coordination at the county level, inadequately skilled staff, and limited TB laboratory network including lack of a functioning Central TB Reference Laboratory (CTRL), which is under establishment. Community involvement in TB care is poor coupled with poor road conditions and flooding as a result of heavy rains, this hindered accessibility to some TB facilities. Way Forward The NTLBP through the MOH needs to advocate and mobilize resources for integration of TB services into the general health care services so as to increase DOTS coverage. The NTLBP needs to train health workers on TB management, print and disseminate PCT guidelines to the TB management units in order to improve access to treatment for patients. The NTLBP needs to expand and strengthen TB laboratory network and seek additional funding for the completion of Central TB Reference Laboratory (CTRL). 3.5 Guinea worm Tremendous progress is being made towards eradicating guinea worm disease in South Sudan. The World Health Organization is supporting the Ministry of Health and working with other partners (The Carter Center and UNICEF) to strengthen guinea worm disease surveillance and advocate for supply of safe drinking water. Of the 542 guinea worm cases reported globally in 2012, 521 of them were reported in South Sudan. The remaining 21 cases were reported in the three countries of: Chad (10), Mali (7) and Ethiopia (4).
29 A chart showing the epidemiological trend of guinea worm disease in South Sudan over the last three years. There is steady reduction of cases It should be noted that the 521 (2012) cases reported in South Sudan represented a reduction of 49% percent compared to the 1,028 reported in the same period in 2011. These cases accounted for South Sudan s 2012 guinea worm cases recorded in 252 villages in Eastern Equatorial, Warrap, Lakes, Jonglei, and West Bahr Al Ghazal. Eastern Equatorial state acounted for 87% of the 2012 cases. The remaining 23% occurred in four states of Warrap (37 cases), Jonglei (24 cases), Lakes (7 cases) and Western Bhar El Gazel (1,case). It should be noted that infection was localized in specific counties and payams. for instance, more than 75% of the cases in Eastern Equatoria occurred in Kapoeta East county and 30/37 cases from Warrap states occured in Gogrial East county. Of the mentioned cases, 337 were contained (65 percent). All the cases were distributed in 30 bomas, 14 Payams and 9 counties. Interruption of indigenous guinea worm disease transmission could be achieved in the next two years. Key Achievements The WCO supported the Ministry of Health (MOH), South Sudan Guinea worm Eradication programme (SSGWEP) to conduct a workshop aimed at developing a communication strategy for the program. The WCO recruited a communication specialist who worked closely with other partners: UNICEF, The Carter Centre, The MOH official, the media and other NGOs. As a result key communication areas and modes were identified that will support the final design of the strategy. WCO continued to support the MOH with advocacy and coordination of the SSGWEP. During the year, the MOH delegates were financially supported to participate in the World Health Assembly discussions on guinea worm eradication. During this time the Minster committed to interrupting indigenous transmission of Guinea worm in the
Photo credit: WHO 30 country by the end of 2013. In addition, the country office supported the MOH team to participate in the regional GWEP meeting for all African countries in Addis Ababa and organized and participated in the regional and annual review meetings to evaluate progress of guinea worm in 2012. WCO also supported the Training of Trainers (ToT) of 80 surveillance officers and state coordinators in Rumbek and Juba town. These in turn trained 648 health workers in ten WHO staff extracts a worm from one of the community members in Eastern Equatoria state. states on guinea worm disease surveillance. The trained health workers are now reporting on guinea worm disease through the county surveillance officers on weekly and monthly basis. As a result, four guinea worm cases in Gogrial East, Warrap state were detected. The WCO further supported the training of 337 community based volunteers in seven at-risk counties. The seven at-risk counties are targeted by the MOH with the assistance of the co-training teams formed during the TOT trainings conducted in Juba and Rumbek towns. The community volunteers are responsible for village level surveillance and health education at the community level. To strengthen and enhance surveillance at the border areas, the country office supported two guinea worm eradication cross-border meetings held in Entebbe Uganda and Gambella Ethiopia. For the first time, South Sudan did not export any guinea worm case to her neighbours and there was no imported case from the neighbouring countries. The WCO supported the MOH with increased countrywide guinea worm disease awareness by supporting surveillance messages aired on Radio and local mobile telephone lines. In addition the country office supported the production and distribution of 8000, 2012 calendars of guinea worm identification cards for health workers and teachers. The cards carried a photograph of an emerging worm and surveillance messages. 500 guinea worm posters were printed and distributed across the country. To advocate for support towards Guinea worm among the military, the WCO in liaison with MOH supported and conducted an advocacy and sensitization workshop for the military and community leaders in the areas where guinea worm has been reported
31 from. A total of 60 senior SPLA officers and 100 community leaders in Eastern Equatorial state were sensitized on guinea worm disease. During the year, WCO officially handed over newly constructed South Sudan GWEP Office at the MOH compound to the Guinea Worm Eradication Program, Ministry of Health. The office is equipped with furniture, VSAT installation, electrical installation and computers for the staff. The WCO will support the office running cost on monthly basis. In addition, the WCO procured and donated a Toyota Land cruizer hard top to the Ministry of Health to support guinea worm disease surveillance in the country. Challenges Insecurity in some states hindered continued surveillance, data collection and reporting especially in Upper Nile and Unity state due to border clashes with Sudan and continued fighting in Pibor County. Poor management of supervision allowances in some states. Poor roads and flooding as a result of heavy rains which hindered accessibility to some locations. Limited skills of some surveillance officers and health workers. Weak supervision of the counties by the state partly due to inaccessibility during the long rainy season, long distance and low motivation among some surveillance officers. Delays in reporting and sometimes lack of reporting by some surveillance officers. Way forward Guinea worm disease is on the verge of eradication and WHO teams at all levels should continue to enlighten the states and county authorities of the progress being made and ensure committed support to the eradication process. The WCO teams in all the ten states need to follow up on all planned activities and funds sent to the MOH and share progress, constrains and frustration encountered with the team in Juba on monthly basis.
Photo credit: WHO/P Ajello 32 Need for the MOH/South Sudan Guinea Worm Eradication to introduce countrywide reward system. 3.6 Onchocerciasis control In 2012, The African Programme for Onchocerciasis Control (APOC) continued to support the South Sudan Onchocerciasis Taskforce (SSOTF) in the bid to establish effective and self-sustainable community-directed ivermectin treatment (CDTI) throughout the onchocerciasis endemic areas in 9 out of 10 states in South Sudan. The CDTI strategy relied on community participation for the distribution of ivermectin to the targeted population. Project Coordinating Officers, County OV Supervisors, Staff from Front Line Health Facilities (FLHF) facilitated the CDTI process by organising communities to participate in CDTI activities. Community selected Community Drug Distributors (CDDs) who were trained to conduct community censuses, provided treatment with ivermectin and kept records of the households treated. Key Achievements The annual quantification and ordering of the 2012 mectizan supply for all the CDTI projects in South Sudan was completed and submitted to the Mectizan Donation Program in January 2012. This was to enable timely delivery of supplies of mass distribution in the course of the year bearing in mind the lead time period of 3 months before the drugs were delivered to the country. For the project areas in Upper Nile state, where the CDTI project are inaccessible during the rainy seasons, mectizan was delivered so that the state could begin their mass distribution exercise before the heavy rain season commenced, to enable them reach the beneficiary communities. The Head of WHO south Sudan Office, hands over a vehicel to the Under Secretary, MOH and the Coordinator for the Onchocerciasis Program to support the programme in the country Emphasis was put on the process of receiving and compiling of the 2011 CDTI training and annual community mass treatment reports. The overall results showed that a total of 16,467 CDDs were trained, all of who were available for the mass distribution exercise, bringing the overall CDD: population ratio across the 5 CDTI projects to 1:347.
33 Though this fell short of the recommended 1CDD:100 population ratio; it was an improvement compared to 1:390 and 1:605 ratios in 2010 and 2009 respectively. A total of 5,526 of the 6,728 at risk communities received annual mass treatment thus achieving a geographic coverage of 82%; and 3,477,340 persons of the total 5,707,037 eligible population in the project received treatment thus achieving a therapeutic coverage of 61%. Three members of APOC Senior Management Team, including the APOC Director visited South Sudan as an action point made at a meeting that was attended by the South Sudan MOH team in Kuwait. The meeting was the 2011 Joint Action Forum (JAF) that made a recommendation that teams visit all the CDTI projects in South Sudan. The team visited all the CDTI project sites and held community meetings with CDTI project beneficiaries in order to verify reports of poor performance of the CDTI projects. The states visited included; Central Equatoria, East Equatoria, West Equatoria, Northern and West Bahr el Ghazal, Warrap and Lakes States. During these visits, interviews and focus group discussions with CDTI implementing staff and document review at different levels were done and meetings with state level officials held at the counties, payams, bomas and communities. The general findings of the mission confirmed the findings of the sustainability of evaluation that recommended that since the CDTI projects were not moving towards sustainability; they need to be re-launched. Mass drug administration in endemic communities commenced during this reporting period. In addition, all the states and counties covered by the 5 CDTI projects had their 2012 supplies delivered to the state ministries of heath and county health departments. These drugs are supposed to treat over 6 million people across the country. With support from the WCO, a detailed plan and budget for re-launching of the CDTI program in the state was prepared and submitted to the MoH and APOC management. Once approved, the format and budget lines used in this proposed plan and budget will be used as the base for preparation of similar budgets and plans for other states after taking into consideration peculiarities in individual states. The WCO supported a delegation from the ministry of health to attend the annual Joint Action Forum, held in Bujumbura, Burundi in December 2012. This was top level decision making body of onchocerciasis control attended by ministers of health from 20 member countries of the African Program for Onchocerciasis Control. South Sudan was represented by the Hon. Minister of Health and the National Coordinator for Onchocerciasis Control program. The Key decisions made on South Sudan were that the CDTI activities be re-launched and that the CDTI projects will be re-structured from five to nine.
Photo credit: WHO 34 The South Sudan 2013 mectizan application was prepared and submitted to the Mectizan Donation Program (MDP). Confirmation of receipt was made and approval process is underway. The onchocerciasis control program expects that the mectizan will be received in March/April 2013 from MERCK so as to have the 2013 mass distribution commence in April/May 2013. Challenges The state Ministry of Health staff together with WHO conduct an assessment during flooding in Aweil, Northern Bahr el Ghazal state A major difference in the amount of funding required for the expected CDTI activity implementation and the actual funding that was available was a challenge during this period. The insufficient funding was due to the progressive planned reduction of APOC & NGDO partner funding and lack of funding from the government. The funds available to the project could only implement an estimated 30 40% of planned activities. It is hoped that with the planned re-launching of CDTI, the funding situation will improve. Lack of leadership and adequate capacity to properly manage CDTI projects. For most of the reporting period, there was no National Coordinator to oversee the implementation of CDTI activities. At project level, the project coordinating officers got overwhelmed by the magnitude of the project management requirements thereby failing to manage the project appropriately. The Minister of Health appointed a new National Coordinator for Onchocerciasis Control. It is hoped that the new coordinator will provide the required leadership for the program. Inadequate staffing in the CDTI project areas. The required staffing at the project level is not available in all the CDTI projects. The Project Coordinators try to multi-task thus compromising the quality of the outputs. In addition there is high turnover of health staff in the NGO-run frontline health facilities, which affected the supervisory base available to the project at county and payam level. High attrition rate of the Community Directed Distributors was equally experienced during this period, mainly associated to lack of incentives to motivate them to continue implementing the program. This was also attributed to lack of adoption of the CDTI philosophy and ownership by the community. All data reported by the CDTI projects is generated by the CDDs who are more often illiterate and find record keeping a challenge. In addition some community level supervisors tend not to appreciate the value of proper record keeping.
Photo credit: WHO/P Ajello 35 Lack of integration of CDTI activities into routine primary Health Care activities. This stems from the history of how the Onchocerciasis control program was implemented in the past; it was vertically implemented by NGOs with minimal involvement of Health authorities at the State and County levels. In addition the project level staff are reluctant of going under the state level authorities as this will mean more supervision of their activities and assets like vehicles and motorcycles. Way forward More community education and sensitization should be conducted by the CDTI project staff with support from the SSOTF and APOC in country staff to address the challenge of inadequate staffing and knowledgeable manpower in the CDTI project areas. All supervisors at the different levels should be trained to supervise those below them in data management in order to improve data management problems. Meeting with State Director Generals for Health and actively advocating for integration of planning budgeting, funding, supervision of CDTI activities; and the integration and management of CDTI staff will solve the challenge of Lack of integration of CDTI activities into routine primary Health Care activities. Chapter Four Emergency Preparedness and Humanitarian Action and the Health Cluster In South Sudan, the Emergency Preparedness and Humanitarian Action is committed to; building capacity in emergency preparedness; ensuring that national capacity is available for emergency response through training and establishment of surge capacity; advocating for political support, ownership and consistent resources for emergency The Ministry of Health team from the national and Jonglei state, conduct a joint preparedness and response and towards assessment in Pibor following a militia attack in the area in 2012 recovery and prepositioning of life saving medical supplies and medicines at central and state levels to respond to any potential outbreaks and health emergencies.
36 Key Achievements Emergency Health Coordination One of the WCO s focus is to strengthen coordination of health at all levels. Being the cluster lead for health, the country office strengthened the coordination mechanism at the central and state levels through supporting the Ministry of health to organize and hold health emergency committee meetings and health cluster meetings. During the meetings, comprehensive and inclusive strategies to effectively respond to the health crisis were discussed and agreed. A total of 64 health cluster meetings were supported and conducted across the 10 states of South Sudan. The country office also supported the Health cluster to develop response plans for six crisis states and contingency health plans for all the ten states. In addition a revised national contingency plan for the health cluster was developed with strategies to respond to the evolving humanitarian situation. The emergency and preparedness plans were made to support the ten states with preparedness to respond to emergencies at all levels. This was mainly in the area of increased cross boarder aggression, tribal conflict as well as militia attacks, which will commonly lead to increased numbers of injured persons, Internally Displaced Persons (IDPs), refugees, vulnerable communities and increased mortality and morbidity numbers. The country office supported the coordination of medical evacuations for the injured during clashes, deployed extra techncial officers, nurses and medical officers in Pibor,Bor,Bentiu,Marialo and Juba teaching hospital. Those deployed, helped manage injured patients, and provided medical escorts for Medvac and ambulances that transported the injured from the airports to key referral hospitals. In total 506 causalities were evacuated to Juba teaching hospital, Malakal and Akobo hospitals for life saving surgeries. Recognizing the importance of coordination and partnership, the Health cluster led partners through the process of developing the 2013 Humanitarian Work plan (HWP), Consolidated Appeal Process (CAP) in line with the humanitarian context in South Sudan. During this time, a total of 33 response plans (projects) were prioritized and included in the UNHWP-2013 estimated at 89M$. On resource mobilisation, WHO as the cluster lead assisted cluster partners to prepare and develop projects for funding in the 1 st and 2 nd rounds of the common humanitarian fund for the year 2012.
Photo credit: WHO 37 Rapid Health Assessments During the year, WCO conducted and participated in rapid health needs assessments in areas affected by the various crises. The areas include; Jonglei state, Unity State, Lakes state, Northern Baher el Ghazal state, Agok and other parts of Raja County and Maban in Upper Nile. Among the assessments that the WCO participated in are; the Inter agency assessments to Pibor,Akobo,Nyirol in Twic East,Lukongule,Gurmuk Payama and in rapid health assessments for outbreak verification in Deng Weec,Twic East,Jur River County,Maban County,Renk County, New fangak Payam,Atar County,Gogrial West county and Nyirol County. The health assessments were critical in identifying humanitarian health needs, and instrumental in identifying and prioritizing public health risks of the affected populations hence enabling the cluster partners and WHO respond appropriately. In total the organization supported and participated in 22 health assessments across the ten states. Ensuring effective emergency response. An injured patient with a gunshot wound admitted at Bor hospital. During the year WHO hired surgeons to support various state hospitals to manage patients wounded during clashes South Sudan is at high risk of health emergencies and epidemic outbreaks. To support the Ministry of Health effectively respond to these emergencies, the WCO strategically prepositioned and distributed interagency health emergency health kits trauma kits, diarrhoea kits, major and minor surgical kits, anaesthetic kits, and outbreak investigation kits to hot spot areas. The full emergency kits were prepositioned at the state hubs with MOH emergency department and in frontline counties of Pibor,Akobo,Tonj East,Renk,Korflus,Raja,Yida,Pigi,Old fangak and Maban counties. Key referral hospitals in Warrap, Lakes, Abyei Administrative Area, Malakal, Bentiu, Jonglei and Juba Teaching Hospital also received emergency kits, assorted medicines and outbreak investigation supplies. In addition, the preparedness level of the MOH/Juba teaching hospital was enhanced and strengthened to support and function as a fallback position for the management of mass casualties and war wounded patients. The Hospital received 7,000 IV fluids, 4 Trauma kits and infection Control materials, to support the management of the mass causalities following clashes in Pibor and Unity states. A total 66 kits were distributed to partner agencies across the ten states of South Sudan in the year 2012.
Photo credit: WHO/P Ajello 38 Given that South Sudan has witnessed many outbreaks in the past, WCO promptly supported the Ministry of Health at the central and state levels with investigations of suspected diseases and outbreaks. During this period, the country office responded to suspected cases of epidemic prone disease and response alerts in Jonglei, Western Bahr el Ghazal state, and Upper Nile state Health Cluster partners attending a health cluster meeting at Juba level among others. To strengthen investigations at the state levels, WHO distributed outbreak investigation kits to all the states as a measure of preparedness to reduce the response time to contain potential outbreaks. Together with the Communicable Disease Surveillance and Response Unit (CSR) unit, a total of 199 outbreak alerts were attended to and verified. In addition, WCO supported the Ministry of Health to conduct mass measles campaigns and routine vaccination activities targeting children at transit camps and refugee camps. In collaboration with UNICEF and MOH, over 356,317 children were immunized against measles at way stations, transit points; refugee settings and host populations in counties that reported suspected and confirmed cases of measles. To further enhance the investigations of disease outbreaks, the WCO supported the Ministry of Health at all levels with financial and logistic support to contain outbreak in the counties. In period, South Sudan faced outbreaks of Hepatitis E, Kala azar, coetaneous anthrax, measles and malaria. The organization provided logistics support to health authorities and partners to transport Kala azar drugs and supplies for the management of Kala azar patients. It s worth noting that WCO is the only supplier of kala azar drugs and was instrumental in the improvement of the quality of the management of the cases. The programme also supported the transportation of ant malaria drugs to the counties of Nyirol,Urol,Pibor,Bor,Renk,Twic,Tonj East,Tonj South,Gogrial East,Guit,Agok,Terekeka,Lanya,Bentiu,Malakal,Rumbek,Raja counties. The programme further donated supplies to support case management of Hepatitis E cases and Acute Watery Diarrhoea (AWD) cases in the refugee setting of Maban and Yida. This was in collaboration with UNHCR and other health cluster partners on the ground. WCO supplied outbreak investigation kits, Personal Protective Equipment kits, and Infection control materials to enable a continued and prompt response to potential outbreaks.
39 The country office also advocated and assisted the MoH-Republic of South Sudan to speed up the distribution of regular essential drug supplies to primary health care facilities. To speed up the process of and ensure prompt case management during the emergencies, WCO supported the directorate of pharmaceuticals to transport supplies and emergency drugs to Malakal, Upper Nile, Warrap, Western Bahr Ghazal state, Unity and Jonglei states to respond to the repeated drug raptures due to delays in the regular cycles of primary health care drug distribution. Supplies were also distributed to Agok, Warrap state, an area currently hosting over 110,000 displaced persons in need of emergency health services. Technical support was also provided during the emergencies at various states. This the WCO did by rapidly deploying technical officers to the areas of Pibor, Akobo, Bor, Renk Maban, Rebkona, Awiel, Twic, Agok, Nyirol,Tonj East, and Raja to support the MOH in responding to the health emergencies. As a result, health coordination, outbreak response, health assessments and disease surveillance were enhanced. In addition six new National Public Health Officers were recruited and placed in six of the ten states. Technical support alone is not sufficient especially in areas with access to health facilities. In order to ensure that all vulnerable people are reached; WCO supported the State Ministries of Health to establish and initiate mobile clinics in the areas reporting high influx of refugees, returnees and displaced persons. During this period, over 174,771 persons directly benefited and were treated from the mobile clinics and restored fixed sites that the country office supported. Health partners were also supported in Pibor, Bor, Awiel North, Awiel Center, Juba Port, Way station, Northern Bahr el Ghazal state and Maban. Through the health cluster mechanisms some health partners were directly supported with life saving drugs in emergencies among them; International Medical Corps,Medair,Nile Hope Development Foundation, Health TPO, Merlin, ACROSS, MSF-B, MSF-CH,MSF-F, Christian Medical Association, UNHCR, THESO, intersos, AAA-Marialo among others. The Ministry of Health continues to have a thin critical mass of health workers to respond to the ongoing emergencies in the country. Staff turnover is high due to lack of salary payment resulting from economic austerity. In this period, the MOH relied heavily on the WHO support during investigations for potential outbreaks, conducting rapid health assessments, and technical guidance in emergencies. In face of the difficulties and shortage of human resources at the department of emergencies and disease control in the MOH-RSS, WCO supported the Ministry of Health with the deployment of epidemiologists to Warrap, Upper Nile, Unity State, Warrap and Jonglei States, and rotated National Public health officers to support the outbreak response in Maban County. In addition, the country office continued to financially and logistically support the response plans of the SMOHs and MOH-RSS through ensuring that health workers
40 were deployed in front line counties and areas that are reported high number of populations with humanitarian concern. Support Supervision The MOH and WCO conducted support supervision visits to areas with emergency operations at the state levels to monitor emergency preparedness and response activities and report on them. Using standardized checklist and monitoring tools, the teams assessed the impact of training activities, logistic and financial support provided to the SMOH rapid response teams.re-enforcement of primary health care concepts and standards through on-job trainings and measures to address identified gaps was also conducted. All planning visits to the field were agreed on by the MOH and the field coordination teams. Support supervision is a support function of emergency response which is very critical in ensuring focused and effective emergency responses. A total of 8 joint support supervision visits were carried out by the national support supervision teams. Challenges Most health workers fled areas of insecurity while others left the government for NGOs. This created a thin cadre at the State Ministries of Health to adequately assist emergency response, making them dependant on WHO for support. There was limited surge capacity for emergency response. Limited storage and warehousing space at county and state level which affected prepositioning levels of emergency supplies. Humanitarian responses in South Sudan remain expensive, this coupled with poor infrastructure makes emergency response delivery costly. Way forward WCO will continue supporting the MOH-RSS to improve national preparedness & response capacity of acute health emergencies. Strengthen the mainstreaming of emergency activities into all programmes of WHO in order to have an integrated and joint response approach to health emergencies. This will be instrumental to the success of the WHO in effectively and timely responding to all potential health emergencies in the country.
Photo credit: WHO/P Ajello 41 The WCO will enhance Partnership with sister UN agencies and NGOs and strengthen information sharing and effective health coordination. Chapter Five Maternal Health The new maternity ward at Bor state hospital. This was constructed by WHO with funding from CIDA In line with the Government s commitment to rapidly reduce maternal and infant mortality as stated in the South Sudan Development Plan 2011-2013(SSDP), the WCO is closely working with the Ministry of Health to achieve this commitment. To realize the aspirations of the SSDP, the Health Sector Development Plan 2012-2016 (HSDP) objectives underlines increasing utilization and quality of health services with emphasis on maternal and child health. And as part of the process and commitment to support the RSS realize a reduction in maternal and infant mortality, the Government of Canada acting through the Canadian International Development Agency [CIDA] and the World Health Organization [WHO] engaged in a partnership to implement a project on strengthening Emergency Obstetric Care in 8 hospitals in South Sudan over a period of five years. The project aims to increase the availability and quality of comprehensive emergency obstetric and newborn care (CEmONC) within 8 hospitals as well as increase access and utilization of CEmONC services among the targeted population. In 2012, focus was given to Bor hospital, Jonglei state, as the first beneficiary state and a pilot for the project. A team comprising of an Obstetrician, Anesthesiologist and Midwife trainer were deployed in Bor Hospital. Key Achievements Increased availability of quality CEmONC services within hospitals in South Sudan There was a continued steady increase in the number of women with obstetric complications receiving CEmONC services during the last one year cumulatively totalling to 796. Compared to 2011, where the peak utilization of services was realized during the months of October to December during the dry spell. While the number of caesarean
CEmONC cases Cases 42 sections and newborns with complications didn t show much fluctuation during the last 10 months, cumulatively totalling to 78 and 24 respectively. During this period, there was a progressive increase in the proportion of patient s treatment following standardized clinical protocol from about 72% in 2011 to about 90% in 2012. This was attributed to emphasis put on the management of mothers using clinical guidelines adopted over a year ago. Up to 20 copies of these guidelines were printed and provided to trained health workers in Bor hospital maternity ward with others management protocols displayed on the walls in the labour suite. In this reporting period, 4 medical officers were trained in CEmONC, 2 of these were recruited, 6 community mid-wives, 3 Maternal and Child Health (MCH) nurses, 4 clinical officers, 3 Nurses were trained and two clinical officers trained in anaesthesia, one of whom is currently practicing. Two medical Officers from Bor State Hospital were offered scholarships by WCO with funding from CIDA to specialize in Obstetrics and Gynaecology as a long term strategy to improve on quality of care. Operational and Organizational Capacity Building To strengthen the operational and organization capacity building for the Bor hospital, the WCO engaged a consultant to support the administration of Bor hospital to develop management guidelines. As a result, management guidelines to improve administrative capacity of the hospital and the State Ministry of Health were developed and shared. This has relatively improved the organization structure of the departments of the hospital. Capital improvements/physical works The construction work of a well equipped modern maternity ward with two operating theatres and labour and delivery rooms commenced in 2012, and was completed in Bor Hospital. In addition Maternity Waiting Homes will be constructed for Bor hospital and other hospitals where the project will be implemented. Monthly CEmONC cases managed from Jan to Dec 2012 Trends in monthly deliveries, CEmONc cases, and admissions 100 90 80 70 60 50 40 30 20 10 0 92 94 76 76 47 50 61 62 65 66 58 49 J F M Ap March June July Aug Sept Oct Nov Dec Month CEmONC cases 200 150 100 50 0 J F M Ap Marc h June July Aug Sept Oct Nov Dec Total deliveries 88 84 103 73 95 64 94 81 99 89 86 78 CEmONC cases 47 92 50 61 62 49 76 65 76 66 94 58 Total admissions 140 186 173 146 149 122 138 143 158 172 162 104 months Total deliveries CEmONC cases Total admissions
Photo credit: WHO/P Ajello 43 Challenges Out of the six (6) Medical Officers initially trained, only 2 are still working in Bor hospital, with others leaving for better paying jobs. Four additional Medical Officers were recruited to replace those who left and training has commenced. The unskilled staff at the maternity ward makes it difficult to have them trained given their low up-take of knowledge. Returnees on arrival at Juba port, receive immunization against tetanus, polio and measles Photo: WHO/Pauline Ajello Due to bad weather patterns of flooding, outreach to payams is affected. Unwillingness from theatre staff to work, expecting new recruitment of staff to specifically handle the new theatre in the new maternity wing. Way forward To improve quality of care for maternal services, there is a need for the Ministry of Health and the State Ministry of Health to recruit qualified staff. There is need for advocacy for NGOs implementing health programs to support the program. This support should be provided to those partners to complement the community outreach activities for CEmONC. Chapter Six Communication, Advocacy, Resource mobilization and Utilization. During the year, WCO managed to successfully conduct communication and advocacy activities and mobilized a considerable amount of resources that enabled it implement health programs and support procurement of medical supplies to support the Ministry of Health. Communication, Advocacy and Visibility During this period, WCO participated in activities that promote the organizations visibility in the country. This was exhibited by participating in the International health
44 days in the country, among them; The World TB Day, World Malaria Day and World Health Day (WHD). Radio talk shows were hosted in 2 radio stations, a TV talk show and 2 press briefings were held to commemorate the World Health Day and World Malaria days. At the occasions WHO delivered speeches and urged the government to treat health as wealth by allocating adequate resources to the sector. In addition, to ensure all partners and donors are updated with all WCO activities, the country office ensured that reports of its activities and those of its partners were documented and communicated to partners and donors on a regular basis. This was done through weekly Emergency Preparedness and Humanitarian Action (EHA) bulletins, health cluster bulletins and quarterly reports. In total, 49 weekly bulletins were produced and shared, 4 monthly health cluster bulletin and 4 quarterly reports. In addition, the WHO country web site was started for the first time in South Sudan. The website was updated with materials provided by WHO Sudan Programmatic areas. WCO office maintains the site and regularly posts information and news items. The web site is valuable tool for information sharing for both internal and external audiences. The WCO produced an advocacy video show casing the work of WHO in South Sudan. The film was shared with the Headquarters, Regional Office and UN communication team at the Juba level. The film was posted on the EMRO-EHA YouTube portal and the WHO South Sudan portal. The role of the WCO in supporting the Ministry of Health in Communication was evident in joint press statements made during National Immunization Days. Joint press statements were also done targeting communication in the area of Meningitis, Haemorrhagic Fever during the outbreak in the neighbouring country of Uganda, Hepatitis E and Kala azar. This resulted in WHO s visibility and highlights of how the organization would support or was supporting. Resource Mobilization During the year, WCO managed to mobilize funds from various donors. The resources mobilized were facilitated by the reliability of funding for the health sector in the country. A total of 53,313,000 United States dollars was received in 2012. The funding was provided by USAID, Danish Government, ANCIDA, Finish Government (ECRF), CARTER, Gates Foundation, Roll Back Malaria (RBM) GTZ, CHF Sudan, GAVI, UNPFI, KNCV, UNDP TB, CHF SOUTH SUDAN, Rotary International and CDC. Other donors that donated in kind include; SANOFI, BAYE, and NOVARTIS.
45 The chats below shows the funds received in 2012 and donors that supported WCO efforts. Funds received in 2012 US $, totalling 53,313,000 Funding by donor in 2012 Chapter Seven Administration and Management The Administration unit is clustered under; Finance, Human Resources Management, Logistics, ICT and general administration. All the mentioned areas are very critical for the success of the WCO. This unit assists the organization develop while remaining relevant to enable it carry out its mandate more effectively and efficiently. During the year, the organization continued to maintain a considerable number of both International and National staff. Many positions were filled to support the Ministry of Health both at the national and state levels, to ensure quality health service delivery and capacity building.
Photo credit: WHO/P Ajello 46 Some of the WHO National and International staff based at Juba and the 10 states of South Sudan poss for a picture with the Minster of Health state health authorities and WHO South Sudan, Head of Country Office