CONTRACTING-OUT OF PRIMARY HEALTH CARE SERVICES IN CONFLICT-AFFECTED SETTINGS: THE CASE OF SOUTH SUDAN by Juliana Bol A dissertation submitted to The Johns Hopkins University in conformity with the requirements for the degree of Doctor of Philosophy Baltimore, Maryland October, 2019 ⃝c 2019 Juliana Bol All rights reserved Abstract South Sudan introduced a nation-wide geographically focused contracting ap- proach with funding from 3 main donors, to rapidly scale-up access to health ser- vices starting mid-2012. The overall aim of the thesis is to assesses its effect and impact on maternal and child health. In the first paper, I provide extensive back- ground on the history of health services delivery in South Sudan prior to assessing progress in increasing health facility utilization among women and children under- five, using routine health facility data. I thus compare the period (2011-2013) tothe policy period (2013-2015) at national and sub-national level using Prais-Winsten and Cochrane-Orcutt regression and find significant increases in health facility uti- lization. Given the overall increase in health facility utilization, the second paper assesses impact of the policy on child mortality using a novel approach to construct a synthetic South Sudan from a panel of lower- and middle-income countries (LMICs), and using data from the World Bank Developmental Indicators (WDI) database. On average, contracting out had a negative effect on the rate of decline ofU5MR during the policy period. These findings suggest limitations in the approach imple- mented in South Sudan. The third paper further evaluates the contracting interven- tion by evaluating three contracting approaches in Jonglei and Upper Nile States; contracting-out (C-O) using non-governmental organizations (NGOs), contracting- in (C-I) using county health departments (CHD) and performance-based contracting (PBC) in select counties. Using difference-in difference (DD) and DD with propen- sity score matching. I hypothesized that contracting-out to NGOs leads to higher performance relative to contracting-in with CHDs, that performance-based contract- ing incentivizes health workers, hence PBC counties have higher utilization relative to non-PBC counties. Results are not as straightforward; there are no significant differences in the double differences for ANC 4th visits, health facility deliveries, DPT 1, DPT 3 and diarrhoea and PBC had no effect on utilization. ii Thesis Committee Primary Readers Antonio J. Trujillo (Primary Advisor) Associate Professor Department of International Health Johns Hopkins Bloomberg School of Public Health Gerard Anderson (Thesis Chair) Professor Department of Health Policy and Planning Johns Hopkins Bloomberg School of Public Health Krishna Rao Associate Professor Department of International Health Johns Hopkins Bloomberg School of Public Health Mary E. Hughes Associate Scientist Department of Population and Family Health Johns Hopkins Bloomberg School of Public Health Alternate Readers Janice Bowie Professor Department of Health Behaviour Johns Hopkins Bloomberg School of Public Health Courtland Robinson Associate Professor Department of International Health Johns Hopkins Bloomberg School of Public Health iii Acknowledgements I would like to extend my gratitude to the Ministry of Health, Republic of South Sudan without whom this work would not be possible. Specifically, Dr. Samson Baba, Dr Alexander Dimiti and Dr. Richard Laku, who not only encouraged me to undertake this evaluation but also wrote letters of recommendation when I was applying to graduate programs. Dr. Laku was kind enough to extend access to the District Health Information System (DHIS) database which underpins this research. Dr. William Clemmer and Dr. Mounir Lado from IMA World Health provided key project documents. Special thanks to Dr. Clemmer for his continuous en- couragement, feedback and guidance with the initial proposal and throughout this process. I would also like to extend my thanks to Mr. James Amum, from the County Health Department (CHD) in Manyo who was kind enough to provide CHD contract documents. Dr. Augustino Ting Mayai who gave critical feedback to the initial draft of this thesis – which meant many more days of additional analysis, but without which this thesis would be weaker.You all significantly extended the scope of this work, and as a result, I was able to improve on the third paper. To my colleagues over the years in South Sudan, Drasiga, Amule, Nellie, Keji, Trueman, Juac, Fadil, Ibra, Koma, Dr Kenyi, Dr.Edward, and so many others. You enriched my time in South Sudan. See you soon! To Dr. Felix Loro Lado, who taught me what it means to be passionate about the work that we do, to always keep in mind the people whom we serve, and to passionately advocate for the least among us. I will be forever grateful for the lessons you taught me, Dr. Felix. You were always the best of us, travel well to the ancestors. May you rest in peace. To my colleagues at the Dept. of International Health and the Dept. of Health Policy, and specifically Ashley Sheffel, Ilona Varallyay, Amy Margolis, Jaya Gupta, Katharine Shelley, Dolapo Fekeye, Jean Oliver, Prof. Darrel Gaskin, Felicia Roane, iv Prof. Janice Bowie, Prof. Courtland Robinson, without whom my academic expe- rience would have been less rewarding. Cristina Salazar who was a strong advocate on my behalf. Thank you so much! My social support network during my time in Baltimore; Judy Njuguna, Camille Brown, Deryck Pearson, Susan Aura, Patrick Huntley, Sarah Michaels, Alonzo Howard. My Mt. Vernon crew; Alex Egner and Willa, meadow, Noah Patterson, Grace Smith, Marta Spangler. My home will always be your home. My cousins, Lalam, Orlando and Chacha. You have always been there through- out all the good and the bad. I appreciate you all. Alsarah- I am so proud of you and always in awe of your awesomeness. Your friendship means the world to me. My thesis committee; Profs. Gerard Anderson, Krishna Rao and M.E. Hughes. Thank you for your feedback and support. I am lucky to have had you as part of this process. Special thanks to my thesis chair, Prof Anderson, for the extensive and crucial feedback, guidance, for making time to meet with me starting from when I first wrote the proposal, to the thesis. I aspire to be likeyou. Last but not least- and it is hard to express my gratitude in words- my advisor, Prof. Antonio Trujillo. I consider you a friend and more importantly, a mentor. I have learned so much from you, you inspired me to think outside the box, you pushed me to be a better researcher, to take classes outside of the School of Public Health, you always made time to meet with me, and you shaped this thesis into what it is. The best decision I made was to ask to be your advisee. I hold the advice you give- to always ensure that your work is accessible, "so that my grandmother can understand" and "always remember that the method is the servant not the master" very close to my heart. This thesis is dedicated to the women and children of South Sudan. v Table of Contents Abstract . ii Thesis Committee . iii Acknowledgements . iv List of Figures . vi List of Tables . vi Introduction 1 1 Paper 1: Rebuilding health-systems to improve maternal and child health in post-conflict countries. 12 1.1 Introduction . 12 1.2 Background on South Sudan . 17 1.2.1 Pre-Conflict and Conflict . 18 1.2.2 Effect on the health system . 21 1.3 The Comprehensive Peace Agreement transition period . 24 1.3.1 Establishing a health system in the transition period . 25 1.3.2 Basic Package of Health and Nutrition Services (BPHS) . 26 1.3.3 Health and demographic indicators . 30 1.3.4 Summary of the transition period . 35 1.4 Post-Independence Period . 36 1.4.1 Contracting out Intervention in South Sudan . 37 1.5 Methodology . 42 1.5.1 Outcome measures . 42 1.5.2 Data Source(s) . 44 1.6 Empirical Strategy . 47 1.7 Results . 50 1.7.1 Maternal health . 50 1.7.2 Child health . 62 1.8 Conclusions . 71 1.9 Appendix . 80 2 Paper 2: Does contracting-out of primary health care services to Non-State Providers reduce child mortality in South Sudan? A vi synthetic control analysis 88 2.1 Introduction . 88 2.2 Background . 90 2.2.1 Theoretical Framework . 90 2.2.2 Contracting-out . 92 2.2.3 Effect heterogeneity . 93 2.2.4 Previous Literature . 95 2.3 Empirical Strategy . 98 2.3.1 Synthetic Control Method . 99 2.3.2 P-values and inference . 100 2.3.3 Data sources and measurement . 101 2.3.4 Sample specification . 102 2.4 Results . 106 2.4.1 Synthetic control analysis . 106 2.4.2 Robustness checks . 112 2.5 Conclusions . 115 2.6 Appendix . 122 2.6.1 Synthetic Control Analysis . 122 2.6.2 Robustness test results . 123 3 Paper 3: Contracting primary health care services in South Sudan: Does type of contract matter? 125 3.1 Introduction . 126 3.1.1 A brief history of contracting . 132 3.1.2 History of contracting in South Sudan . 136 3.2 Contracting in Jonglei and Upper Nile States . 140 3.2.1 Contracting-out with NGOs: C-O (NGO) Contracts . 142 3.2.2 Contracting-in with CHDs: C-O (CHD) Contracts . 145 3.2.3 Performance-Based Contracting (PBC) . 147 3.2.4 Monitoring and evaluation (M&E) . 147 3.2.5 Contract duration and early termination . 149 3.3 Methods . 150 3.3.1 Data Sources . 150 3.4 Empirical Strategy . 153 vii 3.4.1 Difference-in-Difference Estimator with propensity-score match- ing................................. 155 3.5 Results . 156 3.5.1 Unadjusted means .