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Third Party Monitoring of the World Bank Rapid Results Health Project Final Report

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Third Party Monitoring of the World Bank Rapid Results Health Project Final Report 1 / 17 Abbreviations BPHNS: Basic Package of Health and Nutrition Services CH: County Hospital CHD: County Health Department CMA: Christian Mission Aid CMD: Christian Mission for Development CO: Clinical Officer CPA: Comprehensive Peace Agreement FGD: Focus Group Discussions GO: Government GoSS: Government of the Republic of South Sudan (GoSS) HL: Health Link HPF: Health Pooled Fund IMA: IMA World Health IMC: International Medical Corps IO: In-Opposition IOM: International Organisation for Migration IP: Implementing Partner KII: Key Informant Interview LGSDP: Local Governance and Service Delivery Project. MoH: Ministry of Health NGO: Non-Governmental Organisation PHC: Primary Health Care PHCC: Primary Health Care Centre PHCU: Primary Health Care Unit PIU: Project Implementation Unit RRHP: Rapid Results Health Project SGBV: Sexual and Gender Based Violence SMC: Sudan Medical Care SSAID: South Sudan Agency for Internal Development UNKEA: Universal Network for Knowledge and Empowerment Agency WB: World Bank WV: World Vision TPM: Third Party Monitoring 2 / 17 Executive Summary and Findings 1. Introduction The World Bank’s portfolio for South Sudan contains a number of International Development Association’s (IDA) investment projects aimed at improving local governance and service delivery. Although the World Bank (WB) has put in place measures to mitigate political security and fiduciary risks, there remains a gap in managing operational risk in terms of monitoring and evaluation of its investment projects in South Sudan following the resumption of armed conflict in 2013. Due to its strong operational capacity and presence in South Sudan, WB contracted the International Organization for Migration (IOM) in June 2018 to implement Third Party Monitoring (TPM) activities of its Rapid Results Health Project (RRHP) currently being implemented in former Upper Nile State and Jonglei State, and the Local Government and Service Delivery Project (LOGOSEED). The objective of the TPM was to undertake third party monitoring of key components within the World Bank’s portfolio, to supplement World Bank implementation support, as well as to provide independent evidence of program implementation. The Scope of Work (SoW) included: (i) liaising with the World Bank staff and the Project Implementation Unit (PIU), managed by UNICEF; (ii) establishing cooperative linkages with Implementing Partners (IPs); (iii) conducting periodic reviews of project activities at decentralized locations; (iv) physical monitoring of project activities in the; (v) to perform evaluation through various procedures including interviews with beneficiaries to ascertain whether project resources have been received by the intended beneficiaries; and (vi) undertake targeted, ad hoc but systematic verification field visits to confirm accuracy of reporting and the delivery of work undertaken by IPs. The findings reflected in this report are focused on RRHP, one of the Bank’s two ‘frontline’ projects. The report presents an overview of the availability of service provision in health facilities in former Upper Nile state and Jonglei state in South Sudan covered under the RRHP. It includes a comparative analysis, where possible, of performance of health facilities located in Government controlled areas (GO) against those in In-opposition areas (IO). The report is organized into three key areas of inquiry: (i) service delivery – including community access and citizen engagement; and (ii) pharmaceuticals. Background An unstable political environment, protracted conflict and displacement, continued economic deterioration and inflation, has created a disabling environment for a well-functioning health system. Access to primary health care (PHC) services continues to be unavailable for a large majority of the population, with an estimated 3,869,574 South Sudanese women, men and children requiring humanitarian health-care services in 2019.1 The conflict has also destroyed the already scarce community infrastructure; more than 50% of health facilities in host communities function at less than 10% of their 1 South Sudan Health Cluster, People in Need (PIN) for 2019. 3 / 17 capacity.2 Moreover, only 56% of the host community has access to primary health care services in these substandard facilities, leaving 44% of the host community without access to health services. Women and children continue to be the most affected from the crisis and it is projected that nearly 600,000 pregnant and lactating women will be acutely malnourished in 2019.3 With high numbers of pregnant and lactating women acutely malnourished, women and children are likely to be more in need of medical services due to lowered immunity as well as at risk of infection due to their responsibilities as caretakers of sick family members. The population suffers from high rates of maternal mortality, neonatal mortality, infant mortality, >5 mortality and a stunting rate of 25 percent. Women and girls are in addition disproportionately impacted by the protracted crisis due to an increase in sexual and gender-based violence (SGBV). Children under 5 years are vulnerable to vaccine-preventable diseases owing to poor nutrition, low levels of immunization coverage, and widespread disease outbreaks. In the first quarter of 2019 alone, there have been confirmed measles outbreaks in Juba, Aweil East, Aweil South, Gogrial West, Abyei, Mayom, Melut, and Pibor.4 In recognition of the poor health status of the population of South Sudan, the Government of South Sudan (GoSS) has developed a National Health Policy for the period 2016 – 2026, alongside accompanying recommendations, which details key health needs and priorities in the country.5 After the signing of the Comprehensive Peace Agreement (CPA) in 2005, the Ministry of Health (MoH) engaged in formal agreements for the management and delivery of health services with a number of Non- Governmental Organizations (NGOs) in certain states. Agreements included contracting out, contracting in, and an arrangement of performance-based contracting to be implemented in former Jonglei and Upper Nile. Since 2012, primary health care has been delivered by the MoH in cooperation with subcontracted NGOs and financed through three programs, as follows: 1. Integrated Service Delivery Project (USAID) covering Western and Central Equatoria. Funds have been pooled with the DFID funded Health Pooled Fund; 2. Health Rapid Results Project (HRRP) – now the Rapid Results Health Project (RRHP) funded by the World Bank covering two states- Upper Nile State and Jonglei; and 3. Health Pooled Fund (HPF) (DFID-led consortium) covering eight states - Eastern, Western and Central Equatoria, Northern and Western Bahr el-Ghazal, Warrap, Lakes and Unity. 2. Methodology IOM used a mixed-methods approach, incorporating both quantitative and qualitative data collection tools, to provide quality assurance relating to key areas of interest. Data was analyzed at the Juba level and findings were triangulated and verified through a desk review of documentation provided by UNICEF, IPs and health facility staff, as well as any other documents collected in the field. The key areas for verification and quality assurance under the RRHP focused on the following: 2 SSHF 2019 First Standard Allocation - Cluster Template, Prioritized Needs, pp.1. 3 South Sudan HRP, 2019. 4 IDSR South Sudan, Epidemiological Update W11 2019 (Mar 17, 2019). 5 The Republic of South Sudan National Health Policy 2016-2026 4 / 17 1. Service Delivery 1.1 Implementation of routine curative services; 1.2 implementation of outreach activities; 1.3 supporting of advocacy activities at community level; 1.4 implementation of immunization activities as part of outreach programs; 1.5 presence of IPs on the ground; 1.6 documentation of coordination activities between IP and PIU; 1.7 review of the Health Management Information System (HMIS) and data management at facility level; and 1.8 documentation of information keeping and management. 2. Pharmaceuticals 2.1 Availability of essential drugs at facilities; 2.2 record delivery of pharmaceuticals; 2.3 documentation of stock outs at facilities; and 2.4 general documentation of medicines stocks. 3 Citizen Engagement 5.1 Assess whether pharmaceutical supplies and health services are getting to the intended beneficiaries. Additionally, IOM collected information on the availability of basic medical equipment and tracer drugs in some of the health facilities. Data Collection tools • Clinical Facility Checklist Tool: developed to assess service availability; health facility services site capacity; and pharmacy and drug stores (attached as Annex A). • Health Facility Staff Questionnaire: designed to determine staffing levels; reporting; supervision; essential drugs; and outreach activities (attached as Annex B). • Key Informant Interview Questions (KII): assessed presence of IPs on the ground and coordination activities between PIU and IPs; receipt of drug shipments and supply chain management of drugs; and supervision mechanisms (attached as Annex C). • Focus Group Discussions (FDGs): were held with community members served by a specific health facility. The FDGs addressed citizen engagement, participation, and verification of outreach activities occurring in the communities (attached as Annex D). • Tracer Drug Checklist: incorporated towards the end of March and designed to check the availability of fourteen tracer drugs in health facilities at
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