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

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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 (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

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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 State and , 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.

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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 .

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

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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 the time of the visit (attached as Annex E).

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Limitations of the Tool Not all monitoring requirements can be covered by TPM. The tools were not designed to collect Quality of Care information and to assess specified norms and standards of service delivery. Rather, the focus was on availability of services. While IOM endeavored to ensure a level of accuracy when collecting technical data, by having a nurse undertake the clinical facility assessment checklist tool, the analysis was conducted by non-medical staff. Assessing Quality of Care is beyond the scope of IOM’s TPM activities. Service delivery was assessed on the basis of word of mouth through the key informant interview with health staff and triangulated with direct observation and focus group discussions with community members. However, IOM did not directly observe any outreach activities, and therefore this type of activity was reported based on findings from the data collection tools. IOM relied on NGOs/ IPs to coordinate and mobilize a gender-balanced group of community members to take part in FGDs. This may have limited the objectivity of the findings from the FDGs, due to the selection process.

Sample The original intention was to verify thirty percent of all the health facilities presented in the list obtained from UNICEF in October 2018. The planned sample included thirty-two health facilities in twelve Counties in former Upper Nile State, and thirty-six health facilities in twelve Counties in former Jonglei State (please see Annex F). The RRHP funding mechanism for TPM activities will be integrated into the next phase of RRHP and will not be undertaken by IOM; therefore, this report presents the findings of data collected from the verification and monitoring of 27 health facilities in former Upper Nile State (constituting 85 percent of the planned sample) and 22 health facilities in Jonglei State (constituting 61 percent of the planned sample) (please see Annex G). Field level data collection took place between November 2018 and May 2019. A non-probability convenience sample was selected due to the current security situation, which severely limited access to certain areas. IOM endeavored to take all necessary steps to ensure that health facilities in In-Opposition (IO) controlled areas were contained in the sample. However, certain health facilities were located in IO controlled during the initial sampling stages, but these areas were later reclaimed by the Government during the period of field-level data collection. This was the case in , former Upper Nile State, whereby IOM had selected three health facilities to verify that had originally been located in IO controlled areas. At the time of the verification mission, Fashoda was under Government control. This notwithstanding, the sample contains a combination of Primary Health Care Units (PHCUs), Primary Health Care Clinics (PHCCs) in both Government and IO controlled areas.6

Demographics

6 IOM selected health facilities based on the current security situation as per UNDSS guidelines and IOM’s internal security updates. IOM constantly monitored the security situation, which in some cases resulted in adjustments and changes to the proposed sample. For example, IOM preferentially selected health facilities in IO controlled areas in April and May 2019 in order to attain a balanced sample of IO and GO controlled areas.

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In total, IOM verified 49 health facilities currently being managed by 10 Implementing Partners; 27 in former Upper Nile State and 22 in Jonglei. 21 health facilities were located in government-controlled areas, and 28 health facilities were verified in IO controlled areas, encompassing 43 percent and 57 percent of the total verified sample respectively. IOM verified two County Hospitals (CH) in Upper Nile State which were excluded from the final analysis as the sample lacked CHs in Jonglei for comparison; therefore the total number of health facilities in former Upper Nile State was 25 health facilities.Please see the dashboard attached as an annex for a detailed breakdown of demographics.

TPM Challenges IOM faced the some challenges during the data collection process; however, they did not significantly impact upon the overall objective of the project. 1. The distance between locations in hard-to-reach areas impacted upon IOMs ability to verify some of the originally proposed health facilities. Furthermore, the rainy season rendered some locations inaccessible during certain times of the year. IOM had accounted for these factors in the design of the project, though accessing locations located in the Sud (northern Jonglei) was particularly challenging due to the swampy terrain and IOM was therefore unable to visit those health facilities that required access by charter flight. 2. UNICEF was awarded the PIU contract from the World Bank commencing in June 2018. However, the initial contract ran for three months, so – in the early stages of the TPM verification visits – it was difficult to assess the coordination of IPs with UNICEF as the project was still in the early phases of establishment. 3. Accessing health facilities in in IO controlled areas was particularly challenging for the IOM teams, which were required to seek permission from multiple local authority departments, as there is no central authority in Ulang. Furthermore, authorities in Ulang were suspicious of IOM’s activities and sent a minder to accompany the team during the verifications. This was not the case in County where local authorities were cooperative and facilitative.

3. Findings 4.1: Service Delivery The RRHP is relevant to the National Health Policy 2016 – 2026, Policy Objective 1: Service Delivery – to strengthen health service organization and infrastructure development for effective delivery of the Basic Package of Health and Nutrition Services (BPHNS) and Universal Health Coverage. According to the Ministry of Health’s BPHNS guidelines, a PHCU is defined as a frontline health facility staffed by three health staff – two health workers and a community midwife – that offers basic preventative and curative services and health promotion; antenatal care, normal deliveries and family planning; curative care for common diseases; diagnosis and treatment of simple cases; first aid trauma; home treatment and outpatient care; and training activities. The main differences between PHCUs and the PHCCs are the staffing levels: PHCCs are required to have qualified health professionals, availability of a diagnostic laboratory, and a 24-hour basic emergency obstetric and neonatal care, including an observation ward.

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IOM’s assessment of provision of basic service delivery included the availability of Maternity services (antenatal care & postnatal care); Family Planning and Condom Distribution; Basic Curative Services (treatment of malaria, acute respiratory infections, diarrhea, tuberculosis and HIV); Child Health immunizations and vitamin A supplementation; information, education, and communication (IE&C) materials for behavior change; outreach activities; and home-based care. To enable comparison, the two County Hospitals in Government controlled areas that IOM verified in the sample were excluded from the analysis as there were no equivalent health facilities verified in IO areas. Comparison of Basic Service Delivery in South Sudan in In-Opposition & Government Controlled areas. Overall, a larger proportion of health facilities located in GO controlled areas provided services than those located in IO controlled areas, with the exceptions of basic curative services, whereby 82 percent of the sampled health facilities in IO controlled areas were providing these services compared with 74 percent from GO controlled areas. In addition, 18 percent of health facilities in IO controlled areas offered home- based care provision, compared to 16 percent of health facilities in GO locations. An equal percentage of health facilities in IO and GO controlled areas had on-site IE&C materials for behavior change (32 percent). Maternal services were provided in substantially more health facilities in GO areas when compared with IO controlled areas, at 95 percent and 54 percent respectively, whilst for health facilities offering outreach activities, the respective percentages were 79 percent in GO areas and 36 per cent in IO locations. A higher percentage of health facilities in GO locations were providing child health immunizations (84 percent) and vitamin A supplementation (79 percent), against 54 percent for both measures in IO areas. A graph comparing Basic Service Delivery in GO and IO locations is below:

Percentage of HFs Offering Services in IO vs GO Locations

16 Home Based Care 18

32 IE&C Materials 32

79 Outreach Activities 36

37 Family Planning 11

79 Child Health vit A supp 54

84 Child Health Immunizations 54

74 Basic Curative Services 82

95 Maternal Services 54

0 10 20 30 40 50 60 70 80 90 100

GO IO

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Comparison of Health Facilities with Presence of Diagnostic Kits and Vaccine Antigens in IO vs GO Controlled Areas Proportionately, health facilities in GO areas were better stocked with diagnostic kits and vaccine antigens, including BCG, Measles, Polio, Penta, Tetanus and Vitamin A, with 89 percent of health facilities in GO controlled areas having sufficient supplies of diagnostic kits, and 53 percent having antigens available. A total of 79 percent of health facilities surveyed in IO controlled areas maintained diagnostic kits onsite, while 36 percent kept vaccine antigens available at the health facilities.

Percentage of HFs in GO & IO controlled areas that have Diagnostic Kits and Antigens 100

80

60

40

20

0 IO GO

Available diagnostic Kits Antigens

Comparison of Health Facilities with basic equipment present in IO vs GO Controlled Areas IOM assessed the presence of available and functioning equipment in the health facilities at the time of the verification mission. IOM used specific categories for the assessment, including basic clinic equipment and diagnostic tools; basic maternity equipment; basic equipment for family and child health; and basic equipment for immunizations. IOM subsequently calculated the number of basic equipment indicators into categories of all, most, some and no equipment available (see annex A for the full list of equipment assessed). Basic Clinic Equipment: Health facilities assesed in GO controlled areas were better equiped than those in IO controlled areas. This notwithstanding, very few health facilities had all the basic equipement assessed in the checklist, at only 5 percent of health facilities in GO controlled areas and none of the health facilities in IO controlled areas. Basic Equipment for Maternity: None of the health facilities sampled had all basic equipment in the checklist necessary for maternity service provision. Twenty-one percent of health facilities in GO controlled areas had most of the basic equipment, compared with 18 percent in IO controlled areas. Sixty- three percent of health facilities in GO controlled areas had no basic equipment, as against 75 percent in IO controlled areas.

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Basic equipment for immunizations: In GO controlled areas, 42 percent of health facilities surveyed had basic equipment for immunizations, compared with 32 percent in IO controlled areas. Twenty-one percent of health facilities in both GO and IO controlled areas had no equipment for immunizations onsite at the time of the verification. 4.2: Health Facilities delivering Basic Services in Government Controlled Areas The majority of the health facilities observed were offering basic services, but lacked basic equipment, diagnostic kits, and sufficient supplies of all drugs to support adequate delivery of basic health services. There were no major observable differences in provision of basic services between PHCUs and PHCCs, with the exception of those health facilities supported by other INGOs. For example, Town PHCC receives assistance from multiple INGOs, including ICRC (17 onsite staff members) and World Vision. IOM verified a total of nineteen health facilities in GO controlled areas in Upper Nile State (Renk; Melut; ; Fashoda; and Balliet Counties) and Jonglei State (). All of the health facilities surveyed in GO controlled areas had staff on-site at the time of the visit, with the exception of Balliet PHCC in Balliet County, Upper Nile State. The health facility was deserted at the time of the visit and health staff had to be called from the town. Health staff reported that Balliet PHCC employed 30 staff members, of which IOM was able to physically verify 9. Other instances of discrepancies between reported staffing numbers and visible staff on-site included Akoka Town (eight reported but only five on-site) and Anakdiar (ten reported but only four on-site). While health facilities in were sufficiently staffed (121 health staff in total), it was reported to IOM that most are unskilled because incentives offered are too low to attract qualified and experienced staff. Maternity Services: A total of 13 out of 19 (68%) health facilities surveyed in GO controlled areas offer maternity services. Of the 13 health facilities offering onsite deliveries – encompassing nine PHCCs and four PHCUs – four had onsite handwashing facilities, while only two had handwashing facilities and soap and water in the delivery room. Eight out of 13 had clean delivery rooms with delivery beds in a good state and sterilized delivery packs available, though only three facilities had equipment available for newborn care. Trained Birth Attendants (TBAs) were supporting home births in the community in Balliet County due to a lack of beds in the PHCC. Seven health facilities provide family planning services and distribute condoms, but only two have family planning methods available and visible in demonstration boxes or charts. Community members in Bor County reported that the poor uptake of condom can be attributed to condom use not constituting a common practice amongst community members. Basic Curative Services: Fourteen out of 19 (74%) health facilities surveyed offer basic curative services, but only six had all the basic equipment onsite and functioning. Just over half (11 of 19) of facilities had all diagnostic kits present at the facilities, while four had some diagnostic kits but not all. Child Health immunizations: A total of 16 health facilities surveyed offer child health immunizations, while 15 offer those services with vitamin A supplementation. Eight had antigens available onsite, while 11 had cold chain vaccine carriers. Half of those health facilities offering child health immunizations had infant weighing scales, and 13 had syringes available.

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Only two out of the sixteen health facilities, both PHCCs situated in and Makuac Payams, Bor County, were highly functioning as regards the provision of child health immunization. At these PHCCs, IOM observed available and functioning equipment to support immunizations, namely syringes, sharp boxes, infant weighing scales, onsite and visible EPI graph and schedule, as well as EPI reference materials. Furthermore, both health facilities had cold chain vaccine carriers and an available stock of antigens and were properly managing their stock outs with up-to-date vaccine order forms and > 5 health cards completed for patients. In the absence of a cold chain, health facilities will use vaccine carriers with ice packs supplied by the IP during immunization campaigns. Outreach: Fifteen of 19 (79 per cent) health facilities surveyed were conducting outreach activities, though only four out of these health facilities do so using IE&C materials. Three of the 19 health facilities were verified to be providing home-based care. HMIS Reporting: Seventeen of the 19 (89 per cent) health facilities are producing HMIS reports, as well as monthly Integrated Disease Surveillance and Response (IDSR) reports. However, only four health facilities use patient cards to collect primary data, and six have a trained data clerk working at the health facility. None of the 17 health facilities producing HMIS reports have enrollment graph targets versus achievements. The majority of health facilities in GO areas (16/19) had ANC/ PNC registers, while 12 record patient data onto ANC cards. While almost all health facilities verified were producing HMIS reports, the quality of data recorded varied significantly across the health facilities. For example, IOM noted in Balliet that data recorded into the patient registers was not disaggregated by gender. Access to Health Facilities: Focus group discussions were undertaken with community members in Bor County, Jonglei State and Melut County, Upper Nile State to elicit community feedback regarding accessibility and general availability of services and drugs at the health facilities. Community members in both areas generally live within one-hour of the health facilities, rendering these facilities accessible in both the rainy and dry seasons. Specific accessibility challenges noted from the respondents included the challenges for pregnant women and malnourished children to reach health facilities. One respondent in Melut County noted some incidences of child abductions while en route to the clinic, though IOM was unable to verify this. Respondents were generally satisfied with the services they received from the clinic, but did report occurrences in which drugs were unavailable at the clinics. Child immunizations were reported as constituting the most utilized services in Melut. Respondents reported the presence of a health worker at the health facility upon a visit, with an average of two to three visits undertaken in the last three months. Community members were aware of outreach activities being conducted in communities, mostly in the form of house-to-house visits for vitamin A and other vaccinations, and a nutrition outreach to identify malnourished children in the community. FDG respondents in Melut reported that no health worker had visited them at the household level in the previous twelve months, and that they had not been consulted on any health related issues or attended any community health related meetings in the previous twelve months.

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Field Observations: Many of the health facilities verified in GO controlled areas had issues with the physical infrastructure of the buildings. These ranged from small wall cracks to large structural floor cracks. Pest infestations were observed throughout in the pharmacy and patient wards in health facilities in Akoka Town, Baliet, and Malakal. In some health facilities, roofs were at risk of collapse from damp resulting from water leakages. One room in the health facility in Balliet was infested with bats and thus unusable. Health facilities surveyed in Malakal Town were missing portions of the roof and temporary rooms had been erected in the health facility grounds in which to store medicine. While the majority of the health facilities had toilet facilities onsite, almost all of them were not functioning. During the visit to Melut County, the IP reported that one of the health facilities was currently engaged in a dispute with an oil company in Melut, which were trying to relocate the health facility to a different location, leading to a standoff between community and the companies. Water and electricity services had been restricted to the health facility, affecting service provision.

4.3: Health Facilities Delivering Basic Services in In-Opposition Controlled Areas IOM verified 28 health facilities in IO controlled areas covering former Upper Nile State (Tonga and Ulang Counties) and Jonglei State (; Fangak Counties), of which 15 were PHCUs and 13 were PHCCs. The majority of the health facilities were functioning in IO controlled areas, with the exception of two health facilities – in Ulang County, Upper Nile State, and , Jonglei – in addition to one health facility only partially functioning in Tonga County, Upper Nile State. The PHCU in Wangchoat, Fangak County, Upper Nile State, had been abandoned for three months prior to IOMs verification mission. In addition, the Doma PHCU in Ulang County, Jonglei State had been looted on 12 2019, and the community surrounding Doma PHCU had left the area due to insecurity from armed clashes in surrounding areas. The area was still abandoned during IOMs visit on 12 April 2019. Maternity Services: 15 out of 28 (53%) health facilities in IO controlled areas offer maternal services, including ANC and PNC, whilst 4 offer only ANC services. Family planning and condom distribution is offered in 2 of the 28 health facilities. Basic Curative Services: 23 of the 28 (82%) health facilities provide basic curative services, including treatment of malaria, acute respiratory infections, diarrhea, tuberculosis, and HIV. In Ayod, Pagil PHCCs offer inpatient and nutrition services, and deliveries are conducted in the facility, while PHCUs refer difficult cases to the PHCCs. Deliveries are not conducted in PHCUs, but in communities. A total of 22 of the health facilities surveyed had diagnostic kits available onsite, but 7 of which had only some of the diagnostic kits available. Child Health immunizations: 15 of the health facilities surveyed provide child health immunizations. Immunizations are given along with vitamin A supplementation, while 7 health facilities provide only vitamin A supplementation and no child health immunizations. A total of fourteen of the health facilities have cold chain storage either in the form of a functional fridge or vaccine carriers. A total of ten health facilities have antigens available onsite, though four stock only a few antigens and not all. A total of thirteen health facilities have syringes available at the health facility to administer vaccines and sharp boxes for correct disposal. Only four health facilities had EPI reference materials and policies onsite, as well as EPI graph and schedules, and none had enrollment graph targets versus achievements. In both

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Ayod and Longechuk, PHCCs conduct immunization from Monday to Friday, while no Immunization has taken place in PHCUs since November 2018. Outreach. 10 out of 28 (35%) health facilities offer outreach activities, nine of which using IE&C materials. Five support home-based care in the communities. HMIS Reporting: Twenty of the health facilities verified were producing HMIS and monthly reports. Of the eight health facilities that do not produce HMIS reports, two are in Jonglei and six are located in Upper Nile State.7 Two of the health facilities that do not produce HMIS reports do complete monthly reports. None of the health facilities verified in IO controlled areas have staff members who are trained data clerks. A total of eleven health facilities utilize patient cards to record patient level data including ANC/PNC patient cards. Eleven have ANC/PNC registers onsite, though these are used for ANC visits only in four of the facilities. Thirteen health facilities stock and use < 5 health cards to record patient data. Access to Health Facilities in IO Controlled Areas: Access to health facilities in IO controlled areas in Upper Nile State and Jonglei is not considered problematic by focus group respondents, with community members typically walking between 1 - 3 hours to access the nearest health facility. The only location that has access challenges was Fangak County in Jonglei, as it is situated in the Sud, which is typically swampy with multiple river tributaries running through the region. Communities on the opposite river bank to the health facilities are therefore required to cross the river for access, which is at times impassable in the rainy season. A skilled health worker is generally present to attend to patients and overall, patients expressed satisfaction with the services they are receiving. Outreach activities were reported in all of the areas IOM accessed during the verification mission. IOM conducted a FGD with community members in Ayod and Fangak Counties in Jongeli State and Ulang County in Upper Nile State. In Ayod, respondents noted that most community members live within a 1 - 3 hour walk of the nearest health facility. On the whole, services were viewed as satisfactory, though respondents reported that Pagil PHCC does not offer TB services and lacks an on-site maternity ward. Community Health Promoters are active in the community and raise awareness on TB, Cholera, ANC, and malnutrition. Accessing the health facilities is more challenging in Fangak due to the swampy terrain in the Sud, as described above. Respondents were satisfied overall with services received from the health facility and were attended to by a skilled health care worker. Outreach campaigners in Fangak County were active and typically conducted EPI, polio, and measles campaigns. Community members were consulted by CMA (the IP) regarding service provision in the health facility. Field Observations: In Ulang County, there was no discernable difference between the services offered by PHCCs and PHCUs. This may be attributed to the fact that most of the facilities are located far away from one another, somewhat precluding referrals. PHCUs in Ulang were providing onsite delivery services, which are not typically offered at the PHCU level, and were well stocked with major drugs (typically a six- month supply) and testing kits. All PHCUs verified had at least three separate rooms with delivery beds.

7 Jonglei State: Wangchot PHCU, Fangak County; Ayod PHCC, . Upper Nile State: Kuich PHCU, Doma PHCU, Ulang County; Belway PHCU, Warweng, PHCU, Majok PHCU and Pamach PHCU in .

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In Fangak County, PHCCs are far better equipped than the PHCUs in terms of service delivery. Most of the PHCUs have single rooms with limited space that are utilized for ANC, drug dispensing, and consultations. While IOM noted the presence of bat infestations in some of the health facilities in Jonglei, Ulang PHCC was highly functioning, with a well-organized pharmacy; sufficient stocks of drugs for six months; availability solar power; two large fridges stocked with vaccines and antigens; clean and fenced compound; and a equipped waiting space for patients. However, despite its capacity, Ulang PHCC was not conducting deliveries on-site, as it refers expecting mothers to the nearby MSF-run hospital. Although the physical structure was sound, the health facility had a bat infestation in the pharmacy. In Fangak County, one of the health facilities was not operational and had never been visited by the IP (CMA). Boum PHCU was housed in a one room temporary structure made of grass thatch. Although the room was clean, the health facility lacked space for treatment and had no waiting area. Wanglel PHCU was the only health facility in Fangak with an operational incinerator, housed in a two-room concrete structure. In Tonga Payam, Panyikang County, finding sufficient numbers of health staff to supply health facilities in hard-to-reach locations is challenging, as villages often do not have adequate accommodation for health staff sent from bigger towns. The County Commissioner of Tonga reported that health facilities had not been supported since prior to the conflict in 2016, which was corroborated by health staff at Tonga PHCC. There is no County Health Department (CHD) for Panyikang County (most are Malakal-based) and no QoC supervision visits had been conducted at the time of IOM’s verification visit in Tonga. Furthermore, there is no phone network coverage in Panyikang County.

4.4 Presence of IPs on the Ground GO controlled areas: Health Link currently maintains a limited presence on the ground and lacks adequate transportation to ensure regular oversight takes place at the 13 Health Facilities under its management. International Medical Corps (IMC) has a well-established presence in Malakal and conducts regular visits to each of the three health facilities under its management. Regular supervision of health facilities in Kodok Town is undertaken by CORDAID staff, but support to rural health facilities is limited to phone calls or the occasional visit to accessible health facilities located close to the river. CORDAID highlighted a lack of transportation, both land and water, and lack of human resources to physically travel to health facilities in Fashoda, which are often in hard-to-reach locations. Sudan Medical Care (SMC) is currently the implementing partner in Bor County, with 24 health facilities in Bor South under their portfolio. SMC has two project vehicles to access health facilities, but reported a number of accessibility challenges, particularly during the rainy season when roads become impassable due to flooding. This has reportedly lead to delays during delivery of drugs. SMC conducts monthly supervision missions at each health facility in coordination with UNICEF and Bor County CHD; at the time of the interview, UNICEF had last conducted a supervision mission in August 2018. World Vision (WV) is managing seven health facilities in Melut County, former Upper Nile State. WV has a strong presence on the ground in Melut County and visits each of the seven health facilities twice per week on average. World Vision is also implementing partner for three health facilities in Renk Counties,

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Upper Nile State. CHD, in coordination with World Vision ,conducted supervision visits to Renk Civil Hospital in January 2019, Jerbana PHCU in February 2019 and Abukhardra PHCU in March 2019. IO controlled areas: Christian Mission for Development (CMD) is the implementing partner for 15 health facilities in Ayod County, former Jonglei State. CMD has been IP since July 2018 under the current RRHP project. The last supportive supervision visit took place in March 2019 in Ayod. UNICEF and CHD have undertaken regular supervision mission to health facilities in Ayod. No supervision visits had been conducted in Kandak PHCU at the time of the verification, while staff at Normanyang PHCU reported that the Clinical Officer (CO) at the health facility is currently conducting supervision visits. Health Link (HL) is currently managing two health facilities in Panyikang County, namely Tonga PHCC and Oweici PHCC. Health Link has two full time staff based in Malakal. There is provision in the current budget for transport for HL staff to access the health facilities. Though HL recently purchased a vehicle, health facilities in Panyikang County are only accessible by boat. Since December 2018, when UNICEF added two additional health facilities to HL’s portfolio, HL had visited both health facilities in Panyikang County once. There is no network coverage in Panyikang County and no County Health Department Representative. Furthermore, health facilities in Panyikang have received little support since 2013 and no quarterly supportive supervision visits have taken place. UNKEA has three health facilities in Ulang County under its supervision. They reported that there is no budget allocation for transport, which hinders their ability to transport drugs to the health facilities. UNKEA also reported issues with local authorities, including being barred from accessing certain areas for security reasons. UNKEA visits the PHCCs on a daily basis and PHCUs weekly. The last supervision visit conducted to health facilities under the management of UNKEA was undertaken in January 2019 by UNICEF and Ulang CHD. SSAID manages four health facilities in Ulang County, Upper Nile State. They typically hire boats to access health facilities along the river. The IP reported that the last supervision mission to take place in Ulang County was in January 2019, which was conducted by UNICEF and Ulang CHD. The IP noted that the local authorities sometimes hinder operations, which is in line with the challenges IOM faced in Ulang County when undertaking TPM activities.

4.5: Pharmaceuticals

The Drug Supply Chain GO controlled Areas: IPs are responsible for collecting drugs from a central point, namely a town centre, delivered by UNICEF and distributing the drugs directly to each of the health facilities under their management. Since July 2017, IMC has received one shipment of drugs from UNICEF in October 2018, for each of the three health facilities assessed. Health Link received a shipment of drugs for Akoka health facility in early November and mid-November for health facilities in . CORDAID received a shipment of drugs on 7 November 2018. However, at the time of the verification mission in Kodok Town on 13 November 2018, only two of the 14 health facilities had received their quota of drugs. Only Malakal

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Teaching Hospital PHCU placed an order for emergency drugs in the six months prior to the verification exercise. In Bor County, former Jonglei State, SMC received a drug shipment in February 2019. At the time of the verification, Health Link had last received drugs from UNICEF in October 2018 and had completed delivery to all health facilities under their portfolio in GO controlled areas in Upper Nile State. At the time of IOM’s second verification, the organization had purchased a vehicle to cover health facilities in Baliet County and were in the process of hiring boats to access Panyikang County. Under IMA, the CHD of Melut County received drugs 1-2 times per year. World Vision received a shipment of drugs from UNICEF in November 2018. UNICEF sends an email to WV and CHD to notify that the shipment is forthcoming. Each health facility has its own box of drugs with individual records of drugs. WV then delivers the drugs to CHD, where they are stored in CHD’s storeroom located in the Goal compound next to their office. They are not delivered to individual health facilities. Responsible authorities of each health facility have to request drugs as they are needed and do not store their own shipment of drugs in the health facilities. IO Controlled Areas: CMD reported they had received a shipment of drugs from UNICEF on 12 March 2019 and distribute to all 15 health facilities under its supervision takes approximately two weeks on average. In July 2018, during the transition from IMA to UNICEF, CMD stated that the health facilities under their portfolio had run out of essential drugs. Health Link had only visited Tonga PHCC one time to deliver drugs. IOM did not visit Oweici PHCC, so is unable to verify the claim that they have visited monthly since July. Health Link reported multiple challenges when accessing Panyikang County, including multiple checkpoints at which health Link staff have been harassed by IO soldiers and questioned as to why drugs are not supplied to all health facilities under IO control. SSAID reported that they receive drugs twice per year, with the most recent shipment arriving in March 2019 from UNICEF. Delivery of drugs to health facilities generally takes two days, which is reasonable given the small number of health facilities under their management. UNKEA received drugs on a quarterly basis and last received a shipment of drugs from UNICEF in December 2018. They hire speedboats for the purpose of delivering the drugs, with full distribution taking on average four days. Availability of Tracer Drugs IOM assessed the availability of fourteen tracer drugs8 in 29 health facilities in Upper Nile State (Ulang County and Renk County) and Jonglei State (Ayod, Fangak and Longechuk Counties). The Tracer Drug Checklist was added to the TPM toolkit in March, so IOM was unable to capture the difference between availability of tracer drugs in health facilities in GO areas compared with those in IO controlled areas (see Annex E for a detailed breakdown of available tracer drugs per health facility). The checklist assessed the availability of the following drugs: amitriptyline, amoxicillin, atenolol, captopril, ceftriaxone, ciprofloxacin,

8 WHO Global list of medicines included in WHO/HAI surveys, 2010, https://www.who.int/healthinfo/systems/WHO_MBHSS_2010_full_web.pdf

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co-trimoxazole, diazepam, diclofenac, glibenclamide, omeprazole, paracetamol, salbutamol, and simvastatin. A total of 28 of the 29 health facilities verified had stocks of amoxicillin, paracetamol and co-trimoxazole. None of the health facilities had amitriptyline, atenolol, captopril, diazepam, glibenclamide, omeprazole and simvastatin. Eighteen kept ciprofloxacin onsite, and fifteen had stocks of diclofenac. A total of 12 health facilities stocked salbutamol, whilst one health facility stocked ceftriaxone. South Sudan has five specific essential drugs including: dexamethasone, charcoal, albendazole/ mobendazole, tetracycline eye ointment and gentamicin injection. Please see annex H for the full breakdown of available drugs at the clinics where IOM completed the drug checklist.

Availability of major drugs in the Health Facilities 30 Amitriptyline 28 28 28 25 Amoxicilin Atenolol 20 Captopril 18 Ceftriaxone 15 15 Ciprofloxacin Co-trimoxazole 10 12 10 Diazepam

5 Diclofenac Glibenclamide 0 Omeprazole Paracetamol Salbutamol

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