Baseline Survey and Needs Assessment for Children and Mothers Partnerships (Champs) Project in Nzara County, Western Equatoria State- South Sudan

BASELINE SURVEY AND NEEDS ASSESSMENT FOR CHILDREN AND MOTHERS PARTNERSHIPS (CHAMPS) PROJECT IN NZARA COUNTY, WESTERN EQUATORIA STATE- SOUTH SUDAN

Submitted to CATHOLIC MEDICAL MISSION BOARD

Prepared by CATHOLIC MEDICAL MISSION BOARD- SOUTH SUDAN

April 2015

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TABLE OF CONTENTS

TABLE OF CONTENTS ...... 2 ACRONYMS AND ABBREVI ATIONS ...... 5 ACKNOWLEDGEMENTS ...... 1 EXECUTIVE SUMMARY ...... 2 CHAPTER ONE: INTRODU CTION ...... 18 1.1 BACKGROUND ...... 18 1.2 CMMB SOUTH SUDAN COUNTRY PROGRAM ...... 18 1.3 MATERNAL AND CHILD HEALTH: THE GLOBAL CONTEXT ...... 19 1.4 MATERNAL AND CHILD HEALTH: SOUTH SUDAN COUNTRY CONTEXT ...... 23 1.5 OBJECTIVES OF THE BASELINE AND NEEDS ASSESSMENT ...... 28 1.6 SCOPE OF THE ASSESSMENT ...... 30 CHAPTER TWO: DATA CO LLECTION METHODOLOGY ...... 31 2.1 HOUSEHOLD SURVEY ...... 31 2.1.1 SURVEY SAMPLING FRAME ...... 32 2.1.2 SAMPLE SIZE DETERMINATION ...... 32 2.1.3 SAMPLING DESIGN ...... 34 2.1.4 SURVEY ENUMERATOR SELECTION AND TRAINING ...... 35 2.1.5 SURVEY TIMEFRAME AND SUPERVISIONS ...... 36 2.1.6 SURVEY DATA ENTRY AND ANALYSIS ...... 36 2.2 KEY INFORMANT INTERVIEWS (KII) ...... 36 2.3 FOCUS GROUP DISCUSSIONS ...... 37 2.4 FACILITY ASSESSMENTS ...... 38 2.5 LITERATURE REVIEW ...... 39 2.6 ETHICAL ISSUES ...... 39 CHAPTER THREE: RESULTS ...... 41 3.0 BACKGROUND INFORMATION...... 41 3.1 HOUSEHOLD POPULATION AND HOUSING CHARACTERISTICS ...... 42 3.1.1 HOUSEHOLD COMPOSITION ...... 42 3.1.2 EDUCATIONAL ATTAINMENT OF THE HOUSEHOLD POPULATION ...... 43 3.1.3 MARITAL STATUS OF RESPONDENTS ...... 46 3.1.4 RELIGION OF RESPONDENTS ...... 47 3.1.5 HOUSEHOLD ENVIRONMENT ...... 47 3.1.6 HOUSEHOLD POSSESSIONS ...... 49 3.1.7 OCCUPATION ...... 50 3.1.8 HOUSEHOLD DECISION-MAKING ...... 53 3.2 FERTILITY LEVELS, TRENDS, AND FAMILY PLANNING ...... 54 3.2.1 BIRTH INTERVALS ...... 55 3.2.2 CURRENT USE OF CONTRACEPTIVE METHODS ...... 58 3.3: MATERNAL HEALTH ...... 63 3.3.1 ANTENATAL CARE...... 63 3.3.1.1. ANTENATAL CARE COVERAGE ...... 63 3.3.1.2 NUMBER OF ANTENATAL CARE VISITS ...... 65 3.3.1.3 COMPONENTS OF ANTENATAL CARE ...... 66 3.3.1.4 TETANUS TOXOID INJECTIONS ...... 67 3.3.2. DELIVERY ...... 68 3.3.2.1 PLACE OF DELIVERY ...... 68 3.3.2.2 DELIVERY ASSISTANCE ...... 70 3.3.3. POSTNATAL CARE ...... 72 3.4: GENDER-BASED VIOLENCE AND CHILD PROTECTION ...... 74 3.4.1 EARLY CHILD MARRIAGE ...... 75 3.4.2 DOMESTIC VIOLENCE ...... 76 3.4.3 SEXUAL EXPLOITATION AND ABUSE ...... 78 3.4.4 ECONOMIC ABUSE ...... 80 3.4.5 CHILD PROTECTION ...... 82 3.5: CHILD HEALTH ...... 84 3.5.1 VACCINATION COVERAGE ...... 84 3.5.2 ACUTE RESPIRATORY INFECTION ...... 85 3.5.3 FEVER ...... 87

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3.5.4 PREVALENCE OF DIARRHEA AMONG CHILDREN ...... 88 3.5.5 KNOWLEDGE OF ORS PACKETS ...... 89 3.6: MATERNAL, NEWBORN AND CHILD NUTRITION ...... 89 3.6.1. NUTRITIONAL STATUS OF CHILDREN ...... 91 3.6.2 BREASTFEEDING AND SUPPLEMENTATION ...... 93 3.6.2.1 INITIATION OF BREASTFEEDING ...... 93 3.6.2.2 EXCLUSIVE BREASTFEEDING FOR 6 MONTHS ...... 94 3.6.2.3 COMPLEMENTARY FEEDING IN CHILDREN ...... 95 3.6.3 MICRONUTRIENT INTAKE AMONG CHILDREN ...... 98 3.6.4 MICRONUTRIENT INTAKE AMONG MOTHERS ...... 99 3.7 MALARIA ...... 100 3.7.1 OWNERSHIP AND USE OF LONG LASTING INSECTICIDE TREATED NETS (LLITNS) ...... 100 3.8 HIV AND AIDS ...... 101 3.9 NON COMMUNICABLE DISEASES ...... 104 3.10 WATER AND SANITATION ...... 106 3.10.1 ACCESS TO SAFE AND ADEQUATE DRINKING WATER ...... 107 3.10.1.1 MAIN SOURCES OF WATER...... 107 3.10.1.2 DISTANCE AND TIME TO WATER SOURCE ...... 109 3.10.1.3 WATER TREATMENT AND STORAGE ...... 110 3.10.2 ACCESS TO SANITATION FACILITIES AND PRACTICES ...... 111 3.10.2.1 HOUSEHOLD LATRINE COVERAGE AND USAGE ...... 111 3.10.2.2: DISPOSAL OF CHILD’S STOOL...... 112 3.10.2.3 HAND WASHING PRACTICE ...... 113 3.11: HEALTH SEEKING BEHAVIOUR ...... 115 CHAPTER FOUR - FINDINGS FROM HEALTH FACILITY ASSESMENT ...... 123 4.1: DESCRIPTION OF HEALTH FACILITIES AND MANAGEMENT ...... 123 4.2: ESTIMATED POPULATION IN HEALTH FACILITY CATCHMENT AREA ...... 126 4.3: FACILITY CAPACITY (BEDS) ...... 127 4.4: FACILITY STAFF RESOURCES AND TRAINING ...... 129 4.5: FACILITY CAPACITY TO PROVIDE SERVICES ...... 133 4.5.1 OVERVIEW OF FACILITY SERVICES ...... 133 4.5.2 SERVICES AVAILABLE DAILY ...... 137 4.5.3 LABORATORY SERVICES PROVIDED ...... 139 4.5.4 EMERGENCY SERVICES AND REFERRAL ...... 140 4.5.5 INFRASTRUCTURE AND EQUIPMENT ...... 145 4.5.6 REGISTERS AND RECORD KEEPING ...... 155 4.5.7 INFORMATION EDUCATION COMMUNCATION (IEC) ...... 157 4.5.8 VACCINES AVAILABLE...... 158 4.5.9 CONTRACEPTIVES AVAILABLE...... 159 4.5.10 DRUGS AND LAB SUPPLIES AVAILABLE ...... 160 4.6: FACILITY MATERNAL HEALTH SERVICES COVERAGE ...... 163 4.6.1 MATERNAL HEALTH SERVICES COVERAGE JANUARY- DECEMBER 2014 ...... 163 4.6.2 FACILITY FAMILY PLANNING SERVICES COVERAGE (OCTOBER- DECEMBER 2014) ...... 164 4.6.3 FACILITY MATERNAL HEALTH INDICATORS (JANUARY- DECEMBER 2014) ...... 165 4.6.4 COMPLICATIONS SEEN/ MANAGED AT FACILITY (JUNE- DECEMBER 2014) ...... 168 4.7: MANAGEMENT PRACTICES ...... 171 4.7.1 SUPPORTIVE SUPERVISION ...... 171 4.7.2 QUALITY IMPROVEMENT PROGRAMMING ...... 171 4.7.3 FUNDING MECHANISMS AND FEES FOR SERVICES ...... 172 4.7.4 COMMUNITY INVOLVEMENT IN MANAGEMENT ...... 173 CHAPTER FIVE – CAPACITIES AND ANTICIPATED CHALLENGES ...... 176 5.1 CAPACITIES AND OPPORTUNITIES ...... 176 5.2 CHALLENGES AND BARRIERS ...... 180 CHAPTER SIX – CONCLUSIONS AND RECOMMENDATIONS ...... 186 6.1 CONCLUSIONS ...... 186 6.2 RECOMMENDATIONS ...... 186 6.2.1 IMPROVED HEALTH CARE SERVICE DELIVERY...... 187 6.2.2 IMPROVED KNOWLEDGE FOR BEHAVIOR CHANGE ...... 192 6.2.3 IMPROVED CAPACITY OF COMMUNITY GROUPS AND GOVERNMENT...... 195 6.2.4 IMPROVED ACCESS TO EDUCATION ...... 199 6.2.4 IMPROVED ACCESS TO CLEAN WATER AND SANITATION ...... 199 6.2.5 IMPROVED COORDINATION MECHANISMS ...... 201

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6.2.6 CROSS-CUTTING STRATEGIES IN PROGRAM DESIGN AND IMPLEMENTATION...... 202 ANNEX 1: HOUSEHOLD SURVEY TOOL ...... 204 ANNEX 2: KEY INFORMANT GUIDE ...... 223 ANNEX 3: FOCUSED GROUP DISCUSION GUIDE ...... 226

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ACRONYMS AND ABBREVIATIONS

AIDS Acquired Immune Deficiency Syndrome

ANC Antenatal Care

APH Antepartum Hemorrhage

ARI Acute Respiratory Infections

BCC Behavior Change Communication

BCG Bacillus Calmette Guerin – (Vaccine protection against Tuberculosis)

BEMOC Basic Emergency Obstetric Care

CAGs Community Action Groups

CBO Community Based organizations

CHWs Community Health Workers

CMMB Catholic Medical Mission Board

EmOC Emergency Obstetric Care

ENA Essential Nutrition Actions

EPH Essential Package for Health

EPI Expanded Program on Immunization

FGDs Focus Group Discussions

FP Family Planning

GRSS Government of South Sudan

HCP Health Care Providers

HF Health Facility

HINI High Impact Nutrition Interventions

HIV Human Immunodeficiency Virus

ICCM Integrated Community Case Management

ICPD International Conference on Population and Development

IDI In-Depth Interview

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IBP Individual Birth Plan

IMC International Medical Corps

IMCI Integrated Management of Childhood Illness

INGO International Non-governmental Organization

ITNS Insecticide Treated Nets

IYCF Infant and Young Child Feeding

MCH Maternal and Child Health

MDGs Millennium Development Goals

MDR Maternal Death Rate

MDs Maternal Deaths

MNCH Maternal, Newborn and Child Health

MMR Maternal Mortality Ratio

MOH Ministry of Health

MSF Medecines Sans Frontiers

MVA Manual Vacuum Aspiration

NGO Non-Governmental Organization

ORS Oral Rehydration Supplements

ORT Oral Rehydration Therapy

PAC Post Abortion Care

PEP Post Exposure Prophylaxis

PMTCT Prevention of Mother to Child Transmission

PNC Postnatal Care

PPH Postpartum Hemorrhage

RCC Roman Catholic Church

RH Reproductive Health

SHHS II Sudan Household Health Survey (2010)

SPSS Statistical Package for Social Scientists

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STIs Sexually Transmitted Infections

TBA Traditional Birth Attendant

TFR Total Fertility Rate

UNFPA United Nations Population Fund

VCT Voluntary Counseling and Testing

VHC Village Health Committee

WHO World Health Organization

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ACKNOWLEDGEMENTS

CMMB- South Sudan appreciates the opportunity to work with the Nzara County community, health facilities, government stakeholders, and others to conduct this needs assessment and baseline assessment.

Special thanks is owed to the CMMB South Sudan staff for ongoing support throughout the assessment process in regard to information, logistical support, co-facilitation of focus groups and translation, identification of key stakeholders, organization of community health workers, and provision of data.

We are overwhelmingly indebted to the households and stakeholders whom we interviewed for their invaluable time and information that made the study possible. The team is especially thankful for the payam administrators, the Paramount Chief, and other chiefs throughout Nzara, who granted permission to the team to work within the communities, hold interviews, and conduct the surveys.

Additionally, we offer our gratitude to the twelve community members who served as survey enumerators, in addition to two other community members who served as team leaders and supervisors for survey activities. They proved to be dedicated and diligent in the data collection to ensure a representative sample of households was surveyed in Nzara County. We also thank the drivers and field guides who provided vital services throughout the assessment process.

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EXECUTIVE SUMMARY

Context The protracted liberation war in Southern Sudan (1955-2005) caused the destruction of the country’s physical and social infrastructure and led to the death and displacement of over four million people. As a direct result, South Sudanese people have experienced poor health care provision due to the protracted resource and politically motivated conflicts that disrupted the health system. Consequently, the country has some of the worst key health indicators globally, with an average life expectancy at birth for both sexes of 42 years.1

Half of the population (50.6%) lives on less than 1 US$ per day, and the vast majority of the population is engaged in rural subsistence farming and cattle herding. Living conditions are associated with poor access to potable drinking water (less than 50%), poor access to proper sanitation (less than 7%) and high illiteracy rates among the adult population (88% among women and 63% among men).2

The total fertility rate is estimated at 6.7, while South Sudan has one of the highest Maternal Mortality Rates (MMR) in the world, estimated at 2,054 deaths per 100,000 live births.3 Western Equatoria State has the highest maternal mortality in South Sudan (2,327 deaths per 100,000 live births), and hence in the world.4 Early marriage, which is common in South Sudan, puts many young women at an elevated risk of maternal death, and contraceptive use is practically non- existent. Compounding this, the majority of women have very limited access to basic healthcare services needed during pregnancy and after birth; more than 80 percent of deliveries occur at home and mostly at the hands of traditional birth attendants.5

The Infant Mortality Rate (IMR) and Under-five Mortality Rate (UMR) are very high in South Sudan at 102 deaths per 1,000 live births and 135 per 1,000 live births, respectively. Only 13.8%

1 South Sudan Health Sector Development Plan, 2012-2016 (HSDP). 2 South Sudan Health Sector Development Plan, 2012-2016 (HSDP). 3 2006 Sudan Household Health Survey 4 South Sudan 2010 household survey 5 2010 Sudan Household Health Survey

2 | P a g e of children under 12 months have received DPT36 and just 1.8% of under-fives are fully immunized. Major causes of infant and under-five morbidity and mortality are malaria, pneumonia, diarrheal diseases, and malnutrition. Malaria accounts for almost one quarter (24.7%)7 of all diagnoses reported by health facilities in South Sudan, and up to 35% of children below 5 years had suffered from a fever within the two weeks preceding a 2009 household survey.8

Tuberculosis (TB) is among the major causes of morbidity and mortality in South Sudan with an annual incidence of all forms of TB estimated at 140 per 100,000 population.9 The prevalence of HIV/AIDS in South Sudan is estimated at 3%,10 and is expected to increase, mainly due to the low levels of knowledge on HIV/AIDS and prevailing high risk behaviors such as multiple concurrent sexual partners, polygamy without condom use, and other factors such as low school enrollment and poverty. Western Equatoria State has an HIV prevalence estimated at 6.8% in W.E.S., and is one of the primary causes of malnutrition among children under age five years, which is largely related to morbidity. As the HIV epidemic progresses more and more children are becoming orphaned and vulnerable due to AIDS. In South Sudan, 13 percent of children aged 0-17 years old are not living with a biological parent and 54 percent live with both parents.11

Environmental health concerns in South Sudan are widespread, including poor liquid and solid waste management, water pollution and poor excreta disposal. Consequently the prevalence of environment related diseases, such as malaria, typhoid and diarrheal diseases is high. The widespread water contamination, due to poor sanitation as a result of inappropriate solid & liquid waste disposal systems,12 is a major risk factor for these diseases.

Purpose This needs assessment and baseline assessment documents the findings of the proposed Children and Mothers Partnerships (CHAMPS) project. Through CHAMPS, CMMB will focus over a

6 UNICEF 2009 and SHHS 2010 7 UNICEF 2009 8 2009 South Sudan Malaria Indicator Survey (SSMIS) 9 South Sudan Health Sector Development Plan, 2012-2016 (HSDP). 10 2009 Antenatal Care Surveillance Report 11 2010 Sudan Household Health Survey 12 Environmental Health Assessment and future strategic approaches for the Republic of South Sudan, July 2011

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15 year period on the leading causes of maternal and child death such as diarrhea, pneumonia and malaria and it will promote influencers of good health including water, sanitation, nutrition and economic development at the household level. The general objectives of this combined baseline and needs assessment are twofold:

1) Identify the health needs of the Nzara population, including identification of root causes (e.g., systemic poverty, infrastructure, disease prevalence, traditional harmful practices such as early marriage, etc.) in order to design a needs-based responsive program targeting root causes of identified problems.

2) Provide a baseline of the current health and well-being of the targeted population (e.g., women of reproductive age and children) to provide a benchmark against which evaluations may be conducted to determine the effectiveness of the designed program in meeting the needs of the population.

Methodology This assessment utilized various qualitative and quantitative data collection tools and methodologies:  Household Survey Questionnaire: interviewed a representative sample of 500 women (from 471 households, some of which were polygamous) with a child currently under the age of five throughout Nzara County.  Key Informant Interviews (KII): interviewed 12 key stakeholders including government officials, health facility staff, and community leaders.  Focus Group Discussions (FGDs): facilitated 13 focus group discussions conversation with women, men from all five payams in Nzara County.  Health Facility Assessments: assessed the only mission hospital (Nzara Mission Hospital); all five primary health care clinics (PHCCs), namely Nzara, Basukangbi, Sakura, Ringasi, and Good Samaritan; and three primary health care units (PHCUs).

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Key Findings Education: Out of the women surveyed in Nzara County, only one-third (32.4 percent) from peri- urban areas and one-quarter (25.1 percent) from rural areas completed primary school, and only 5.4 percent from peri-urban and 4 percent from rural areas completed secondary school, while 7.2 percent of women from rural areas received no formal education.. Education is particularly challenging for girls who face early marriage and the burden of household tasks, and boys who are expected to become providers at a young age. Other key challenges for children to attend school include: lack of transportation; lack of school fees; lack of food; lack of clean water at schools; and lack of access to secondary school in some areas; and lack of protected school structures and teachers in others.

Family Planning: Women from rural areas are more likely to become pregnant within 24 months of the birth of their last child (92 percent) then are women from peri-urban areas (64 percent), and a woman who has completed primary school is much less likely to give birth to another child within 12 months of the last birth (16 percent) than a woman with no formal education (39.5 percent). Many women in Nzara County, and some men, indicate a strong desire to use contraceptives. However, many men, in particular, are also opposed to contraceptive use, citing both religious and traditional reasons, and many women expressed fear of violence if husbands were to discover that their wives were using contraceptives. Only 25 percent of women surveyed in Nzara County reported that they are using some method to delay getting pregnant, and the majority utilize abstinence to delay pregnancy as opposed to modern contraceptive methods. Despite high adolescent fertility rates, community members also report that young girls fear visiting health workers for contraceptives, who may stigmatize them as “prostitutes.”

Antenatal Care: Just over half of the women in Nzara in rural areas surveyed (57 percent) reported that they saw a midwife for ANC during their last pregnancy compared to 41 percent of women from peri-urban areas, followed by 18 percent of rural women and 13 percent of peri-urban women who saw a nurse, while 20 percent of peri-urban women saw a doctor and 13 percent of rural women saw a traditional birth attendant (TBA). Just under half (49 percent) of women surveyed from peri-urban areas of Nzara County had four or more ANC visits during their last pregnancy

5 | P a g e and 44 percent had 2 to 3 visits, compared to 41 percent of women from rural areas who had four or more visits and 50 percent who had 2 to 3 visits.

Delivery: Only 28 percent of women from peri-urban areas and 12 percent of women from rural areas surveyed in Nzara County delivered their last baby at a health facility. Women in Nzara County who completed primary school are more likely to deliver their baby at a health facility (61 percent) than women with no formal education (37 percent). The majority (63 percent) of women from rural areas in Nzara County who did not deliver their last baby at a health facility reported that this was due to the nearest health facility being too far away, while half (50 percent) of women from peri-urban areas reported that the reason is dissatisfaction with the quality of service. Most women walk to facilities, and for many the distance is too great. In emergencies, particularly for women in rural areas, roads may be impassable during rainy season, and without any emergency vehicles available, many cannot afford to pay to hire a motorbike to take them to a referral facility in the case of obstructed labor or another emergency.

Postnatal Care: A primary health concern for women in Nzara County is death as a result of postpartum hemorrhage; women are typically sent home immediately after delivery and may bleed for two days following the delivery. If they return to the PHCU it is not uncommon to find that no one is available, or may be referred but cannot afford transport. Further, no misprostol is available in any of the PHCCs or PHCUs visited. Women surveyed in Nzara County report that in half (50.8 percent) of deliveries of the last baby, this check-up was provided within 24 hours of delivery.

Gender-Based Violence: Gender-based violence was reported as a critical health concern in Nzara. Gender-based violence takes many forms in Nzara County, including early child marriage, physical violence, rape, emotional violence, and economic violence. Community members in Nzara report that girls may get married as early as age 12; reasons for early marriage provided by community members include: systemic poverty, rape or pregnancy followed by marriage to the perpetrator, lack of economic opportunity, and pressure from family for girls to become married as a sign of prestige. Young girls who are married at age 12 are also more likely to bear children as early as 13 and face higher complications in pregnancy and delivery.

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Compounding the problem of early marriage and child-bearing, polygyny (e.g. the practice of having more than one wife) is also widespread in South Sudan and Nzara County, which heightens exposure to sexually transmitted diseases, including HIV. Rape and sexual exploitation of young girls is not uncommon, yet no psycho-social services exist in Nzara County to assist survivors. Lastly, in addition to physical abuse, according to all women throughout Nzara Payam who participated in focus group discussions, they unanimously and emphatically reported that women in polygamous marriages face a greater likelihood of economic neglect; both her and her children may be at greater risk, for example, of malnourishment due to competition over resources among co-wives. Additionally, household survey data supported this data with quantitative data showing, for example, higher rates of malnourishment among children in polygamous families compared to monogamous families, and clear differences in health-seeking behavior and ANC between co-wives of the same household.

Child Protection: Child protection issues are also of great concern, particularly due to high fertility rates and low family planning use, resulting in children born to young mothers and fathers who may not have the parenting skills, and to mothers who may not desire their children. Additionally, HIV/AIDS and other illnesses resulting in the death of parents creates a population of vulnerable orphans. The range of physical abuse includes burning, hitting with objects, and kicking; emotional abuse includes withholding love and care; and economic abuse includes parental failure to provide essentials such as clothing or school fees. It is not uncommon for children to pay their own school fees, and may be vulnerable to exploitative situations to earn money. Reasons cited for such abuse include alcohol consumption by fathers and increasingly by mothers, poverty, and lack of education. Orphans and disabled children are particularly vulnerable to abuse, neglect, and exploitation.

Child Health: Over one-third (35 percent) of mothers in rural areas of Nzara County surveyed, compared to 20 percent of mothers in peri-urban Nzara Payam surveyed reported that they have lost a child under the age of two years. Health facility staff interviewed report that complications due to severe malaria is a major cause of death of children under age five, while community members report causes of death of under-fives as diarrhea, edema, typhoid, fever, and malaria. Out of all the women in Nzara County surveyed, 71 percent of mothers confirmed upper respiratory infections in their

7 | P a g e child under the age of five within the past two weeks, while 53.1 percent reported that their child had fever, and 63.4 percent reported that their child had diarrhea. Community members report that they often cannot manage to bring their children to a health facility because of lack of transport, and PHCCs and PHCUs are not all equipped and supplied on a daily basis to provide services. Additionally, many parents wait until it is “too late” before seeking care.

Maternal, Newborn and Child Nutrition: Out of the children under age 5 from Nzara County included in the survey, 22 percent in rural areas and 10 percent from peri-urban areas were found to be suffering from malnutrition or at risk of malnutrition. About 3 percent of the children in rural areas and one percent from peri-urban areas from Nzara County included in this survey were found to have severe acute malnutrition (defined as those children whose MUAC is less than 110mm), while 7 percent from rural areas and 5 percent from peri-urban areas had moderate acute malnutrition (defines as those children whose MUAC is between 110- 125mm). Generally, the risk of acute malnutrition in Nzara (defined as those children whose MUAC is between 125 mm and 135mm) in rural areas is 12 percent and 4 percent in peri-urban areas. The prevalence of edema is 48 percent in peri-urban areas and 17 percent in rural areas. The prevalence of edema is 48 percent in peri-urban areas and 17 percent in rural areas. Children in polygamous families are more likely to suffer from severe acute malnutrition (12 percent) then are children from monogamous families (2 percent), are more likely to suffer from moderate acute malnutrition (27 percent) compared to children from monogamous families (4 percent), and are at more risk (31 percent) of malnutrition than children in monogamous families (7 percent).

HIV/AIDS: Community members and key informants in Nzara report that HIV/AIDS is one of the main health concerns for men, women, married couples, adolescents, children, and babies in Nzara. An overwhelming majority (91 percent) of the women surveyed in Nzara have heard of an illness called AIDs and out of these, 83.4 percent know that people can reduce their chances of getting the AIDS virus by having just one sex partner who is not infected and who has no other partners. However, despite this knowledge polygamy without condom use and widespread risky behavior of multiple sexual partners is common. Key informants in the area report that co-infection is also a concern, particularly with TB and syphilis among women and men. Community members

8 | P a g e report that there is high knowledge and education about HIV, how to prevent it, and about testing and treatment.

Community members also report increased openness to discuss HIV. Only 9.4 percent of women surveyed in Nzara County have never been tested; however, while 32.7 percent of women from rural areas were tested within the past three months, only 11.6 percent of women from peri-urban areas were tested. Children and babies that are tested typically adhere to treatment, although there are facility and community reports of children’s deaths as a result of HIV.

Non-communicable Diseases: Community members and key informants in Nzara cite alcoholism as a key health concern in the area that is leading to liver ailments, and is a driving factor behind GBV, HIV, and preventing access to nutritious foods and healthcare in the area. Just over half (54.9 percent) of the respondents have heard about non-communicable diseases such as cancer, diabetes and hypertension. However, many community members are not aware of different types of cancers, and in particular cervical cancer. On average, less than nine percent of the respondents have information on early diagnosis and early treatment of these non- communicable diseases and only 8.5 percent know where one can receive diagnosis and treatment for these diseases.

Water and Sanitation: Although three-quarters (77 percent) of households in peri-urban areas of Nzara County report using boreholes as their main water source, the majority (68 percent) of rural households surveyed in Nzara County use unimproved water sources such as unprotected dug well (50 percent), surface water (13 percent), or unprotected spring (3 percent). Community members in Nzara report that many families collect drinking water directly from the river or shallow water sources contaminated by human and animal feces (e.g., livestock such as cows, dogs). However, water treatment is not widely practiced in the area; the majority (85 percent) of the households in Nzara County took no action to make their water safe while only 14 percent reported that they treat their water. Community members note the following reasons for not treating drinking water: no chlorine and don’t like change in water from chlorine; takes too much time to boil water; treated water (e.g. boiling) loses its taste and people don’t like to drink it; lack of education about why to

9 | P a g e treat water and some religious beliefs such as, ‘God gave us clean water so it must be safe to drink,’ how to treat water, and little public discussion about hygiene and sanitation.

While 17 percent of peri-urban women and only 2 percent of rural women surveyed in Nzara County report that they access water within the WHO recommended distance (within the compound), 49 percent of peri-urban women walk up to 1 km compared to 39 percent of rural women, and 14 percent of peri-urban women walk between 1-2km compared to 38 percnet of rural women. One-fifth (20 percent) of both rural and peri-urban women walk over 2 kilometers, and in cases over 5 kilometers, to reach the nearest water source. Community members from across Nzara County in rural areas report that it can often take anywhere from two to five hours to fetch water.

Due to recent sanitation initiatives, only 8 percent of women in Nzara County report that their family has no access to a latrine and uses the bush outside their homes to relieve themselves. The majority (91 percent) of households from rural areas report having access to a latrine as compared to 96 percent of households in peri-urban Nzara Payam.

Health Seeking Behavior: Community members and key stakeholders identified multiple factors that influence health-seeking behavior at Nzara Mission Hospital or one of the PHCCs or PHCUs. Some of these factors identified include: - Too far of distance on bad roads to Nzara hospital and PHCs discourages people. - Lack of 24 hour care, inadequate skilled staff and supplies at PHCs discourages people from making long journeys. - Lack of a functioning referral system and emergency vehicles. - Lack of education/ awareness regarding the importance of seeking health care services to treat specific ailments. - Cost of receiving care at referral hospital (Nzara MH) and cost of transportation to reach the referral hospital (Nzara MH or Yambio State Hospital). - Gender inequality and GBV prevent many women and girls from accessing health services. - Use of traditional birth attendants (TBAs) for home births is familiar and has been practiced for generations.

Conclusions

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Minimizing preventable deaths and improving the health of mothers and children is an important step towards the attainment of Millennium Development Goals 4 and 5 in South Sudan. From the results of this assessment it is evident that the delivery of maternal and child health services remains a critical challenge facing the attainment of MDG 4 and 5 specifically in Nzara County of Western Equatoria State, South Sudan. The community in Nzara County faces ongoing health challenges, most notably as a result of widespread HIV/AIDS, poor maternal health, malaria, diarrhea, typhoid, and other health problems with root causes based in systemic poverty and gender inequality throughout the area.

Key underlying challenges in accessing quality health care for maternal and child health care services include: long distances on poor roads that are sometimes impassable, and lack of transport to reach the few available health facilities; understaffed/ poorly staffed health facilities; poor health facility infrastructure, equipment, and supplies; and health seeking behavior including lack of knowledge, and gender inequality; and religious beliefs and practices (e.g. those that discourage the use of family planning and basic hygiene).

However, Nzara is well-positioned with many existing opportunities and capacities to overcome some of the key challenges preventing access to quality health care services for community members. These individual and organizational strengths may be leveraged in close partnership to address underlying root causes such as poverty and gender inequality in order to improve maternal and child health care service delivery sustainably.

Recommendations

The following recommendations are based predominantly on community members and key informants’ opinions within Nzara County on the best solutions to improve the health of women and children in their community and corroborated by the analysis of findings:

Support improved health facility infrastructure, equipment, and skilled staff in close coordination with IMC leading the ISDP effort to ensure complimentary work that does not duplicate existing efforts:

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- Increase skilled staff at all health facilities, particularly those with midwifery skills, and referral skills. - Work with existing cadre of IMC community health workers/ promoters to compliment IMC efforts and conduct critical outreach efforts. - Increase number of health facilities to ensure places that currently lack health facilities, such as Babadga in Ringasi, have access to primary health care. - Compliment existing IMC efforts to equip health facilities with appropriate equipment and supplies to provide MNCH services, including emergency obstetric care, cervical cancer screening and infant feeding programs, with a focus on facilities not currently supported by IMC. - Compliment IMC efforts to equip and upgrade health facilities with appropriate equipment, supplies, and trained staff to provide HIV counseling and treatment by making testing, equipment, trained staff, supplies, and treatment available at each PHCC in each payam, or by providing a regular and reliable mobile community outreach HIV service that provides monthly testing, care and treatment throughout Nzara County. - Create an operating theater at Nzara Mission Hospital and train staff to perform lifesaving surgeries. - Provide HIV counseling and testing at schools for girls and boys. - Support existing efforts to improve referral mechanisms and Standard Operating procedures (SOPs) for referrals throughout Nzara County and to Yambio State Hospital, and support ongoing quality care at Yambio State Hospital. - Provide an equipped ambulance for Nzara County, as well as an “emergency motorbike” at each PHCC and one PHCU in Sangua where no PHCC exists. - Identify potential partners, such as UNOPS, who may assist in road improvement. - Improve communication between PHCCs, PHCUs, Nzara MH, health posts, and the community at large. - Open “youth friendly corners” and safe spaces for girls within schools and clinics. - Create mother shelters, which are husband/ male friendly.

Support implementation of IEC targeted to specific groups on topics prioritized by the community via:

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- Parents (mothers and fathers) are taught about harm of early marriage and importance of education for girls. - Parents and chiefs are taught to discourage men from beating their wives and children. - Police are sensitized with knowledge on appropriate action to take in cases of abuse, neglect, maternal or child death, etc. - Chiefs are sensitized with knowledge about dangers of early marriage and abuse in order to take action and counsel women and men in the community, including ongoing talks with groups of men in each village. - Community-wide sensitization is held on gender-based violence, including early child marriage, and the negative impacts of alcohol consumption. - Community-wide sensitization is held on essential health package issues, including maternal health, cervical cancer screening, nutrition, family planning benefits and facts, malaria and proper use of mosquito nets, HIV/AIDS, PMTCT, disease prevention, water treatment, sanitation and disposal of solid/ human waste, and personal hygiene. Identify impactful opportunities, such as discussing at a child’s funeral the cause of death and link between poor hygiene and disease (due to earlier failed radio/ community workshop attempts to change behavior on hand washing). - Expectant mothers and their male partners are educated about danger signs in pregnancy, when to seek care, dangers in using traditional care rather than formal care, and breaking down myths and taboos related to pregnancy. - Adolescents and married/ single women and men are targeted for awareness on HIV/AIDS and STI transmission, testing, and treatment. Men, who are more frequently resistant, require extra encouragement from chiefs to get testing and treatment. - “Being faithful” counseling and workshops for couples are held. - Pregnant women and their male partners, parents of newborns and young children, and their elders are targeted for awareness proper nutritious feeding of pregnant women, PMTCT, Option B+, testing and treatment of HIV-exposed babies. - Adolescent girls and boys, and single/ married women/ men, including new parents, are educated about modern FP methods and health benefits/ economic benefits of child spacing, and myths in the community. - Use IEC methods that are community driven and via: face-to-face (e.g., door-to-

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door); drama/ street theater performed by people within Nzara County; church; schools beginning with with very young children, community meetings (such as strengthened Village Health Committee meetings or others) advocated for by men; radio, and use of peer-to-peer and groups led by community leaders.

Support the capacity of community groups and government actors in priority areas: - Provide leadership skills for women, boys, and girls to improve their ability to contribute to designing and implementing program activities. - Train community leaders, including church pastors/ preachers, and headsmen strategies to discuss key health issues with community members. - Provide parenting workshops and mentorship opportunities to families, especially men. - Train local magistrates and police on laws related to GBV, property rights etc. - Support formation of various groups, including: youth groups (e.g., youth friendly corners) for adolescent girls and boys to discuss issues such as HIV, GBV, RH, early child marriage, etc.; women’s savings clubs with support/ training for growing gardens; nutrition groups; Safe Motherhood groups (SMAG); Prevention of Positives groups; and men’s groups. - Train CHWs and community groups, such as SMAG, on birth preparedness. - Work with the District Community Health Office and Nzara MH to build upon the existing HMIS system to promote a unified reporting system. - Work with MOH/ MCDMCDH to train Nzara MH, PHC, and health post staff in providing mother baby packages and a wide range of services including maternal, neonatal and child health management, clean delivery care, FP, cervical cancer screening, FANC, youth friendly services, Post Abortion Care (PAC), Basic Emergency Obstetric and New-born Care (BEmONC), and post-rape care and comprehensive GBV response.

Improve access to education of girls, disabled children and OVC to help them escape from poverty and abuse via: - Provision of educational support to learners and families with a focus on girls, particularly in transition from primary to secondary school. - Support improved structures with protection of rain so that learners may learn uninterrupted throughout the rainy season, including girls’-only schools.

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- Support improved water and sanitation at schools, including latrine facilities that take into account adolescent girls’ hygiene needs during menstruation. - Provision of materials to school girls to assist them in hygiene during menstruation to allow them to go to school (e.g. soap, underpants, and pads). - Support construction of a boarding facility for girls and vulnerable children. - Support improved conditions for teachers and a cadre of teachers to provide quality education throughout all payams. - Strengthen existing efforts in Nzara County to address needs of all vulnerable children, including young girls who are pregnant or have children; and expand support to families of vulnerable children throughout Nzara beyond Nzara Payam in more remote areas.

Support improved water and sanitation facilities via:

13 Cost-Effectiveness: Diarrheal Incidents Avoided per $1000, Available at: http://www.povertyactionlab.org/policy- lessons/health/child-diarrhea

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Support coordination and linkages among communities, NGOs, and government actors to facilitate ownership, efficiency, and synergy via: - Support existing government efforts to lead coordination among various actors with a community-based response. - Identify existing efforts (INGO, CBO, or government) to link to and leverage. - Support functioning VHCs which may be incentivized through disease-specific or health condition-specific t-shirts and allowance for transport/ lunch. - Support government and INGO efforts to effective partnerships at all levels: government, donors and with credible NGOs / CBOs committed to maternal, MNCH goals. - Support coordination of a comprehensive and integrated “one-stop shop” at in each PHCC with psycho-social, medical, and legal support for SGBV survivors. - Locate the CHAMPS office is based in Nzara County and not in Yambio. - CHAMPS should work closely on an ongoing basis with Nzara County government, payam administrators, the Paramount Chief and the 8 executive chiefs under him. - Support ongoing efforts to create a comprehensive development plan.

Cross-cutting strategies that will be important in designing and implementing program activities include: - Always be respectful of preserving local culture and traditions by making a concerted effort to develop programming that integrates local culture. - In marketing and branding of CHAMPS, it should be presented as a more holistic program that aims to help families, including men, and not just women and children; if it is perceived by men, who are key decision-makers, as targeting only women and children, they may dismiss the program as a “woman’s issue” and choose not to be involved in making it successful (e.g., avoid calling it/ branding it as a “program for women and children’s health”). - Acknowledge and address the challenge of engaging in community-driven activities in an area with a war-affected population and low levels of education. Community-driven and led activities must be simple, incentivized, and complimented with significant efforts to mentor, guide, and supervise community members who are taking leadership roles.

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- Acknowledge that human beings work on incentives and motivations. o Expecting that community members work on a volunteer basis is not realistic or sustainable, and has led to failed efforts in the past. Health promoters, for example, may be motivated by t-shirts and other in-kind support, including transport refund. o Expecting that community members will be self-motivated to seek preventive health care at expense of their time and transport money (e.g. vaccinations, ANC, etc.) to avert future disease is not realistic. Practical, evidence-based, and effective incentives should be identified that provides immediate rewards for improved health-seeking behavior, such as providing mother and baby delivery kits to women who attend ANC regularly.14

14 Abhjit, et al (2010). Improving immunization coverage in rural India: clustered randomized controlled evaluation of immunization campaigns with and without incentives. Available at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2871989/pdf/bmj.c2220.pdf

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CHAPTER ONE: INTRODUCTION

1.1 BACKGROUND

CMMB is a leading faith-based International organization with operations in Africa, Latin America and the Caribbean; with the mission of improving global health care for the world's poor, by building healthy, sustainable communities through community engagement and partnerships, CMMB has been in operation for 100 years and six years in South Sudan in the field of health care, HIV & AIDS (treatment, care and support), PMTCT, and Voluntary Counseling and Testing (VCT).

1.2 CMMB SOUTH SUDAN COUNTRY PROGRAM

As CMMB enters its second century, we envision a focus on programs which will effectively impact the lives of children and mothers. Our forward looking vision is to partner with communities and individuals in need in South Sudan as well as agencies and donors in a long term strategic way to address the leading causes of maternal and child death, disability and illness through Children and Mothers Partnerships (CHAMPS).Through CHAMPS, CMMB will focus on the leading causes of maternal and child death such as diarrhea, pneumonia and malaria and it will promote influencers of good health including water, sanitation, nutrition and economic development at the household level. CHAMPS which represent a 15 year commitment by CMMB to the community will serve as primary model for improving health and building a strong community for the future.

CMMB has previously implemented programs in partnership with the US government such as the Born to live program, the PEPFAR funded Aids Relief care and treatment program, Global Fund (community mobilization for demand creation) and Mothers to Mother PMTCT peer to peer program). CMMB has supported comprehensive management of HIV/AIDS working with the SMoH to reduce new HIV infections and provide care, support and treatment for people living with HIV/AIDS. Since September 2011, CMMB has been supporting the SMoH in operating the Ezo ART Clinic, providing care and treatment to HIV/AIDS patients; and in February, 2013

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CMMB also initiated the Safe Motherhood Project supporting Emergency Obstetric and Neonatal Care (EmONC) Services in Ezo County. Starting January 2014, CMMB picked up the implementation of the Integrated Service Delivery Project (ISDP) in Mvolo County of WES funded by Jhpiego for the USAID Bureau for Global Health’s flagship Maternal and Child Health Integrated Program.

1.3 MATERNAL AND CHILD HEALTH: THE GLOBAL CONTEXT

Maternal mortality refers to the number of women who die as a result of childbearing, during pregnancy or within 42 days or six weeks of delivery or termination of pregnancy in one year, per 100,000 live births during that year.15 Complications of pregnancy and childbirth are the leading causes of pre-mature death among women in developing countries (World Bank, 2005).

Globally, 800 women die from pregnancy or childbirth-related causes every day; 99% of them in developing countries. In 2013, the maternal mortality ratio in developing countries was 230 per 100,000 live births compared to 16 per 100,000 live births in developed countries. Almost 75 percent of maternal death arise from five complications: severe bleeding during and after childbirth, infections, pre-eclampsia and eclampsia, complications from delivery and unsafe abortions. These complications highlight the critical need for proper antenatal care, skilled birth attendants during birth and care and support in the weeks after childbirth.16

The causes of maternal deaths are similar around the world. Globally, 80 percent of such deaths have direct causes, mostly due to obstetric complications of the pregnant state (pregnancy, labor and the pueperium). These arise from interventions, omissions, incorrect treatment or a chain of events resulting from any or a combination of these. The single most direct cause of maternal deaths is obstetric hemorrhage, generally occurring during postpartum.

15 World Health Organization (1996) “Revised 1990 Estimates of Maternal Mortality”. WHO/FRH/ MSM/96.11 World Health Organization, Geneva 16 World Health Organization. (2014). Maternal Mortality [Fact sheet]. Retrieved from http://www.who.int/mediacentre/factsheets/fs348/en/#

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Other major direct causes are obstructed labor; puerperal infection (sepsis) often a consequence of poor hygiene during delivery; unsafe induced abortion and hypertensive disorders of pregnancy particularly eclampsia (pregnancy-induced convulsion). Indirect causes like malaria, HIV and anemia also contribute to maternal deaths (WHO/UNFPA/UNICEF/World Bank, 1999). For every woman who dies, an estimated 15 to 30 women suffer from chronic illnesses or injuries as a result of their pregnancies. Complications that can lead to death occur in nearly 15 percent of all pregnancies worldwide (Royston and Armstrong, 1989; Koblinsky et al., 1993); with adolescents being at greater risk.

Pregnancy is the leading cause of death for young women aged 15 to 19 worldwide, with complications of childbirth and unsafe abortion being the major factors. For both physiological and social reasons, girls under 15 are five times more likely to die than those in their twenties (UNFPA, 2004, Conde-Agudelo et al., 2005; Temmerman et al. 2004).

The Maternal Mortality Ratio (MMR), which measures the obstetric risk associated with each pregnancy, was estimated to be 400 per 100,000 live births globally in 2000. MMR estimates are highest in Africa (830), followed by Asia (330), Oceania (240), Latin America and the Caribbean (190), and the developed countries.17 The disparities in obstetric risks that women face over a lifetime are extreme.

More recently, the attention of funding partners has been focused on the Human Immunodeficiency Virus (HIV) and Acquired Immune Deficiency Syndrome (AIDS) epidemic, which has undoubtedly been at the cost of maternal health programs. One key strategy adopted by the international community, and itself a target of MDG 5, is to increase the proportion of births assisted by health professionals (doctors, nurse-midwives and nurses with midwifery skills). The evidence of skilled attendance reducing maternal mortality is overwhelming.

Poor maternal health and health care has serious implications for survival of the newborn as well (Lawn et al., 2005). Skilled care at birth also reduces infant mortality (UNFPA, 2004). In one study that reported on child outcomes for mothers who died in labor, all the newborn babies died within

17 Villar J, Bergsjø P. 2002. WHO Antenatal Care Randomized Trial: Manual for the Implementation of the New Model.

20 | P a g e one year of birth (Greenwood et al., 1987; cited in Lawn et al., 2005). The risk of death for children less than 5 years is doubled if their mothers die at childbirth, and at least 20 percent of the burden of disease among children under the age of five is attributable to conditions directly associated with poor maternal and reproductive health, nutrition, and the quality of obstetric and newborn care (World Bank, 1999).

High levels of maternal mortality correspond with child mortality (also known as the under-five mortality rate), which refers to the probability per 1,000 that a newborn will die before reaching the age of five.18 In 2012, 6.6 million children died under age five, with roughly 44 percent dying during the neonatal period (the first 28 days of life) and another third dying from preventable diseases such as pneumonia, diarrhea and malaria.19

In places where there are high maternal and child mortality rates, they are often compounded with high rates of HIV/AIDS, TB, malaria and other communicable diseases. The HIV/AIDs epidemic continues to infect and affect many lives throughout the world, even after claiming almost 40 million lives to date. In 2013 alone, about 35 million people were living with HIV, along with 2.1 million new HIV cases and 1.5 million HIV/AIDS-related deaths.20

Close to 50 percent of the 35 million people worldwide living with HIV/AIDS, are located in Southern and Eastern Africa, although this region only accounts for only 5 percent of the world’s population. HIV is the leading cause of death for women of reproductive age in this region. 58 percent of HIV-positive adults are women, with a high percentage of the newly infected being women aged 15-24. The prevalence rate among this group is almost double that of their male counterparts, which emphasizes their status as a vulnerable population.21

18 World Bank. (2014). World Bank Data. Retrieved from http://data.worldbank.org/indicator/SH.DYN.MORT 19 United Nations Inter-agency Group for Child Mortality Estimation. (2013). Levels and Trends in Child Mortality Report 2013. Retrieved from http://www.who.int/maternal_child_adolescent/documents/levels_trends_child_mortality_2013.pdf?ua=1 20 World Health Organization. (2014). HIV/AIDS [Fact sheet]. Retrieved from http://www.who.int/mediacentre/factsheets/fs360/en/ 21 UNAIDS. (2013). Getting to zero: HIV in eastern and southern Africa Regional Report 2013. Johannesburg, South Africa.

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Several studies have indicated a strong correlation between gender-based violence (GBV) and HIV transmission. Women that encounter GBV have a 50 percent greater risk of acquiring HIV than those not facing physical or sexual violence. This issue is a critical factor in the fight against HIV since more than one in three women experience physical and/or sexual violence by a partner or non-partner. According to WHO, more than 150 million girls under the age of 18 have experienced some form of sexual violence.22

Water, Sanitation and Hygiene (WASH) international programs are essential in ensuring that safe drinking water and basic sanitation are accessible to people around the world. In 2011, 768 million people did not have access to improved drinking water sources and sanitation coverage was at 64 percent. That translates to 2.5 billion people without access to improved sanitation facilities and practicing open defecation.23

These have a domino effect, resulting in weak referral systems and poor logistics for management; lack of access to, and availability of quality skilled care; weak national human resource development and management and unclear policies concerning practice regulation; and inadequate community involvement and harmful socio-cultural beliefs and practices.

The presence of a skilled attendant at every birth was agreed to be the single most effective intervention for maternal mortality reduction. This notwithstanding, interventions need to adopt a holistic approach, focusing on all levels of the health care delivery system: community, primary health care and referral levels. In this context, the World Health Organization (WHO) adopted the Making Pregnancy Safer initiative to support countries in strengthening their health system to improve their response to emergency obstetric care.

In 2000, lack of progress in a range of health areas brought United Nations (UN) member states to adopt the Millennium Development Goals (MDGs) agreeing to increase efforts to improve maternal health and reduce child mortality against specific targets. To support countries in Africa

22 UNAIDS. (2013). UNAIDS calls for an end to gender-based violence [Press Release]. Retrieved from http://www.unaids.org/sites/default/files/web_story/20131122_PS_GenderBasedViolence_en_0.pdf 23 World Health Organization and UNICEF. (2013). Progress on Sanitation and Drinking-Water- 2013 Update. Retrieved from http://www.unicef.org/wash/files/JMP2013final_en.pdf

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In February 2004, the Road Map for accelerating the Attainment of the MDGs related to Maternal and Newborn Health (MNH) in Africa was developed by partners. The specific objectives of the Road Map are: (1) To provide skilled attendance during pregnancy, childbirth, and the postnatal period, at all levels of the health care delivery system; and (2) To strengthen the capacity of individuals, families, and communities to improve maternal and neonatal health.

1.4 MATERNAL AND CHILD HEALTH: SOUTH SUDAN COUNTRY CONTEXT

The protracted liberation war in Southern Sudan (1955-2005) caused the destruction of the country’s physical and social infrastructure and led to the death and displacement of over four million people. The Comprehensive Peace Agreement (CPA), signed in 2005, brought the war to an end. South Sudan then began a significant political, economic and social transition. Part of this transition included a referendum in January 2011 whose outcome resulted in the historic birth of a new nation, the Republic of South Sudan (RSS), on the 9th July 2011.24

The population of the Republic of South Sudan is estimated at 8,260,490 million people,25 more than 90% of whom live in rural areas. South Sudanese people have experienced poor health care provision due to the protracted resource and politically motivated conflicts that disrupted the health system. Inevitably, this resulted in the country having the worst key health indicators globally. The total fertility rate is estimated at 6.7, while the average life expectancy at birth for both sexes is 42 years.

For some years now, a major challenge to achieving any planned outcomes has been the very low health sector budget. The health sector budget as a proportion of the national budget has declined

24 South Sudan Health Sector Development Plan, 2012-2016 (HSDP). 25 2008 Census, Southern Sudan Centre for Statistics & Evaluation (SSCSE)

23 | P a g e from 7.9% in 2006 to 4.2% in 2011. Similarly, development assistance to the health sector has dropped from US$214.8 million in 2009 to US$169 million in 2010.26

South Sudan is endowed with vast natural resources, which include arable agricultural land, fresh water, minerals and oil. However, income per capita is extremely low—about half of the population (50.6%) lives on less than 1 US$ per day. In addition to high levels of poverty, South Sudan has a high disease burden and low levels of education, thus ranking as one of the poorest countries in the world. The vast majority of the population is engaged in rural subsistence farming and cattle herding. Living conditions are associated with poor access to potable drinking water (less than 50%), poor access to proper sanitation (less than 7%) and high illiteracy rates among the adult population (88% among women and 63% among men).27

South Sudan has one of the highest Maternal Mortality Rates (MMR) in the world, estimated at 2054/100,000 live births.28 Although close to 46.7%29 of pregnant women attend at least one ANC visit, only 14.7% of deliveries are attended by skilled health professionals. Institutional deliveries account for just 12.3% of births, while the contraceptive prevalence rate is 4.7%. The caesarean section rate, a good indicator of access to Comprehensive Emergency Obstetric & Neonatal Care (CEmONC), is only 0.5%30 of the population served in the three teaching hospitals (Juba, Malakal and Wau). Women of reproductive ages in South Sudan are exposed to high birth rates, raising concerns over maternal health. Early marriage, which is common in South Sudan, puts many young women at an elevated risk of maternal death. Contraceptive use is practically non-existent and majority of women have very limited access to basic healthcare services needed during pregnancy and after birth. More than 80 percent of deliveries occur at home and mostly at the hands of traditional birth attendants.31

26 South Sudan Health Sector Development Plan, 2012-2016 (HSDP). 27 South Sudan Health Sector Development Plan, 2012-2016 (HSDP). 28 2006 Sudan Household Health Survey 29 2010 Sudan Household Health Survey 30 Report of Strengthening of Hospital Management in South Sudan, caesarian section rate in the 3 Teaching Hospitals was 0.5%. SHHS 2010 also confirms the same figure of 0.5%. 31 2010 Sudan Household Health Survey

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Infant Mortality Rate (IMR) and Under-five Mortality Rate (UMR) are very high at 102 per 1000 live births and 135 per 1000 live births, respectively. The EPI program performance is suboptimal with only 13.8% of children under 12 months having received DPT332 and just 1.8% children under-five years of age fully immunized. Other major causes of infant and under-five morbidity and mortality are malaria, pneumonia, diarrheal diseases, and malnutrition. 22.7%33 of children with diarrhea received oral rehydration therapy and only 35.1% of children with suspected pneumonia are taken to an appropriate healthcare provider or health facility.

Malaria accounts for almost a quarter (24.7%)34 of all diagnoses reported by health facilities in South Sudan. According to the 2009 South Sudan Malaria Indicator Survey (SSMIS), up to 35% of children below 5 years had suffered from a fever within the two weeks preceding the survey. Only 12% of children with fever were treated with an appropriate anti-malarial medicine within 24 hours of the onset of fever. Although 60%35 of households have one or more insecticide-treated nets, information on appropriate, consistent and correct use of bed nets is lacking. The Malaria Control Program’s main interventions are case management and distribution of bed nets through community mobilization. Challenges include early diagnosis and treatment as well as insufficient vector control.

Tuberculosis (TB) is among the major causes of morbidity and mortality in South Sudan. The annual incidence of all forms of TB is estimated at 140 per 100,000 population (79/100,000 are smear positive cases), while TB specific mortality is estimated at 65 per 100,000 population. The treatment success rate for smear positive pulmonary TB was 79% in 2008. There are 41 TB diagnostic and treatment centers which successfully treated 9,894 patients from 2005 through 2010. Directly Observed Treatment (DOTs) coverage is currently 48%. The challenges facing the National Tuberculosis Program are low case detection, TB-HIV co-infection and low recording and reporting.

32 UNICEF 2009 and SHHS 2010 33 SHHS 2010 34 UNICEF 2009 35 SSMIS 2009

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The prevalence of HIV/AIDS in South Sudan is estimated at 3%,36 with the epidemic considered to be generalized, albeit some areas are described as hot spots. The prevalence is expected to increase, mainly due to the low levels of knowledge on HIV/AIDS and the prevailing high risk behaviors. There are 17 HIV treatment centers in South Sudan taking care of about 8,000 clients (about 5% are children) with close to 2,500 on Antiretroviral Therapy (ART). The HIV program has established 55 Prevention of Mother to Child Transmission (PMTCT) and over 105 HIV Testing and Counselling (HTC) sites that are integrated into existing health care structures. Main challenges include low levels of knowledge about HIV/AIDS, multiple concurrent sexual partners, poverty, low school enrolment and a huge gap in strategic information (the extent of the epidemic and key populations affected). The over dependence of the program on the Global Fund and MDTF for implementation is a critical challenge for sustainability.

A significant number of women in South Sudan are in polygamous marriages, putting them at an increased risk of contracting sexually transmitted diseases. Fewer than 10 percent of those in polygamous marriages/unions model safe sex practices, including condom use.37 There is little knowledge of HIV/AIDS transmission among South Sudanese women, another key factor that may lead to risky sexual behaviors in the population. Moreover, a significant proportion or 79 percent of the respondents in this study expressed that it is right for husbands to beat their wives or partners for whatever reason deemed appropriate, indicating a culture with high acceptance of violence against women.38

As the HIV epidemic progresses more and more children are becoming orphaned and vulnerable due to AIDS. In South Sudan, 13 percent of children aged 0-17 years old are not living with a biological parent, compared to 11 percent in 2006; 54 percent live with both parents.39 Nearly 11 percent have lost a father and only 1 percent lost a mother, and out of the total number of children studied, 17 percent live with either one or both biological parents.40 Unlike children of living parents, orphaned children are least advantaged in access to health and educational services.

36 2009 Antenatal Care Surveillance Report 37 2010 Sudan Household Health Survey 38 2010 Sudan Household Health Survey 39 2010 Sudan Household Health Survey 40 2010 Sudan Household Health Survey

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Children who are orphaned or living away from their parents may be at an increased risk of neglect or exploitation if the parents are not available to assist them.

Neglected Tropical Diseases (NTDs) are endemic in South Sudan and account for a considerable proportion of the disease burden. The major NTDs include leishmaniasis, trypanosomaisis, onchocerciasis and schistosomiasis. While all age groups are afflicted by these conditions, children and women are the most affected. The major challenge in control and management of the NTDs is the vertical programming approach as well as the lack of a vector control unit in the MOH.

Besides Malaria, TB and HIV/AIDS, epidemic prone communicable diseases contribute to the burden of diseases in the country. This poses a great challenge to the nascent Emergency Preparedness and Response Department, which has to frequently respond to outbreaks of diseases, such as measles, Kala-azar, meningitis, cholera, cutaneous anthrax and hepatitis E. The weak disease surveillance and response system, coupled with inadequate funding, compromises their capacity to promptly control epidemics.

Anecdotal evidence indicates that the burden of non-communicable diseases (NCDs) is on the rise, especially injuries related to road traffic accidents, cardiovascular diseases (hypertension, stroke) and diabetes. NCDs control has never been prioritized in the MoH budget since 2005. The main challenge for NCDs control is the lack of strategic information on their prevalence and associated risk factors.

While the burden of ophthalmic conditions in South Sudan is significantly high, eye care services to respond to this burden are insufficient. The overall active trachoma prevalence rate is 64% among children aged 1-9 years, whilst blindness due to trachoma is estimated to be 1.6%. 50% of areas surveyed in South Sudan are considered meso endemic for onchocerciasis, while 38% are hyper endemic. Mass drug administration along with health education is currently being implemented in a few selected Counties. The challenges to the control of ophthalmic conditions include insufficient funds, lack of trained human resources and poor infrastructure (unpaved roads, lack of clean water, lack of basic education).

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South Sudan experiences recurrent cycles of acute and chronic childhood malnutrition in line with seasonal and geographical variations. The overall prevalence of global acute malnutrition (GAM) and severe acute malnutrition (SAM) amongst children under five is 21% and 7.63% respectively. The prevalence of stunting among under-fives stands at 25%. While several fragmented programs exist to address the problem of malnutrition, a more comprehensive and robust strategy that addresses the root causes of malnutrition is required to decisively control the issue.

Western Equatoria State has an HIV prevalence estimated at 6.8% in W.E.S., and one of the primary causes of malnutrition among children under age five years, which is largely related to morbidity. Western Equatoria State has the highest maternal mortality in South Sudan (2,327 deaths per 100,000 live births),42 which in turn has the highest rates of maternal deaths in the world.43 Cultural practices, traditional beliefs, social and economic constraints continue to hamper access to healthcare, resulting in a mere 19.4% of mothers giving birth deliver with a skilled birthing attendant.44 Access to Yambio State Hospital from Nzara County, particularly from harder to reach areas such as Ringasi and Basukangbi payams, is severely limited during the rainy months of May- October when many roads become impassable.

1.5 OBJECTIVES OF THE BASELINE AND NEEDS ASSESSMENT

The general objectives of this combined baseline and needs assessment are twofold:

41 Environmental Health Assessment and future strategic approaches for the Republic of South Sudan, July 2011 42 South Sudan 2010 household survey 43 2,054 deaths/ 100,000 live births, South Sudan 2010 household survey 44 South Sudan 2010 household survey

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1) Identify the health needs of the Nzara County population, including identification of root causes (e.g., systemic poverty, infrastructure, disease prevalence, traditional harmful practices such as early marriage, etc.) in order to design a needs-based responsive program targeting root causes of identified problems.

The qualitative and quantitative data outputs provide the community, health facilities, partners, and all stakeholders with an understanding of both the risk factors that contribute to poor health outcomes, and capacities and opportunities that may be built upon (e.g., physical assets and human resources).

Further, this will contribute to responsive, needs-based program design based on the community context. This will assist in establishing realistic indicator targets, designing interventions, identifying potential partners and resources required, and plan for mitigating potential barriers to program implementation.

Specifically, this assessment seeks to:

i. Establish the current performance on defined maternal and child health indicators in Nzara County. ii. Identify the current situation of women and children´s health in terms of accessibility and utilization of health services. iii. Identify the leading causes of mortality and morbidity among children below 15 years, pregnant mothers and women. iv. Identify potential viable interventions that are anticipated to impact saving the lives of children, mothers and women.

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v. Identify current relationships and resources in community that can facilitate the implementation of identified interventions.

vi. Identify the underlying causes of poverty and other underlying issues which impact health outcomes in Nzara County.

vii. Identify the underlying gaps resulting in inadequate health service delivery. viii. Mobilize community leaders and members to play a central role in identifying opportunities, vulnerabilities, capacities and resources to improve the health of women and children in Nzara County.

1.6 SCOPE OF THE ASSESSMENT

The following tasks were performed to produce this assessment:

i. Review of project documents and understanding the project design and contextual framework.

ii. Utilize pre-designed and tested CMMB data collection tools and methodology for data collection of both qualitative and quantitative data.

iii. Conduct literature review of available county/government and other partner sources of maternal and child health statistics in the area.

iv. Train enumerators (12 men and women from the catchment area) and two supervisors from the catchment area to use pre-tested survey tools to ensure standardized methodology, application, safety, and ethical standards during data collection.

v. Implement and supervise field data collection, data input and cleaning, analysis and report writing.

vi. Write final report summarizing qualitative and quantitative data findings and analyses, including recommendations of stakeholders.

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CHAPTER TWO: DATA COLLECTION METHODOLOGY

This assessment utilized various qualitative and quantitative data collection tools and methodologies:  Household Survey Questionnaire: A detailed household survey (previously designed and pre-tested by CMMB in Kenya) was conducted, interviewing a representative sample of 470 women with a child currently under the age of five throughout Nzara County. (See Annex 1 for the survey tool used).  Key Informant Interviews (KII): A semi-structured interview guide (previously designed and pre-tested by CMMB in Kenya) was used to facilitate interviews with twelve key stakeholders including government officials nationally and within Nzara County, health facility staff, the Paramount Chief of the Nzara County area, and others identified from within the community. (See Annex 2 for the KII guide).  Focus Group Discussions (FGDs): FGDs were held (utilizing a previously designed and pre-tested guide from CMMB in Kenya) with various community members within Nzara County in various locations. Each FGD consisted of approximately 10 participants. A total of 11 FGDs were held, including: women (11) and men (11) in Basukangbi, women (6) and men (10) in Sangua, women (9) and men (9) in Ringasi, (11) women and (10) men in Sakure, women (9) in Nzara, (4) Traditional Birth Attendants (TBAs) in Nzara, and males (10) and females (5) from a youth group in Nzara. (See Annex 3 for the FGD guide).  Health Facility Assessments: A health facility assessment (previously designed by CMMB and tested in Kenya and Zambia) was conducted to identify staff, resource, supplies and equipment capacities and gaps, at health facilities throughout Nzara County. Health facility assessments were conducted at the only mission hospital (Nzara Mission Hospital), all five primary health care clinics (PHCCs), four of which are government clinics, and one which is a mission clinic (Nzara, Good Samaritan, Basukangbi, Ringasi, and Sakure), and three primary health care units (PHCUs), Sangua II, Nakpazigi and Nangirimo.

2.1 HOUSEHOLD SURVEY

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This was a cross-sectional study whereby data was collected on key indicators utilizing pre- designed CMMB survey in Nzara County.

2.1.1 SURVEY SAMPLING FRAME

For each of the five payams in Nzara County (Nzara, Basukangbi, Sangua, Sakure, and Ringasi), the sample design was based on a sampling frame consisting of the list of all bomas (or villages) with their respective number of households and total population, prepared by the community health workers working in the catchment area.

2.1.2 SAMPLE SIZE DETERMINATION

A random sample of mothers with children under the age of five was selected from area within the entire rural (Basukangbi, Ringasi, Sangua, and Sakure payams) and peri-urban (Nzara Payam) are of Nzara County. The sample based on an estimated total population estimate of 79,995 in Nzara County. The sample was determined using Fischer’s (1998) formula shown below: n = Z2 PQ D d2 n = {Z2PQ}/ {d} 2 Where, n = desired sample size (assuming the population in Nzara County is greater than 10,000) z = standard deviation is usually set at 1.96 (or more simply at 2.0) which corresponds to the 95 percent confidence level p = the proportion in the target population estimated to have a particular characteristic q = 1.0-p d = degree of accuracy desired, usually set at 0.05 or occasionally at 0.02 n = {(1.96)2 (0.40) (0.60)}/ {(0.05)2} ≈ 370 Households.

Additional surveys were collected, for a total sample of 471 households in order to increase the confidence of the sample. Also, surveys were collected from two co-wives from within polygamous households, bringing the total sample size to 471 households and 500 individuals surveyed (e.g. 29 additional co-wives were surveyed). This was done to collect comparative data

32 | P a g e on the health and nutrition status of women and their children within polygamous households (co- wives). Polygamous households were also randomly selected.

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2.1.3 SAMPLING DESIGN

A multistage sampling technique was used. First, purposive non probability sampling was used to identify clusters based on the 20 bomas (e.g. villages) and population estimates from each payam and boma. The sampling frame consisted of sampling household from all wards and all villages throughout the district.

TABLE 1: NUMBER OF HOUSEHOLDS SAMPLED PER CLUSTER

Cluster Frequency Percent Bakpara 14 2.8 Basukangbi 27 5.4 Bureangburu 22 4.4 Dingapai Boma 6 1.2 Kpasua 20 4 Nabubu 15 3 Nakpazigi 22 4.4 Namaiku 30 6 Namama 13 2.6 Nangirimo 17 3.4 Ndoromo 10 2 Ngbambia 2 0.4 Nzara Centre 95 19 Kpasua 14 2.8 Ringasi 17 3.4 Sakure 51 10.2 Sangua 1 18 3.6 Sangua 2 53 10.6 Yabongo 39 7.8 Yabua 15 3 Total 500 100

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Upon arrival in each boma (cluster), the data collection teams identified the center of the sub- location with the assistance of the payam administrator in the area. Each cluster was assigned with a team of 3-6 enumerators. Enumerators systematically sampled every 5th household from the center of the cluster until the appropriate sample size is completed in relatively more densely populated areas, with the exception of areas that are sparsely population, where enumerators and supervisors worked together to identify sampling from homes covering vast areas, ensuring representation and inclusion of the most marginalized homes living far from boma centers.

Systematic sampling was used to select households from each cluster where a female adult with a child less than five years old is residing. In the event that an adult female with a child less than five years was to residing at a selected household, enumerators sampled the next immediate home.

2.1.4 SURVEY ENUMERATOR SELECTION AND TRAINING

Survey enumerators were selected by CMMB South Sudan staff with the assistance of International Medical Corps (IMC). A total of 12 male and female community members were selected based on their experience and skills; ability to speak, understand, and write both English and Zande (the main local language spoken in Nzara County), as well as some who spoke Arabic and Lingala (Congolese dialect); and representation from all areas of Nzara County. In addition, two field supervisors from the community were selected and included in training with targeted supervision training.

A two day training session was conducted February 2-3 in Nzara County for the 12 enumerators and two supervisors to build a shared understanding on the objectives of the pre-tested CMMB household survey. About fifty percent of the training consisted of presentation of the survey and discussion of safety and ethics, how to properly fill the data, how to ensure appropriate sampling of the survey, and enumerator code of conduct in the field. The rest of the training included small group discussion of each individual survey question and one-on-one survey practice in groups of two. Large group discussion was held following practice to review questions, difficulties the enumerators had with the survey, and to review proper field procedures.

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2.1.5 SURVEY TIMEFRAME AND SUPERVISIONS

The survey implementation was conducted from February 4 through February 18, 2015. Each enumerator was responsible for conducting approximately 35 - 40 interviews each over a period of 12 working days. Close supervision was maintained between the two supervisors and the field staff throughout this time period. Supervisors led two separate teams and conducted spot checks and managed any identified challenges throughout the time period.

Considerable care was taken in trying to achieve a high response rate and obtain complete and good quality data. Supervisors reviewed all filled questionnaires from enumerators before accepting them to ensure completeness, consistency and validity. Completed questionnaires were collected by supervisors on an ongoing basis throughout this time period.

2.1.6 SURVEY DATA ENTRY AND ANALYSIS

The CMMB M&E Manager modified and utilized a database in SPSS previously designed by CMMB Zambia. Four data entry associates were engaged to enter data on a rolling basis from February 9 – February 20. Data was cleaned and SPSS Statistics 20.0 was used for analysis. Completed questionnaires were first examined visually for completion and possible inconsistency, and then entered in to computer using Statistical Package for Social Science (SPSS) version 20 to clean and analyze the data.

2.2 KEY INFORMANT INTERVIEWS (KII)

A semi-structured interview guide (previously designed and pre-tested by CMMB in Kenya) was used to facilitate interviews with 12 key stakeholders including government officials in Nzara County (County Health Director, County Commissioner, and RSS Director), Nzara Mission Hospital staff, Yambio Hospital staff (not located in Nzara County but the closest facility conducting C-sections and referral hospital for patients from Nzara) and MSF staff currently supporting Yambio Hospital, IMC staff who are supporting most of the health facilities in the county through a USAID-funded ISDP project and working within communities, CMMB child protection and GBV officers, and the Paramount chief of Nzara County.

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The purpose of the key informant interview guide was to identify key issues affecting women and children’s health within Nzara County by knowledgeable people from within the community. (See Annex 2 for the KII guide). Subjects discussed include: - Availability of health care services in the community - Community perceptions on access and quality of health services - Community structures to support health services - Capacity of a community, government, private, NGO, and CBO stakeholders - Disease patterns and health seeking behavior - Community linkages and partnerships - MCH strategies and programmatic approaches - Community involvement in development of policies and strategies affecting their own health, as well as management of activities or programs affecting their health - Community resources that can be leveraged for promoting women and children’s health - Prevalence of gender-based violence (GBV) and child abuse/ child labor within the community

Each stakeholder interview conducted took approximately 1.5 – 2 hours to implement. The assessment leader and the CMMB M&E staff person conducted all stakeholder interviews. Stakeholders were identified by CMMB South Sudan in consultation with government officials, chiefs, and community members.

2.3 FOCUS GROUP DISCUSSIONS

FGDs were held (utilizing a previously designed and pre-tested guide from CMMB in Kenya) with various community members within Nzara County in various locations. Each FGD consisted of approximately 10 participants. A total of 13 FGDs were held, including: women (11) and men (11) in Basukangbi, women (6) and men (10) in Sangua, women (9) and men (9) in Ringasi, (11) women and (10) men in Sakure, women (9) in Nzara, (4) Traditional Birth Attendants (TBAs) in Nzara, and males (10) and females (5) from a youth group in Nzara. (See Annex 3 for the FGD guide).

The purpose of the FGDs was to identify key issues affecting women and children’s health within Nzara County from the perspective of a representative sample of different segments of the community in different locations of Nzara. Some FGDs were held in the most rural areas of Nzara

37 | P a g e such as Basukangbi and Ringasi payams, while others were held in more peri-urban areas in Nzara payam to ensure a representative sampling of various community perspectives (See Annex 3 for the FGD guide). Subjects discussed include: - General health concerns that are a priority within communities, including common childhood illnesses and main causes of child mortality - Perceptions about men and women’s family planning methods, uses, and access to family planning, including identification of key barriers to family planning uptake - Community knowledge regarding maternal health, accessibility of maternal health care, and health seeking behavior for maternal health care - General access to health care, available services, and key barriers to health care services - Common non-communicable diseases in the community and knowledge about diseases, including breast cancer, cervical cancer, and prostate cancer - Community perspective regarding sources of drinking water, access to drinking water, time spent on collecting water, water-related diseases, community knowledge and practices in treating water and hygiene, and community practices in disposal of solid and human waste - Main sources of livelihoods for men and women, access to land and other assets, and sources of food

Each FGD conducted took approximately two hours to implement. The female assessment leader conducted all FGDs with women with the assistance of a CMMB South Sudan ART community outreach leader for translation, while the male CMMB South Sudan M&E specialist conducted all FGDs with male community members and chiefs. FGD participants were identified via payam administrators and chiefs within each payam who were requested to invite community members with certain characteristics (e.g., married women with children), and who were not “leaders” in the community, with the exception of the FGDs held with the chiefs or specific groups such as youth groups or women’s groups with specific members, to ensure a representative sample of community members.

2.4 FACILITY ASSESSMENTS

A health facility assessment (previously designed by CMMB and tested in Kenya and Zambia)

38 | P a g e was conducted to identify staff, resource, supplies and equipment capacities and gaps, at health facilities throughout Nzara County. Health facility assessments were conducted at the only mission hospital (Nzara Mission Hospital), all five primary health care clinics (PHCCs), four of which are government clinics, and one which is a mission clinic (Nzara, Good Samaritan, Basukangbi, Ringasi, and Sakure), and three primary health care units (PHCUs) (Sangua II, Nakpazigi PHCU in Ringasi Payam, and Nangirimo PHCU in Sakure Payam.

The In-Charge or available nurse or administrator at each facility were surveyed by the assessment leader and/or the CMMB South Sudan M&E specialist. Assessments identified the type of support the facilities receive from Nzara County or other organizations in terms of technical supervision, financial and human resources, medical supplies, etc. At each facility the entire infrastructure and supplies were surveyed to identify the equipment and drugs available, IEC displayed, register and data for the catchment area, and the environmental issues and conditions of the facility and the available equipment.

2.5 LITERATURE REVIEW

Publicly available documents were reviewed, including: - Government of South Sudan reports, publications, and statistics (national and for Western Equatoria State, Nzara County), including SHHS II data on health, poverty, HIV, and other key statistics. - International reports, publications, and statistics, including sources such as World Health Organization, United Nations Development Program, and others.

Key findings and national statistics are described in the Context section below, and are also integrated into the needs assessment findings as a reference point to compare the findings in Nzara with national statistics and data.

2.6 ETHICAL ISSUES

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All qualitative and quantitative data collection, analysis, and reporting followed strict safety and ethical considerations. All CMMB staff and enumerators involved in qualitative and quantitative data collection were trained on international safety and ethical considerations.

Oral consent procedures were used for most data collection activities. Most community members included in the survey sample and focus group discussions had low levels of literacy, making written consent inappropriate. Further, no identifying information was collected and oral consent provided another layer of anonymity. To obtain oral consent, enumerators for household surveys and focus group discussions read the consent form to the participant. Enumerators asked the participant if they understood the voluntary nature of the study to ensure that they understood that they could refused to answer any questions, withdraw from the study at any time, and ask if they have any questions.

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CHAPTER THREE: RESULTS

3.0 BACKGROUND INFORMATION

This baseline study report presents both qualitative and quantitative results thematically in areas central to maternal and child health and health (MNCH) services in Nzara County of Western Equatoria State, South Sudan, including focus on nutrition, water, sanitation and hygiene. Specific health topics explored with presented results include antenatal care, delivery, intra partum care, post-natal care, and child health services including immunization. Findings related to maternal nutrition, early initiation of breastfeeding, exclusive breastfeeding, complementary feeding, usage of LLITNs and child nutrition status are also presented. Access to safe drinking water and sanitation, non-communicable diseases and accessibility to medication can also be found in this results section. Quantitative data presented from survey results is strengthened by qualitative findings from focus groups and interviews to contextualize the data and further explore root causes, beliefs, and perceptions influencing observed health and health service delivery conditions.

Nzara County is located in Western Equatoria State, which is located in southwestern South Sudan and shares a border with Democratic Republic of Congo (DRC) and the Central Africa Republic (CAR). Nzara County comprises of five payams, one of which may be considered peri-urban (Nzara Payam) with a population of about 37,438 people, and the remaining four payams (Sakure- 18,195, Sangua-12,950, Ringasi-2,695, and Basukangbi- 8,716) which are rural. The entire catchment area in Nzara County contains approximately 79,995 people, although it is assumed that the population may be higher due to an increase of returned displaced persons and others from neighboring countries.

Most people are engaged in subsistence farming, with a small middle class who work for Image: Fishermen on river near Nzara Village Nzara County government or international non-profit organizations (INGOs). Some men are also engaged in producing coal for burning, and many women produce local beer for sale made of cassava.

There are no tarmac roads in Nzara County—they are all made of dirt, some in particularly bad condition with large craters that make them impassable during rainy season. The only markets with supplies such as salt, sugar, cooking oil, and other essentials are located in Nzara Payam. Most homes are small circular or square structures made of either brick (more frequently in peri-urban areas) or mud (more frequently in rural areas) with a thatched roof.

The majority of people in Nzara County are from the Zande tribe and speak Zande. The Zande people are ruled traditionally by a Paramount Chief located in Nzara Payam, who is responsible for civil matters in the area. Individual chiefs rule under the Chief in each of the five payams, along with chiefs who serve under them as leaders of each boma (village). Chiefs are gatekeepers to the community. Other tribes also live in Nzara County, as well as people from DRC and Uganda, who speak other languages including Arabic, Lingala, and Swahili.

3.1 HOUSEHOLD POPULATION AND HOUSING CHARACTERISTICS

This section summarizes demographic and socioeconomic characteristics of the population in the households sampled in the survey. For the purpose of this survey, a household was defined as a person or a group of persons, related or unrelated, who live together and who share a common source of food. The Household Questionnaire (see Appendix 1) included a schedule collecting basic demographic and socioeconomic information (e.g., age, marital status, education attainment, and religion) of respondents. The household questionnaire also obtained information on housing characteristics and household possessions. The information presented in this section is intended to facilitate interpretation of the key demographic, socioeconomic, and health indices presented later in the report.

3.1.1 HOUSEHOLD COMPOSITION

Information on key aspects of the composition of households is important because it is associated with the welfare of the household. Economic resources are often more limited

in large households than in small households. Moreover, where the size of the household is large, crowding can lead to health problems.

The data show that the mean size of a household in Nzara County is 8 people. A total of 96 households were sampled from Nzara Boma, which may be considered to be a peri- urban area, and 404 are from the surrounding rural areas in the four other payams, and some bomas from Nzara Payam that are considered rural. The majority of households have between 4 and 10 family members.

Table 2: Size of Household

Number of Number of Percentage of Number of Percentage of Total members in households Households households Households household (Peri-urban) (Peri-urban) (Rural) (Urban)

1 0 0% 1 0% 1 2 0 0% 5 1% 5 3 2 2% 26 7% 28 4 7 7% 43 11% 50 5 12 13% 43 11% 55 6 16 17% 48 12% 64 7 9 9% 41 10% 50 8 8 8% 32 8% 40 9 8 8% 39 10% 47 10 8 8% 43 11% 51 11 6 6% 12 3% 18 12 2 2% 15 4% 17 13 0 0% 15 4% 15 14 2 2% 10 3% 12 15 2 2% 9 2% 11 16 4 4% 0 0% 4 17 2 2% 1 0% 3 18 2 2% 3 1% 5 20 1 1% 8 2% 9 22 1 1% 3 1% 4 25 2 2% 1 0% 3 43 1 1% 0 0% 1 95 100% 398 100% 493

3.1.2 EDUCATIONAL ATTAINMENT OF THE HOUSEHOLD POPULATION

Education can impact access to knowledge about health, health-seeking behavior, and awareness about prevention of specific diseases and conditions, and warning signs for critical illness. Education of a mother can impact how and when she seeks ANC and

postnatal care, decides to deliver a baby at a facility or at home, and seeking routine health care and treatment for her children. A woman’s education may also affect how she is able to make decisions and bargain within her household with her husband or partner regarding household expenditures on health care and transportation to seek healthcare.

Out of all women surveyed in Nzara County, only one-third (32.4 percent) from peri-urban areas and one-quarter (25.1 percent) from rural areas completed primary school, and only 5.4 percent from peri-urban and 4 percent from rural areas completed secondary school. While less than one percent of women attended tertiary college/ university, less than one percent of women from peri-urban areas received no formal education, compared to 7.2 percent of women from rural areas who received no formal education.

FIGURE 1: EDUCATIONAL ATTAINMENT OF FEMALES SURVEYED

Education Attainment

35.0% 32.4%

30.0% 25.1% 25.0%

20.0%

15.0% Percentage

10.0% 7.2% 5.4% 4.0% 5.0% 0.9% 0.9% 0.4% 0.0% No formal Primary Completed Secondary Tertiary education Completed college/University

Peri - Urban Rural

SAMPLE SIZE: N=498(RURAL=403; PERI-URBAN= 95)

According to community stakeholders and community members, education is particularly challenging for boys and girls, especially past primary school. Due to poverty and lack of

livelihood opportunities, families generally do not prioritize education. Key challenges for children to attend school: - Lack of transportation (for some children school is too far too walk to and there is a lack of vehicles, transport, or money for transport/ fuel). Once children complete primary school, the only option for secondary school is located in Nzara Payam; for children living far away in Ringasi or Basukangbi Payam many are not able to go to secondary school (past P6). - Lack of ability for families to pay for school fees. Girls from Nzara Payam (age 18-20), all in primary school, reported that they all work to pay for their own school fees (e.g., making and selling bread, oil, cassava flour, or brewing beer). One girl reported that her father has four wives and 20 children; she is responsible for herself as her father takes no responsibility for her. - Some schools do not have sheltered structures (such as in Sangua Payam), so when it rains it is often not possible to teach children. - There are inadequate numbers of teachers and qualified teachers. Teachers are often absent, and many have left the outlying payams to go to Nzara Centre where the quality of life is better. - Many schools lack clean water, presenting challenges for students who may board, and discouraging quality teachers who are not able to cope without water, among generally poor living conditions. - Schools lack latrines; once girls reach puberty and begin to menstruate, they do not attend school during their menses, or when they are expecting it, and miss much of their learning. This delays or prevents many girls from finishing primary school and continuing to primary school (e.g., girls age 18-20 interviewed in Nzara Payam were still completing P5 and P6 in primary, and stated that they all are absent from school during their menses). - Early child marriage and/or early pregnancy (sometimes around age 13 for girls). - Child labor (e.g., boys and girls with agriculture, and girls with household tasks). Stakeholders and community members interviewed identify early marriage and early pregnancy as a key reason why girls may leave school early.

3.1.3 MARITAL STATUS OF RESPONDENTS

Marital status may affect a woman’s health seeking behavior for herself and her children. Women who are married may face challenges within their households in terms of decision- making on when it is necessary to access health care. Single women may face other challenges from other household members or extended family in terms of decision-making. Women who are either single or married may face unique challenges in accessing resources required to pay for transport to reach a health facility. Polygamy is not uncommon throughout Nzara County, and co-wives may also face additional challenges including competition for resources, such as food.

Age at first marriage for many girls may impact their access to education, and in turn, access to knowledge about health care and services. Married and single women also face unique challenges in risk factors related to their health, such as contracting HIV and other sexually transmitted diseases, becoming pregnant, and experiencing gender-based violence.

Over three-quarters (79 percent) of the mothers in Nzara County who were surveyed report being married, while 14 percent report being single or never married. Nearly one-fifth (14.7 percent) of households surveyed were found to be polygamous, where two or more wives were married to the same man. More polygamous households were found in rural areas (16.3 percent) than in peri-urban areas (6.3 percent).

Table 3. Marital Status of Women Surveyed

Peri-urban Rural Total Marital Status Frequency Percent Frequency Percent Frequency Percent Single/Never 30 40 70 Married 31% 10% 14% Married 63 66% 331 82% 394 79% Divorced/Separated 0 0% 20 5% 20 4% Widowed 3 3% 12 3% 15 3% Total n=96 100% n=403 100% n=499 100%

3.1.4 RELIGION OF RESPONDENTS

Religion may influence women and men in decision-making on certain behaviors, such as fertility and family planning choices, such as using contraception. Religion may also play a factor in when or how to seek health care services. For example, one woman in a focus group discussion in Sangua Payam stated about diseases such as typhoid, “We believe here that God has created everything pure, [so we don’t see the value in] washing hands [to prevent disease.” Another woman in the same group stated about resistance to family planning, “We rely on the bible to guide us—it tells us children are a gift from God so we should keep producing.”

Traditional spiritual beliefs may also play a role in accessing health care, such as seeking treatment or health advice from traditional healers, or identification of causes of diseases or health conditions that involves witchcraft. The majority of women surveyed in Nzara (50.8 percent) reported that they belong to the Roman Catholic faith, followed closely by 44.4 percent who reported that they belong to the Protestant faith.

Table 4: Religion of Women Surveyed

Valid Cumulative Religion Frequency Percent Percent Percent Protestant 222 44.4 44.5 44.5 Muslim 6 1.2 1.2 45.7 Roman 254 50.8 50.9 96.6 Catholic Adventist 15 3.0 3.0 99.6 Others 2 .4 .4 100.0 Specified Total 499 99.8 100.0

3.1.5 HOUSEHOLD ENVIRONMENT

The physical characteristics of the dwelling in which a household lives are important determinants of the health status of household members, especially children. They can also be used as indicators of the socioeconomic status of households. Respondents in the survey were asked a number of questions about their household Image: Children stand in front of typical homes in Nzara County environment, including questions on the type of flooring, walls and cooking fuel.

Table 5 presents characteristics of the dwellings where respondents live. These characteristics reflect the household’s socioeconomic situation. They also may influence environmental conditions—for example, in the case of the use of biomass fuels, exposure to indoor pollution—that have a direct bearing on the health and welfare of household members. The majority of households (95.6 percent) surveyed in Nzara were observed to live in dwellings with floors made of earth or sand.

Table 5: Main material of the floor in households surveyed

Valid Cumulative Main Floor Material Frequency Percent Percent Percent Earth/Mud/Dung/Sand 454 90.8 95.6 95.6 Wood Planks 6 1.2 1.3 96.8 Palm Bamboo 2 .4 .4 97.3 Cement 6 1.2 1.3 98.5 Carpet 6 1.2 1.3 99.8 Others Specified 1 .2 .2 100.0 Total 475 95.0 100.0

Cooking and heating with solid fuels can lead to high levels of indoor smoke, a complex mix of health-damaging pollutants that could increase the risks of acute respiratory

diseases. Solid fuels are defined as coal, charcoal, wood, straw, shrubs, and agricultural crops.

The majority of women surveyed in Nzara (86 percent) reported that they primarily use firewood as cooking fuel in their households, while 14 percent report using charcoal made from wood.

Table 6: Type of fuel used for cooking

Peri-Urban Rural Total Fuel Type Frequency Percent Frequency Percent Frequency Percent Electricity 0 0% 1 0% 1 0% Charcoal 30 56 86 from Wood 31% 14% 17% Firewood 66 345 411 /Straw 69% 86% 83% Total 96 100% 402 100% 498 100%

3.1.6 HOUSEHOLD POSSESSIONS

The availability of durable consumer goods is a useful indicator of a household’s socioeconomic status. Moreover, particular goods have specific benefits. For instance, having access to a radio or a television may expose household members to innovative ideas; a refrigerator prolongs food longevity and storage; and a means of transport allows greater access to many services away from the local area.

Table 7 shows the availability of selected household goods in Nzara. The vast majority of households (89.8 percent) report that the land on which the dwelling is built is owned by a member of the household45, while 2.7 percent pay rent, 1.2 percent pay no rent with consent of the owner, and 3.9 percent report squatting. The majority of households (80.7 percent)

45 In this area much of the land is not demarcated or registered by the government, so does not have formal land titling or ownership. This data is interpreted as people reporting “ownership” based on informal but traditional ownership of land recognized by the communities and local chiefs.

report that a bicycle is owned by the household, 18.8 percent report that a motorcycle/ scooter is owned, and only 2 households (0.5 percent) report owning a car or truck.

Table 7: Household Possession

Household Possession Frequency Percent Bicycle 322 80.7% Motorcycle 75 18.8% Car/Truck 2 0.5% Total 399 79.8%

Total Surveyed 500

3.1.7 OCCUPATION

A family’s income may significantly influence access of women and children to health care, particularly in terms of availability of resources to pay for transport. A woman’s access to a secure livelihood and reliable source of income can also affect her bargaining power and control/ management over a family’s resources on how income is spent on education, health care, and food. The availability of viable livelihood opportunities for women may also influence health outcomes for her and her children—the absence of a safe and secure livelihood may result in inability to access proper nutrition and clean drinking water, and may also increase risk for women and girls to partake in risky behavior, such as exchanging sex for food or other essentials, which may increase risk for violence and HIV/AIDS.

More women in peri-urban areas of Nzara County report that they are not engaged in any type of outside work (92 percent) compared to only 62 percent of women in rural areas who report the same. Women in rural areas are predominantly engaged in selling food (15 percent) and harvesting (10 percent).

FIGURE 2: TYPE OF WORK WOMEN PERFORM IN NZARA

Type of Work Women Perform 100% 92% 90% 80% 70% 62% 60% 50% 40%

Percentage 30% 15% 20% 10% 8% 10% 1% 2% 1% 3% 1% 0% 2% 2% 0% 0%

Peri-Urban Rural

SAMPLE SIZE: N=483 (RURAL=388; PERI-URBAN= 95)

Unemployment is common and in some areas, when asked what men do for work, women responded unanimously, “They drink alcohol all day.” Men typically work as informal laborers performing manual piecework labor, as needed, for farms or for private homes. They also produce charcoal for sale, and produce bricks for constructing homes in the area.

Community members report that the main source of economic activity in Nzara is subsistence farming. Women and men are both heavily engaged in cultivation activities, most typically for their own subsistence, and many women also brew local alcohol, made from cassava, which they sell to men. Typical crops grown in the area include cassava, maize, rice, millet, sesame, papaya, potatoes, beans, pumpkin, okra, banana, sugar, and other vegetables. In the rainy season there is more abundance of vegetables, but in the dry season the most commonly found foods are dried meat and fish. In some areas hunting of wild animals and fishing is also a key source of food and livelihoods. Some beekeeping for honey production projects have also been reported in a few areas. Some women also produce palm oil and cassava flour. Men reportedly are the ones who sell produce or goods at market.

Female community members report that there are several limitations in terms of cultivation:

- The forest vegetation makes it very challenging to clear large amounts of land.

- There are not viable markets to sell produce. Due to the poor road conditions, it is difficult to get goods to market where they can earn a profit. Getting goods to Juba where there is high demand would be helpful, but the roads are so bad that it takes 3-4 days (if the truck doesn’t turn over), and the goods are spoiled by then. The produce in Juba predominantly comes from Uganda over a good road.

- Past efforts in forming women’s collectives for farming have failed, for two key reasons:

o Organizations came and trained a few females, and then charged them with responsibility for forming groups. Most group members were untrained, and lacking skills the groups disbanded.

o There was a lack of market. Even though some groups began producing more, the food went to waste (during the rainy season), and without a profit the individual women did not see any benefit to their work and contribution.

Animal husbandry and livestock rearing was not commonly mentioned in much of Nzara County, except for in Basukangbi where they noted they have goats (who share open water sources with the people). Community members report that livestock in the area was destroyed when the LRA came to the area and people fled the homes.

In all focus group discussions with female community members in Nzara County, women noted that due to the lack of viable livelihood opportunities and income, it is the norm, rather than the exception, for girls and women to barter sex for money, to pay for food, clothing, and education expenses for themselves and/or their children.

3.1.8 HOUSEHOLD DECISION-MAKING

Decision-making in a household is an indicator of a woman’s bargaining power with her partner, husband, or other male relatives she may live with. Women’s decision-making power over household decisions may also be an indicator of the decision-making power she has over other areas—such as when and how money is spent on food, clothing, health, and education. It can also serve as an indicator of a woman’s vulnerability to violence and susceptibility to HIV/AIDS and other sexually transmitted diseases, as it indicates how much power she may have to negotiate when and if she has sex with her partner and if it is protected, or negotiations over family planning and contraceptive use.

Although 11 percent married women living in rural areas of Nzara report that they make decisions about how money is spent in their households jointly with their partner/ husband, and 55 percent report that they make such decisions alone, nearly one-third (31 percent) of married women in rural areas report that their husband/ partner makes decisions alone about how money is spent in the household. More than one-third (35 percent) of married women in Nzara Payam report that their husband/ partner makes decisions about how to spend money within the household alone, while only 2 percent report making decisions jointly with her husband, and 59 percent of women make decisions alone about how to spend money.

FIGURE 3 HOUSEHOLD DECISION-MAKING REGARDING MONEY SPENT

Household Decision Making 90% 84% 79% 80% 70% 59% 60% 55% 50% 35% 40% 31%

Percentage 30% 20% 9% 11% 10% 6% 6% 5% 6% 6% 2% 1% 3%3% 0% 0%0% 0% Respondent Husband/Partner Respondent and Someone else Respondent and (Woman) Husband (Partner Someone else Jointly) jointly

Married Peri-urban Single Peri-urban Married Rural Single Rural

SAMPLE SIZE: N=481 (MARRIED RURAL=315; SINGLE RURAL= 70; PERI-URBAN MARRIED= 63; PERI-URBAN SINGLE=33)

3.2 FERTILITY LEVELS, TRENDS, AND FAMILY PLANNING

Couples are motivated to adopt a family planning method when they are offered improved access to and quality of reproductive health services. Adequate information about methods of contraception enables couples to develop a rational approach to planning their families. It contributes to maintaining the health of the mother, children and the entire family, ensuring that each family member has access to the limited available resources for survival. Access to family planning is critical for birth spacing and protection from unwanted pregnancy and the achievement of women’s reproductive health desires. Religion, traditional practices, and gender roles and bargaining power of women within households also play a role in family planning.

Image: Children at focus group discussion where their mothers participate in Nzara County

3.2.1 BIRTH INTERVALS

The length of intervals between births contributes greatly to the level of fertility and also affects the health of both the mother and the child. Examining birth intervals provides insights into birth patterns and maternal and child health. Studies have shown that children born fewer than 24 months after a previous sibling are at greater risk of having poor health and that such births threaten maternal health.

Women from rural areas are more likely to become pregnant within 24 months of the birth of their last child (92 percent) then are women from peri-urban areas (64 percent). Co- wives from polygamous households are slight more likely (36.2 percent) to become pregnant within 12 months of the birth of the last child than are women from monogamous households (34.8 percent), and women from monogamous households are also more likely to space their children at least 36 months apart (5 percent) compared to co-wives from

monogamous households (0 percent). Not surprisingly, a woman who has completed primary school is much less likely to give birth to another child within 12 months of the last birth (16 percent) than a woman with no formal education (39.5 percent).

FIGURE 4: AVERAGE SPACING AMONG CHILDREN (MONTHS)

Months Between Children Born 60% 53% 50% 39% 40% 36% 28% 30% 19%

Percentage 20% 16%

10% 7% 1% 0% 0-12 Months 12-24 Months 24-36 Months More than 36 Months

Peri-urban Rural

SAMPLE SIZE: N=453 (RURAL=365; PERI-URBAN= 88)

Out of the 323 mothers from Nzara who became pregnant within 12 months of delivering the last child, the majority of both rural (47 percent) and peri-urban (74 percent) women reported that the reason was that she was not aware that she could become pregnant. However, nearly one-fifth (19 percent) of women from rural areas reported that the reason was because her husband decided. Only 9 percent of rural women and 1 percent of peri- urban women stated that she does not like family planning.

FIGURE 5: MAIN REASON FOR IMMEDIATE PREGNANCY LESS THAN 12 MONTHS AFTER DELIVERY

Reasons for Pregnancy Less than 12 Months After Delivery

74% 80% 70% 60% 47% 50% 40% 30% 19% 15% 12% 9% 9% Percentage 20% 5% 10% 3% 1% 0% 4% 0% I planned to Was not Husband Decided I don't like Others have an aware I could decided so together with family immediate get pregnant my partner planning follow up pregnancy

Peri-urban Rural

SAMPLE SIZE: N=323 (RURAL=237; PERI-URBAN= 86)

Some women and men from Nzara County have knowledge regarding the use of child spacing, and understand that spacing of children can be better for the mother’s and child’s health, and may be better for the family economically. Many women in Nzara County indicate a strong desire to use contraceptives, stating, “We are tired of caring for children.”

Community members report that in some families women and men decide together when the next child should be born. Many women in focus group discussions stated that women in their communities want to use family planning for more space between babies to ensure the health of mother and child. Men in some focus group discussions, like one held in Sangua, also are aware of the health and economic value of child spacing and are supportive of the use of family planning. TBAs in Nzara Payam also noted increased demand for contraceptives among men. One TBA reported that the husband of a woman who is currently pregnant with her 16th pregnant asked the TBA how they can “make it stop.”

However, female community members report that in the majority of households in Nzara County men are the primary decision-makers about when to have more children and how many to have, noting that culturally they are the heads of household and primary decision- makers. Men, they report, place great value on having many children, and are opposed to the use of family planning. The mothers of husbands, or mothers-in-law, are also noted to put pressure on women to produce more children in frequent order. One common reason provided for wanting to have many children is to provide insurance for the parents in older age; because of the high child mortality rate, having many children is desirable for parents to ensure there might be at least one child who will survive and may be capable of providing for parents in older age. Some women also reportedly value having many children in subsequent order in order to maintain a large family due the high probably that at least one child will die. In one focus group discussion, a woman reported that out of the ten children she gave birth two, three had died; other women reported similar figures.

3.2.2 CURRENT USE OF CONTRACEPTIVE METHODS

Respondents in the baseline survey were asked if they were currently doing something or using any method to delay or avoid getting pregnant. About 25 percent of women surveyed from Nzara County reported that they are currently using some method of contraception to avoid or delay getting pregnant.

A slightly higher percentage of women from rural areas (27 percent) reported use of family planning “CAN I START TAKING compared to the peri-urban area of CONTRACEPTIVES AFTER MY BABY IS BORN? HOW DO I GET BIRTH Nzara Payam (19 percent) who CONTROL? WE WANT IT!” reported the same, although much of - Sakure Payam female community member this family planning, particularly in rural areas, is in the form of traditional methods such as abstinence; modern contraceptive use remains low. Nationally,

96 percent of women of reproductive age in South Sudan do not use any form of contraceptive (SHHS II).

FIGURE 6: CURRENTLY DOING SOMETHING OR USING ANY METHOD TO DELAY OR AVOID GETTING PREGNANT

Percentage of Women Currently Using Family Planning Method to Avoid Pregnancy 30% 27% 25% 25%

20% 19%

15%

10%

0% Peri-urban Rural Total Percentage of Women

SAMPLE SIZE: N=456 (RURAL=365; PERI-URBAN= 91)

However, the types of contraceptives utilized are predominantly condoms among those in peri-urban areas (76 percent) compared to only 27 percent of condom users in rural areas. IMC found a key challenge in condom distribution in Nzara County—people prefer to buy condoms at a cost to taking them free from the clinic, mostly due to branding. People have strong brand preferences, such as for “Rough Rider,” for example, and there is a common belief that the condoms distributed by hospitals are not strong enough and break.

Almost half (41 percent) of women from rural areas report using “other” methods of contraceptives, which was in most cases identified as abstaining from sex. Other modern methods of contraception such as pills or injectables have reportedly very low use among women surveyed.

FIGURE 7: FAMILY PLANNING METHOD USED

Family Planning Methods Used 90% 76% 80% 70% 60% 50% 41% 40% 27% 30% Percentage 20% 8% 6% 6% 6%5% 5% 5% 6% 10% 0% 3% 1% 0%1% 0%3% 0% 0% 0%1% 0%

Peri-Urban Rural

SAMPLE SIZE: N=95 (RURAL=78; PERI-URBAN= 17)

Community members report that many families in Nzara County are beginning to see the benefit of family planning due to economic hardship in terms of inability to provide food for all family members, school fees, and poor health. Although some community members report that women and men decide together how and if family planning is used, both women and men from Nzara County report that frequently husbands/ male partners, and sometimes a woman’s in-laws, determine if a couple will use family planning, when, and how.

A group of school girls from Nzara Payam reported that sometimes school-going girls will use contraceptives, but it is rare because it is “not part of our culture,” while also noting that girls in school do not want to become pregnant because they do not want the burden of caring for children. However, community members report that adolescent girls face challenges in seeking and receiving family planning methods. Due to lack of education and training, many health workers may accuse younger girls of being

prostitutes, and as a result many young girls avoid seeking contraceptives and care due to this stigma. Generally, a key challenge in delivering family planning with modern contraceptive options to all communities throughout Nzara County is the lack of competent staff. Although there was some training by UNFPA in implants, for example, lack of supplies resulted in unpracticed skills.

Women from Nzara Payam reported that many women fear the reactions of their husbands if they take family planning. They reported that earlier in the week a woman in their village was “nearly killed” by her husband who beat her severely after discovering she was taking birth control. She was chased from her home, and returned two days later after neighbors implored her to return to breastfeed her infant that she left at home. Other community members report that a husband may become violent if he discovers his wife used emergency contraceptive. There must be protocols that staff use to assist women while ensuring their safety and security after the emergency contraceptive is taken. More social workers are critical to make this endeavor successful.

When women do access family planning, they typically visit Nzara Mission Hospital or Nzara PHCC. For those who live in Basukangbi, contraceptives are not currently offered at the PHCC and the distance to Nzara is too great; they face barriers in transportation to access family planning in the form of contraceptives. In some instances community health workers have distributed contraceptives in more hard-to-reach areas during monthly outreach activities.

Community Health workers and women in Nzara County report that the most popular type of contraceptives are injectables as it is easier to remember than taking a pill daily, and less room for user error. At Nzara PHCC, this is reflected by 100 percent of the women who are using family planning in the last quarter (October – December 2015) using injectables, and confirmed by women and the midwife at Sangua II PHCC who only have pills available; women stated they would much prefer injectables but it is not an option for them. All contraceptives at the hospital and PHCs are provided free of charge. For women who

want a more lasting contraceptive option, such as Norplant, they are referred to Yambio Hospital.

Many barriers exist to accessing and using family planning: - Although there is an increasing number of men who want to use family planning due to economic hardship and changing attitudes, many women throughout Nzara County report that there is status attached to having many children, which causes men to refuse family planning use. Further, many men believe that his wife’s fertility is under his control, some stating, “I paid a dowry for my wife; it is her duty to give me children.” In some cases the mother-in-law also resists use of family planning for the same reason. As a result, family planning is not discussed openly in some communities. - Women report fear that if they do not produce children for their husband that he will take on another sexual partner or will beat her. - Community members report that their religious beliefs prevent them from using family planning and that it is God’s will to produce many children. One woman stated about resistance to family planning, “We rely on the bible to guide us—it tells us children are a gift from God so we should keep producing.” - Community members report that it is rare for men to accompany women to clinics to receive family planning information and contraceptives. Women report that they are counseled at health facilities to discuss family planning options with their husbands and decide together; however, women in some areas report that discussing family planning with their husbands remains taboo—she fears that he will beat her if she discusses it with him, or may accuse her of wanting family planning because she is sleeping with another man. - There is still misunderstanding among many people, and men in particular, that using contraceptives will cause a woman to be barren permanently, and so there is resistance. - Poor health facility staff training on modern contraceptives, including how to prescribe it, educate patients on its use, and provide safe and non-judgmental care to all persons, including adolescent girls.

- Sometimes contraceptives are distributed, but no information is given on how to use it properly. Some women use it incorrectly, particularly with pills.

As a direct consequence of the lack of available contraceptives combined with very low bargaining power of young girls and women, the community reports frequent cases of girls (primarily in the ages of 12- 20) who are seeking abortions, typically by purchasing drugs from a pharmacy in Nzara. There are reported cases of death following attempted at-home abortions using different combinations of drugs; women in Sangua Payam reported that there was recently a 15 year old girl who died after taking drugs for an abortion when she was two months pregnant.

3.3: MATERNAL HEALTH

The health care that a mother receives during pregnancy, at the time of delivery, and soon after delivery is important for the survival and well-being of both the mother and her child. This chapter presents findings in these areas of importance to maternal health and also addresses problems in access to health care.

3.3.1 ANTENATAL CARE

Information on antenatal care is of great value in identifying subgroups of women who do not utilize such services and in planning improvements to these services. The data on antenatal care provides details on the type of service provider, the number of antenatal visits made, the stage of pregnancy at the time of the first and last visits, and the services and information provided during antenatal care, including whether tetanus toxoid was received.

3.3.1.1. ANTENATAL CARE COVERAGE

The major objective of antenatal care during pregnancy is to identify and treat problems such as anemia and infection. It is during an antenatal care visit that screening for complications occurs and advice is given on a range of issues, including place of delivery and referral of mothers.

The majority of women in rural areas of Nzara surveyed (57 percent) reported that they saw a midwife for ANC during their last pregnancy compared to 41 percent of women from peri-urban areas, followed by 18 percent of rural women and 13 percent of peri-urban women who saw a nurse. One-fifth of peri-urban women (20 percent) reported seeing a doctor or medical assistant, and 13 percent of rural women saw a traditional birth attendant (TBA). Seven percent of rural women and two percent of peri-urban women surveyed reported that they did not see anyone for ANC during their last pregnancy. Women with no formal education are more likely to see no one for ANC; in fact, no woman who completed primary or secondary school went without seeing anyone for ANC, while 7.5 percent of women with no formal education (representing all women who did not see anyone for ANC), did not see anyone for care. Women with no formal education (14.5 percent) are also more likely to have seen a TBA then are women who completed primary education (11.4 percent) and secondary education (0 percent).

FIGURE 8: WHO SEEN FOR ANC FOR THE LAST CHILD

Health Provider Seen for ANC for Last Child 60% 57%

50% 41% 40% 38%

30% 20% 18% Percentage 20% 13% 7% 10% 4% 0% 0% 1% 2% 0%

Peri-Urban Rural

SAMPLE SIZE: N=500 (RURAL=404; PERI-URBAN= 96)

However, many PHCCs and PHCUs lack basic equipment, including blood pressure machines, lighting for deliveries at night, pain killers, and maternal and neonatal resuscitation trays, so the midwives and nurses at clinics and units are limited in the ANC they may provide.

3.3.1.2 NUMBER OF ANTENATAL CARE VISITS

Antenatal care visits can be more effective in avoiding adverse pregnancy outcomes when it is sought early in the pregnancy and continues through to the time of delivery. Antenatal care is more beneficial in preventing adverse pregnancy outcomes when it is sought early in the pregnancy and is continued through delivery. Early detection of problems in pregnancy leads to more timely referrals in the case of women in high-risk categories or with complications. Health professionals recommend that the first antenatal visit occur within the first three months of pregnancy, that subsequent visits continue on a monthly basis through the 28th week of pregnancy, and that visits thereafter take place every two weeks up to the 36th week (or until birth). Under normal circumstances, WHO recommends that a woman without complications should have at least four antenatal care visits, the first of which should take place during the first trimester.

The baseline established that nearly half (49 percent) of women surveyed from peri-urban areas of Nzara County had four or more ANC visits during their last pregnancy and 44 percent had 2 to 3 visits, compared to 41 percent of women from rural areas who had four or more visits and 50 percent who had 2 to 3 visits.46 Eight percent of women from rural areas and six percent form peri-urban areas reported that they only had one ANC visit. Nationally, only 17 percent of women in South Sudan have at least four ANC visits (SHHS II).

FIGURE 9: NUMBER OF ANTENATAL CARE VISITS DURING PREGNANCY

46 This higher rate of ANC compared to national averages could be attributed to two factors: 1) IMC has been working to increase ANC visits in Nzara County, and 2) the data from the SHHS II in 2010 could be outdated enough to not reflect improvements nationally in increased ANC visits.

ANC Visits 60% 49% 50% 50% 44% 41% 40%

30% Peri-urban

Percentage 20% Rural

10% 6% 8% 0% 1% 0% 4 or more times 2 to 3 times Once Never Number of Times ANC Visits

SAMPLE SIZE: N=421 (RURAL=328; PERI-URBAN= 93)

3.3.1.3 COMPONENTS OF ANTENATAL CARE

Measuring the content of antenatal care is essential for assessing the quality of antenatal care services. Pregnancy complications are a primary source of maternal and child morbidity and mortality. Therefore, pregnant women should routinely receive information on the signs of complications and be tested for them at all antenatal care visits. To help assess the quality of antenatal services, respondents were asked whether they had received each of the following services at least once during the antenatal care visits: weight measurement; blood pressure measurement; urine and blood sample collections.

Among women who received antenatal care for their most recent birth in the two years before the survey, 89.7 percent reported that they had been informed of the signs of pregnancy complications.

When asked to specify some of the signs of pregnancy complications that would make them seek immediate care at a health facility the majority of women surveyed in Nzara, 45 percent identified fever, 16 percent reported vaginal bleeding, and 15 percent reported severe abdominal pain.

FIGURE 10: IDENTIFICATION OF WARNING SIGNS IN PREGNANCY

Common Danger Signs in Pregnancy Reported 50% 45% 45% 40% 35% 30% 25% 20% 16% 13% 15% 15% 9% Percentage 10% 5% 0% 0% 0% 1% 0% 0%

Symptoms

SAMPLE SIZE: N=497

3.3.1.4 TETANUS TOXOID INJECTIONS

Neonatal tetanus is a leading cause of neonatal deaths in developing countries where a high proportion of deliveries are conducted at home or in places where hygienic conditions do not exist. Tetanus toxoid (TT) immunization is given to pregnant women to prevent neonatal tetanus. If a woman has received no previous TT injections, she needs two doses of TT during pregnancy for full protection. However, if a woman was immunized before she became pregnant, she may require one injection or not require any TT injections during pregnancy, depending on the number of injections she has already received and the timing of the last injection. For a woman to have lifetime protection, a total of five doses are required.

Three-quarters (79.6 percent, or 323/405) of women surveyed in Nzara reported that they received two or more doses of tetanus toxoid vaccination during pregnancy, compared to the national average of 37.5 percent of women in South Sudan who were reported to be

protected against tetanus in 2010 (SHHS II).47 In some places of Nzara County, such as in Buskangbi Payam, tetanus toxoid vaccine is not available at the PHCC due to a non- functioning refrigerator; thus, many women in that area are not able to travel the long distance over bad roads to Nzara Payam to receive the injection.

3.3.2. DELIVERY

3.3.2.1 PLACE OF DELIVERY

Increasing the proportion of babies that are delivered in health facilities is an important factor in reducing the health risks to both the mother and the baby. Proper medical attention and hygienic conditions during delivery can reduce the risks of complications and infection that can cause morbidity and mortality to either the mother or the baby.

Results of the survey showed that only 28 percent of women from peri-urban areas and 12 percent of women from rural areas of Nzara County delivered their last baby at a health facility, consistent with the national average of 11.5 percent of women in South Sudan who delivered their last baby at any type of health facility (SHHS II). Women in Nzara County who completed primary school are more likely to deliver their baby at a health facility (61 percent) than women with no formal education (37 percent).

As expected, the majority (63 percent) of women from rural areas in Nzara who did not deliver their last baby at a health facility reported that this was due to the nearest health facility being too far away, compared with 23 percent of women from peri-urban areas who reported the same reason. Half (50 percent) of women from peri-urban areas reported that the reason is dissatisfaction with the quality of service, compared to only 10 percent of women from rural areas who report the same reason. A small percentage of both rural (9 percent) and peri-urban (11 percent) women reported that the reason was because the cost was too high.48

47 Nzara County performance on TT could be higher than the national average due to two factors: 1) ISDP activities in the area may have significantly improved the number of women receiving ANC and TT; and 2) SHHS II household survey data taken nationally was in 2010 before ISDP activities improved ANC and TT. 48 The “cost” is presumably associated with costs of transport or cost of food and supplies to travel and stay at a nearby mother’s shelter, since no fee is charged for delivering a baby in any facility in Nzara. Another

FIGURE 11: REASONS FOR NOT DELIVERING AT HEALTH FACILITY

Reasons for Not Delivering at Health Facility

70% 63% 60% 50% 50% Peri-urban 40% Rural 30% 23% Percentage 18% 20% 16% 11% 9% 10% 10%

0% Distance Cost Disatisfaction with Others Quality of Care Reasons

SAMPLE SIZE: N=259 (PERI-URBAN=44; RURAL=215)

Community members report that health facility delivery is encouraged. In some places, such as in Sangua Payam, the chief has issued an order that all women must deliver in a health facility; the community reports that this has been effective in ensuring more women go to facilities in Sangua to deliver.

The distance to many PHCCs, and especially to Nzara PHCC or Nzara MH is too great for many women who walk by foot. In addition, there are no mother’s shelters for women to come prior to delivery and wait (except for a new shelter at Yambio Hospital with 30 beds), or cooking facilities for mothers to prepare their food while they wait. Women in more remote areas of Nzara report that due to these challenges, confounded by lack of money for transport, women prefer to stay close to their homes with the assistance of a TBA. Phone networks are also poor in remote areas, so in the case of emergency or

possibility is that there is a perceived cost (e.g. women have incorrect information and believe they will be charged for the services, when in fact they are free).

delivery complications it is challenging to seek help. Many cases that are emergencies cannot be attended to in a timely manner, and community members report accounts of births that happen on the road or under trees when a mother is in transit to Nzara Mission Hospital via foot or bicycle. There are also accounts of maternal and neonatal deaths in their communities due to lack of emergency transport. In Sangua, there was a recent report of a woman who gave birth to twins—she was referred to Yambio during the delivery but did not reach in time, and one of the babies died.

Additionally, many female and male community members reported that there are perceived problems with midwives and staff at Nzara PHCC and Nzara MH—many women report that they are fearful to give birth at those facilities because they are “abused” verbally by the midwifes and staff, and left to labor without anyone paying attention. For this reason, many women state that they prefer giving birth at their homes where they are attended with greater perceived care and empathy by TBAs.

Community members and key informants also noted that early marriages leading to early pregnancy as early as 12 or 13, and in some cases pregnancy outside of marriage as early as age 10, is a key cause for concern as the “girls bodies are not ready yet to have children.” Some TBAs report that they immediately refer young pregnant girls to Yambio Hospital as their pelvic opening is not large enough to safely deliver the baby at home, or at a PHCC or PHCU.

3.3.2.2 DELIVERY ASSISTANCE

Skilled attendance at all births is considered to be the single most critical intervention for ensuring safe motherhood, because it hastens the timely delivery of emergency obstetric and newborn care when life-threatening complications arise. Skilled attendance denotes not only the presence of midwives and others with midwifery skills, but also the enabling environment they need in order able to perform capably. It also implies access to a more comprehensive level of obstetric care in case of complications requiring surgery or blood transfusions. Skilled attendance refers to a professional with midwifery skills working

within an enabling environment or health system capable of delivering appropriate emergency obstetric care for all women who develop complications during childbirth.

The mothers surveyed were asked to specify the person who had assisted them in the delivery of their last baby. Overall, women in Nzara County reported that 41 percent were assisted by a midwife, 0 percent by a doctor, and 14 percent by a nurse (who may not have skills in delivery). Nearly one-fifth (19 percent) report that a friend or relative assisted in the delivery of their last baby, and 16 percent reported that they were assisted by a TBA. This indicates a higher percentage of women in Nzara County assisted by skilled attendants than the national average of 19 percent of all women who were delivered by a skilled attendant (SHHS II).

FIGURE 12: SKILLED DELIVERY Percentage of Women Reporting Skilled Birth Attendanct During Last Delivery 45% 41% 40% 35% 30% 25% 19% 20% 14% 16%

15% Percentage 10% 4% 5% 0% 2% 2% 2% 0%

Birth Attendant

SAMPLE SIZE: N=475

The use of traditional birth attendants (TBAs) remains popular among women, even when delivering at a facility. Many women report that a TBA will accompany her to a facility in the event of complications, or as standard procedure once a woman has reached active labor. Several PHCCs and PHCUs also report that TBAs assist women in delivery at the

facilities, in part due to lack of adequate skilled staff at the health facilities. Several organizations, including CMMB, Red Cross, ECS, UNICEF, and World Vision, have trained TBAs in the county with basic midwifery skills. Still, TBAs are not formally recognized or paid for their services. The government has recently trained a cadre of “community midwives” who receive one year, 6 month training, and are recognized staff at some health facilities.

3.3.3. POSTNATAL CARE

A large proportion of maternal and neonatal deaths occur during the first 48 hours after delivery. Thus, postnatal care is important for both the mother and the child to treat complications arising from the delivery, as well as to provide the mother with important information on how to care for herself and her child. It is recommended that all women receive a check on their health within two days of delivery.

In Sakure, for example, the number one health concern reported by female community members is post-partum hemorrhage that frequently results in death. They report that they are typically sent home immediately after delivery and may bleed for two days following the delivery. If they return to the PHCU it is not uncommon to find that no one is available, or may be referred to Nzara Centre but they cannot afford transport (200 South Sudanese pounds roundtrip on a boda boda which needs to be paid upfront in advance of the journey). Further, no misprostol is available in any of the PHCCs or PHCUs visited.

To assess postnatal care utilization, survey respondents were asked whether, for their most recent birth in the two years preceding the survey, if a health care provider checked on the child after delivery. Just under half of women from Nzara County reported that a nurse, midwife, community health worker, or TBA checked on their baby after delivery. More women in peri-urban areas (48 percent) report that a nurse checked on their baby, while the majority of women in rural areas (44 percent) reported that a midwife checked her baby. Women in Nzara County report that in half (50.8 percent) of deliveries of the last baby,

this check-up was provided within 24 hours of delivery. Nearly one-fifth (17 percent) of women from rural areas reported that traditional birth attendants checked on their baby.

FIGURE 13: WHO CHECKED ON BABY’S HEALTH AT TIME OF BIRTH

Percentage of Babies Checked by Provider after Birth 60% 48% 50% 44% Peri-urban 40% 30% Rural 30% 20% 14% 17% Percentage 11%12% 10% 3% 3% 5% 3% 2% 0% 1% 2% 2% 0%2% 0%

Provider Type

SAMPLE SIZE: N=251 (PERI-URBAN=44; RURAL=207)

Community members and key informants in Nzara County, including health facility staff at various PHCCs and PHCUs, report that the distance many women live from the hospital or health facilities prevent many women from returning for, or seeking, postnatal care. At many facilities women return home immediately following the birth of the baby (within hours). Community members report that it is not uncommon for women to have infections after returning home from delivery. Community members report that if there are postnatal complications women will seek care at the nearest health facility, but some remain home if the distance is too far.

When asked for the signs of illness that would indicate the child needs treatment, significantly higher percentages of women from rural areas reported danger signs when compared to mothers from peri-urban areas. For example, 67 percent of women from rural areas mentioned “fever” compared to only 18 percent of women in peri-urban areas, 50 percent of women from rural areas mentioned “vomits everything” compared to only 8 percent of women from peri-urban areas who mentioned the same, 38 percent of rural women mentioned “diarrhea” compared to only 8 percent of women from peri-urban areas, and 33 percent of rural women mentioned “not eating or drinking” compared to only 4 percent of women from peri-urban areas who mentioned the same.

FIGURE 14: KNOWLEDGE OF SIGNS OF ILLNESS THAT WOULD INDICATE YOUR CHILD NEEDS TREATMENT

Percentage of Women Reporting Each of the Danger Signs 80% 67% Peri-Urban 70% 60% Rural 50% 40% 38% 40% 33% 30% Percentage 18% 20% 8% 8% 4% 4% 6% 10% 1% 4% 1% 1% 0% Not Eating Lethargic or High Fever Fast Vomits Diarrhea Other or Drinking Difficult to Breathing Everything (crying, ) wake Danger Signs

SAMPLE SIZE: N=500 (PERI-URBA961; RURAL=404)

3.4: GENDER-BASED VIOLENCE AND CHILD PROTECTION

Gender-based violence (GBV) was reported as a critical health concern, mostly for women and girls in Nzara County, by most key informants and female community members. GBV

takes many forms in Nzara County, including early child marriage, physical violence, rape, emotional violence, and economic violence. As one key informant stated when identifying a root cause of gender-based violence, “Gender inequality is ingrained early on for both boys and girls. Girls are told early on that their ‘minds are small.’”

Child protection issues are also of great concern, particularly due to high fertility rates and low family planning use, resulting in children born to young mothers and fathers who may not have the parenting skills, and to mothers who may not desire their children. Additionally, HIV/AIDS and other illnesses resulting in the death of parents creates a population of vulnerable orphans.

3.4.1 EARLY CHILD MARRIAGE

Although there are widely recognized and understood risk factors associated with early marriage among young girls, this remains a common practice in South Sudan; the most recent national household survey indicates that close to 7 percent of women aged 15-49 in South Sudan enter marriage or related union before their 15th birthday, and nearly half (45 percent) entered union before age 18 (SHHS II). One-third of these women report having already given birth to a child or are currently pregnant with their first child, which has serious negative health implications for both mother and child (SHHS II).

Compounding the problem of early marriage and child-bearing, polygyny (e.g. the practice of having more than one wife) is also widespread in South Sudan, which heightens exposure to sexually transmitted diseases. Nationally, 41 percent of all unions investigated in 2010 were found to be polygamous (SHHS II). Literature shows that women who share a husband are at an increased risk of STIs, including HIV, and have less positive reproductive outcomes. And even more worrisome, there is low condom use by males in polygamous relationships (SHHS II). Another serious health concern that women face is the traditional practice of passing a wife to the brother of her deceased husband. Combined with polygamy, this is a very dangerous practice in the spread of HIV.

Community members in Nzara report that girls may get married as early as age 12, when culturally a girl is considered a woman, at which point they typically leave school. Reasons for early marriage provided by community members include: systemic poverty, rape or pregnancy followed by marriage to the perpetrator, lack of economic opportunity, and pressure from family for girls to become married as a sign of prestige. Some women in the community note that trends are that more girls are increasingly marrying at younger ages than previously.

A key challenge to early marriage is the traditional support of leaders for early marriage. In some cases, chiefs reportedly may benefit from instances of early marriage resulting from a rapist marrying the rape survivor. In these instances, a chief may be paid by the perpetrator to facilitate the marriage. There is also reported political support at many levels for continuation of this traditional harmful practice.

As a direct consequence of early marriage, community members report that many girls become pregnant with their first baby as early as age 13, with examples of girls as young as 10 years old when they have their first baby. Younger girls have less bargaining power within their marriages and may face additional risk for forms of GBV, including physical violence, economic violence, and emotional violence. Female community members and health workers also reported that younger girls face more complications in pregnancy and deliveries, such as obstructed labor due to too small/ under-developed pelvic bones. Adolescent pregnancies are typically referred to Yambio Hospital as they are high risk pregnancies, although not all girls have family support or are able to arrange transport to go to the hospital.

3.4.2 DOMESTIC VIOLENCE

Nationally, 54 percent of women in South Sudan reported that they believe the husband is justified in beating his wife or partner if she went out without first seeking his permission, 62 percent believe beating is justified when the wife or partner neglects her child or children, 52 percent believe it is justified if a woman argues with her husband or

partner, 47 percent believe it is justified if she refuses to have sex with a husband or partner and 41 percent believe that beating is also justified if the woman burns the food (SHHS II). Overall, 79 percent of the female respondents nationally find it justifiable for men beating their wives or partners for any one of the reasons suggested in the study (SHHS II).

Community members in Nzara County report that physical beating of women within households is common and accepted by many women and men as a form of punishment. One key informant reported that this type of violence is not considered by many a form of GBV, but rather “corrective measures” that a husband is responsible for taking as the head of household. Female community members in Sangua Payam, for example, reported that it is common for men to drink and beat their wives and children severely, sometimes running the women out of their homes to sleep in the bush. Common reasons female community members gave for women being beaten by their husbands include: - Man has been drinking - Man has a girlfriend - Wife refuses sex (and man “thinks she already had sex with someone else”) - Wife speaks in a rude manner to husband or “purposefully” disobeys husband - Wife doesn’t cook food when husband asks - Woman asks for money to buy food or other household essentials - Woman asks for transport money to bring sick child to health facility - Husband does not like when wife advises him - Wife requests to use family planning or abstain from sex to “WOMEN ARE THE ONES WHO avoid pregnancy PROMOTE VIOLENCE. THEY - Wife discloses positive DELIBERATELY VIOLATE THE MAN’S RULES.”- Female community member from HIV status to husband Nzara - Co-wives in polygamous marriages

fight with one another (verbally or physically) so husband intervenes and beats the wife “at fault.”

Physical abuse mostly goes unreported to authorities as it is viewed as a household matter. Women who are beaten are often encouraged by family elders and parents to return to the husband to resolve the problem. Traditionally, conflict between a man and wife is resolved by the husband’s parents and family.

3.4.3 SEXUAL EXPLOITATION AND ABUSE

Rape is occurring within Nzara County, which is increasingly “THE PROBLEM IS THAT SCHOOL being recognized as a problem GIRLS’ SKIRTS ARE TOO SHORT. THEY which is punishable by 3 to 7 BUY THE UNIFORMS IN THE MARKET AND SHORTEN THE HEMS. THEY ARE years imprisonment. School girls TEMPTING THE MEN.”- Female community report that it is not uncommon member from Nzara for school girls to be raped by “big men” on the way home from school. Rape cases of girls as young as age 6-7 have been seen with some frequency at Nzara MH due to physical trauma suffered. Women in Sakure also reported that it is not uncommon for men in their community to rape young Congolese boys because, according to these female community members, “the boys are foreigners and an easy target—they can’t do anything about it.”

Older school girls noted that there are no health facilities that girls can go to for treatment, and that girls typically do not seek health treatment following rape. Although MSF in Yambio has facility to handle sexual abuse cases in terms of psycho-social support, these services are not available within Nzara County.

Community members report that it is very common for young girls, beginning at age 10 or up, to engage in sex for favors (usually money), sometimes with their peers, but often

with older men with money. Community members note that girls are often noticed by older men on their way too or from school or fetching water, and that the man will offer her a gift or money in exchange for sex. If a girl becomes pregnant, the man is expected to pay a “dowry” in the form of money to the girl’s family. Community members report that men in these cases will often “disappear.” Further, men often bribe police to drop cases against them if families bring a case forward. Girls face other barriers in bringing formal complaints forward, such as lacking formal birth certificates required for the process; poor mothers/ fathers cannot afford to pay for her birth certificate, bribes, and other fees required to push a case forward. In addition, in order to move forward with a rape case a from is required to be completed by a medical professional documenting the rape patient’s injuries; it is reported that it is common practice at some facilities, and specifically at Nzara Mission Hospital, for nurses to demand 50-60 South Sudanese pounds to see a rape patient and fill the form, which discourages victims from coming forward to receive medical attention and pursuing legal action.

Additionally, during the time of the assessment there was a report of two girls (around age 15) who were raped in Nzara Payam on their way from school by soldiers staying in one of the three military camps located in the areas. One family reacted but backed down after a potential conflict between the soldiers and community became a threat. These types of incidents with soldiers as perpetrators reportedly go unpunished due to the politics involved.

Rape is not uncommonly resolved traditionally by marrying the survivor to the perpetrator. In one reported case, a girl who was raped had a marriage arranged to the perpetrator by her father. She ran away to the police and taken to a safe space. However, the following day, the girl, fearing that her father would beat her, returned home. When the Ministry of Social Welfare went to follow-up they were told by the parents that there was no issue because, “the girl is happily married.”

3.4.4 ECONOMIC ABUSE

Community members and key informants also report that women and girls also face economic abuse in Nzara County. Men are viewed as the heads of household with decision-making power, and frequently keep all any income that they earned. These begins at marriage when a dowry is provided to the woman’s family by the man. At that point, women report that she becomes the property of the man and the man can do as he pleases. Further, if there is divorce, men have rights to keep the children because of the dowry paid, and community members report that frequently children who remain with their father are neglected (e.g. health, nutrition, education) by the new wife the father marries. The estranged mother typically returns to her parents’ home and is expected to send money to pay for her children’s school fees, food, etc.

Alcohol abuse is reported as a source of problems in the community, and women in the community report that men prefer to spend money on alcohol rather than on medicine, food, school fees or other household necessities. Women report that many fear asking men for money to purchase food or other household items in fear that the husband will feel embarrassed or ashamed for not having money to give and will act out by beating his wife. As a result of poverty and lack of decision-making over household income, community members report increasing incidences of “WE DON’T KNOW HOW MUCH THE prostitution and girls and MEN EARN. WHEN THEY ARE PAID THEY SPEND IT ALL ON ALCOHOL AND women, both married and THERE IS NOTHING LEFT. MAYBE unmarried, who exchange sex THEY WILL GIVE ENOUGH FOR A for money in order to buy food, QUARTER OF THE SCHOOL FEES, BUT education, or other household IT’S UP TO US [WOMEN] TO PAY FOR EVERYTHING.”- Female community member items. from Nzara

Some women noted that there are particular families that are vulnerable to this type of economic violence. Single women who are abandoned by their husbands, perhaps for another woman, are often left with pressure from the community, stigma, and lack of resources. Often their younger adolescent daughters are at risk for engaging in sexual

relationships with older men for money. Women in the community also report that pregnant women frequently do not have adequate nutritious food intake.

Additionally, women in the community report that there is more often conflict between co-wives in polygamous households where there are anywhere between two to six wives, than there is cooperation and harmony, typically due to competition for resources such as food for their children. It is reportedly not uncommon for one man to have between three and five wives in Nzara County. Both men and women reported that men must be “strong-willed” with an ability to treat his wives equally, but women report that more often than not the man fails in doing so. Women report that in some polygamous households where one wife is stronger, that those children may be well-fed and clothed, while the children of the other “weaker” wife may be neglected, and even malnourished. Younger wives reportedly often get preference in terms of resource allocation. One woman reported that, “men spend their money on alcohol and the newest wife, while the rest of the wives have to fend for themselves.”

Various community leaders and organizations are attempting to address GBV in Nzara County and there is increasing awareness about GBV and its existence in communities. During a focus group discussion with men in Sangua Payam, for example, men noted that violence against women was wrong and that it was “hardly not happening at all in the community.” Although women from the same community reported that beating of wives and children is quite common in Sangua (daily), the men’s responses shows that there is increasing awareness of right and wrong and the correct response to GBV.

3.4.5 CHILD PROTECTION

Child protection issues in Nzara County include issues related to early child marriage, sexual exploitation, gender-based violence, and early pregnancy before a girl’s physical body is mature enough to safely carry and delivery a baby. In addition to these issues explored above, other forms of child abuse prevalent in Nzara County include physical, emotional, and economic abuse of children perpetrated frequently by mothers, fathers, and other close family members. The range of physical abuse includes burning, hitting with objects, and kicking; emotional abuse includes withholding love and care; and economic abuse includes parental failure to provide essentials such as clothing or school fees. It is not uncommon for children to pay their own school fees, and may be vulnerable to exploitative situations to earn money. Reasons cited for such abuse include alcohol consumption by fathers and increasingly by mothers, poverty, and lack of education.

As a result of abuse, children may leave home and stay with relatives, or they may go to the market in Nzara Centre where they may find a way to earn money, such as selling second-hand clothing. Typically orphans do not receive appropriate care in their extended family environments; after losing one or both parents they may be neglected, become second class, “MOST CHILDREN [IN NZARA COUNTY] ARE NOT SAFE IN THEIR given heavy house or farm work, HOMES.”- Female community member from and may be deprived of basic Nzara needs such as clothing and hygiene. These children may experience severe stress and frequently drop out of school. They may also break the law, and due to lack of juvenile courts or justice system, children may face further abuse and exploitation in prisons where they are mixed with adults.

CMMB staffs child protection officers who provide psycho-social support to identified children, in some cases with the assistance of trained community volunteers in Sakure,

Sangua, and Nzara who assist in identifying potential child protection cases. There is also an orphanage, Rainbow House, for children whose parents died from HIV and HIV positive orphans, is run by the Camboni Sisters in Nzara Centre, but few other social support organizations exist to address the need of children suffering from various forms of abuse. There is a significant lack of available services, support, and care for disabled children. Particularly past the age of five, parents and families lack the tools, knowledge, and support required to provide appropriate care to children with disabilities. This has negative outcomes on the child’s physical, mental, and emotional health.

The lack of available services is, in part, due to lack of political will to address the issue. When terminology such as “child rights” is used, for example, or initiatives are viewed as “outside initiatives” spearheaded by international NGOs, there is little government and community ownership over child protection laws and acts in place. It is imperative that child protection work is seen as a community-driven initiative.

Many community members in Nzara County do not view “child abuse” as a concern, noting that it is a parent’s duty to “correct” a child’s behavior through various forms of punishment. However, when community members and officials understand the type of abuse that occurs, they may be more likely to accept abuse of children as a problem. For example, in one case a mother abandoned a four year old and two year old alone in their home and left Nzara, and they were found wasting and malnourished some weeks later. In another instance a five month old was abandoned by its mother and, although cared for physically by the grandmother, experienced no socialization or language and failed to learn to speak. In one other instance, a 15 year old mother abandoned her three month old baby in a market while she drank with an older man; after the police found the baby in the market and located the mother they returned the baby home with her, but one month later the baby was found dead after the mother fell on the baby while drunk. These anecdotes are not uncommon, and may elucidate for community members the severe neglect and abuse experienced by many children in Nzara County born to mothers and fathers that are too young to become responsible parents.

3.5: CHILD HEALTH

Of special importance to child health and survival are birth weight and size, childhood vaccination status, and treatment practices for respiratory infection, fever, and diarrhea. This information influences the design and implementation of programs aimed at reducing neonatal and infant mortality. Nationally, the probability of dying before the age of one year old is 75 per 1,000 live births, and before the age of five 105 per 1,000 live births (SHHS II). Boys have a higher mortality rate than do girls, with an under-five mortality rate of 113 among males and 92 among females (SHHS II). Nzara Mission Hospital reports a pediatric mortality rate of 1.5 percent in the facility for the year 2014. There were a total of 49 deaths (44 from malaria, one from HIV, and two from severe pneumonia). Severe and chronic anemia in children is also reported as a common ailment seen at Nzara MH.

Community members in Nzara County report that common ailments that children suffer from include measles, convulsions, fever, diarrhea, anemia, typhoid, cough, syphilis (through non- sexual contact with infected family members), malaria, edema, and hernia. Further, community members report that there are common cases of children dying under the age of five, most frequently due to diarrhea, but also due to edema, typhoid, fever, malaria, and other problems. Measles is a problem; one community member reported a recent case of one month old infant dying at hospital from measles—he was born on the road when the mother was traveling to Nzara Centre to deliver, so she returned home instead of going to hospital, and he never received care after his birth.

Over one-third (35 percent) of mothers in rural areas of Nzara County surveyed, compared to 20 percent of mothers in peri-urban Nzara Payam surveyed reported that they have lost a child under the age of two years.

3.5.1 VACCINATION COVERAGE

Universal immunization of children against the six vaccine-preventable diseases (namely, tuberculosis, diphtheria, whooping cough (pertussis), tetanus, polio, and measles) is crucial to reducing infant and child mortality. Differences in vaccination coverage among subgroups of the population are useful for program planning and targeting resources toward areas most in need.

According to the World Health Organisation, a child is considered fully vaccinated if he or she has received a BCG vaccination against tuberculosis; three doses of DPT vaccine to prevent diphtheria, pertussis, and tetanus (or three doses of pentavalent which includes two additional vaccines); at least three doses of polio vaccine; and one dose of measles vaccine. These vaccinations ought to be received during the first year of life.

The baseline survey collected information on the coverage for these vaccinations among all children born in the two years preceding the survey. The results showed that 73 percent received pentavalent vaccines, and 67 percent received the measles vaccine. Nationally, 26.3 percent of children under the age of 24 months received a measles vaccine, 34.4 percent received BCG, received 13 percent received all three doses of DPT/DPT, and 13 percent received all three doses of polio (SHHS II).

Female and male community members throughout Nzara County reported that measles is a common ailment for children in Nzara, and reported it is a cause of death among children from age 0-5. They also reported that in many areas immunizations for BCG are not available for children, such as in Basukangbi Payam where the PHCC does not have a functioning refrigerator to store vaccines.

3.5.2 ACUTE RESPIRATORY INFECTION

Acute respiratory infection (ARI) is one of the leading causes of childhood morbidity and mortality throughout the world. Early diagnosis and treatment with antibiotics can prevent a large number of deaths caused by ARI. In this baseline survey, the prevalence of ARI was estimated by asking mothers whether their children under age five had been ill in the two weeks preceding the survey with a cough accompanied by short, rapid breathing, which

the mother considered to be chest related. These symptoms are compatible with pneumonia. It should be noted that the morbidity data collected are subjective in the sense that they are based on the mother’s perception of illness without validation by medical personnel. Community members in Nzara County noted that coughing was a key health concern for children under the age of five in the area, and many noted that the cause of the cough was “the air.”

Asked if their children under five years had a cough accompanied by short, rapid breathing in the two weeks before the survey, 71 percent of mothers confirmed upper respiratory infections in their child. Out of those children with ARI symptoms, 42 percent sought advice or treatment from a health facility or a health care provider, and 87 percent sought advice for ARI symptoms. Treatment for the sick child was provided primarily by nurse (28 percent), followed by doctor (13 percent) and community health workers (58 percent). Nationally, 19 percent of children had ARI symptoms in the two weeks preceding the SHHS survey. Among children with ARI symptoms nationally, advice or treatment was sought from a health facility or a health provider for 47 percent of those children (SHHS II).

Out of the 161 mothers who reported that they brought their ill child with ARI symptoms to see a provider, 19 percent in the peri-urban Nzara Payam saw a nurse and 63 percent saw a doctor, whereas 62 percent in rural areas saw a community health worker, 29 percent saw a nurse, and only 8 percent saw a doctor.

FIGURE 15: WHO GAVE YOU ADVICE OR TREATMENT?

Type of Provider Seen

70% 63% 62% 60% 50% 40% 29% 30% 19% 19% Percentage 20% 8% 10% 0% 1% 0% Doctor Nurse Auxillary Nurse Community Health Worker

Peri-urban Rural

SAMPLE SIZE: N=161 (PERI-URBAN=16; RURAL=145)

3.5.3 FEVER

Fever is a symptom of malaria and other acute infections in children. Malaria and other illnesses that cause fever contribute to high levels of malnutrition and mortality. Although fever can occur year-round, malaria is more prevalent after the end of the rainy season. For this reason, temporal factors must be taken into account when interpreting fever as an indicator of malaria prevalence. Because malaria is a major contributory cause of death in infancy and childhood in many developing countries, the so-called presumptive treatment of fever with antimalarial medication is advocated in many countries where malaria is endemic. It is important that effective malaria treatment be given promptly to prevent the disease from becoming severe and complicated.

In the baseline survey, mothers were asked whether their children under five years had a fever in the two weeks preceding the survey and if so, whether any treatment was sought. The results show that 53.1 percent of children under five were reported to have had fever in the two weeks preceding the survey. Advice or treatment was sought from a health facility or provider for 77.3 percent of the children who had fever in the two weeks preceding the survey. The results further showed that among children with fever, 68.6 percent took drugs to address the fever.

3.5.4 PREVALENCE OF DIARRHEA AMONG CHILDREN

Dehydration caused by severe diarrhea is a major cause of morbidity and mortality among young children, although the condition can be easily treated with oral rehydration therapy (ORT). Exposure to diarrhea-causing agents is frequently related to the use of contaminated water and to unhygienic practices in food preparation and disposal of excreta.

Mothers in Nzara County were asked if any of their children aged 0-59 months has had diarrhea in the last one month preceding the survey. The survey found that 63.4 children (aged 0-59 months) had diarrhea. In interpreting the findings of the baseline, it should be borne in mind that prevalence of diarrhea varies seasonally—at the time of the survey it was dry season without rains; during dry season there are reportedly more cases of diarrhea than there is during rainy season. Nationally, 44 percent of children under 24 months and 26 percent of children older than 48 months had a diarrhea episode in the two weeks preceding the SHHS II survey (SHHS II).

Community members and key informants, including health “DIARRHEA IS THE MOST COMMON workers, report that diarrhea is ILLNESS FOR CHILDREN IN NZARA. very common among children SOMETIMES THEY [PARENTS] WAIT TO BRING A SICK CHILD TO THE under age five in Nzara County, HOSPITAL AND IT IS TOO LATE.” and many believe that it is a - Community member from Nzara leading cause for death of children in the community. Most community members and key informants point to lack of clean, untreated water and poor hygiene in households as the main cause of diarrhea. However, community members report that some people do not realize that they are becoming sick due to contaminated water; some blame illness on unknown causes that are untreatable in clinics. During dry, hot seasons health workers observe increased cases of diarrhea, presumably due to decreased water sources, stagnant/ standing water, and increased flies. Discussion on water and sanitation is further described in subsequent sections of this report.

Community members from more remote areas of the county in Basukangbi and Ringasi payams report that they often cannot manage to bring their children to the clinic because of lack of transport. In addition, PHCCs and PHCUs are not open every day, or they have limited hours, so parents fear going to the clinic and then waiting too long, and may find that there are drug stock-outs. As such, it is reported that there are instances, particularly in more remote areas, where parents stay at home and only bring the child to a health facility after the condition has worsened or is extreme. If a child dies at home, they are typically buried by their family and it is usually not reported to officials.

3.5.5 KNOWLEDGE OF ORS PACKETS

A simple and effective response to dehydration caused by diarrhea is a prompt increase in the child’s fluid intake through some form of oral rehydration therapy, which may include the use of a solution prepared from packets of oral rehydration salts (ORS). To ascertain how widespread knowledge of ORS is in Nzara County, women were asked whether they knew about ORS packets.

The results show that 42.1 percent of the mothers in Nzara County have heard of ORS packets and can describe the correctly.

Community members in Nzara report that there is not enough ORS, especially in remote areas of Nzara. ORS can be easily obtained from Nzara MH, but women may have to walk far to get ORS for a baby or child with diarrhea. For many this is too far to go and they do not have money for transport. As a result, some mothers in these more remote areas wait until the child’s condition is extreme, and by the time they reach the facility it is too late and the child may die.

3.6: MATERNAL, NEWBORN AND CHILD NUTRITION

In this section, we describe mothers’ understanding of child nutrition including early initiation of breast feeding, exclusive breast feeding and complementary feeding.

Adequate nutrition is critical to child development. The period from birth to two years of age is important for optimal growth, health, and development. Unfortunately, this period is often marked by growth faltering, micronutrient deficiencies, and common childhood illnesses such as diarrhea and acute respiratory infections (ARI). Feeding practices reported in this chapter include early initiation of breastfeeding, exclusive breastfeeding during the first six months of life, continued breastfeeding for up to two years of age and beyond, timely introduction of complementary feeding at six months of age, frequency of feeding solid/semisolid foods, and the diversity of food groups fed to children between six and 23 months of age.

A woman’s nutritional status has important implications for her health as well as the health of her children. Malnutrition in women results in reduced productivity, an increased susceptibility to infections, slow recovery from illness, and heightened risks of adverse pregnancy outcomes. For example, a woman who has poor nutritional status as indicated by a low body mass index (BMI), short stature, anemia, or other micronutrient deficiencies has a greater risk of obstructed labor, of having a baby with low birth weight, of producing lower quality breast milk, of mortality due to postpartum hemorrhage, and of morbidity of both herself and her baby.

Community members and key informants in Nzara report that malnutrition is a key concern, including wasting, especially for children under the age of five. Malnutrition, however, is reportedly not recognized as a health concern that is treatable at clinics, and some mothers, especially in more rural areas, blame unknown causes for a child “not being well” and do not believe a clinic is able to provide treatment for the child. There is general lack of understanding and knowledge about malnutrition in many areas.

Female community members report that malnutrition, or food insecurity for many females, is more common during the dry season when there is not adequate water to grow vegetables. During the rainy season they report growing adequate amounts of food, but it does not last through the dry season so many families go hungry.

Female community members report that when food is scarce typically the male head of household is the first to eat, followed by boys and girls, and the mother eats last. Women in Nzara County noted that it is very common for girls and women in their community to exchange sex for money in order to buy food. During focus group discussions in Nzara County, women in particular commonly reported that women and children in polygamous households are often treated differently. In one typical example provided, a mother with six children was divorced from her husband, but the children remained living with the father (per his rights to his children). Although the mother had a garden of cassava, another wife of their father did not allow the children to harvest or prepare the cassava; that responsibility was hers to distribute, which she did by allocating more of the cassava to her own children than she did to the six children of the mother who was divorced. This common story in Nzara County holds true for children of “unfavored” wives in polygamous households, as well as orphans, who are often reportedly neglected in terms of food and emotional security.

3.6.1. NUTRITIONAL STATUS OF CHILDREN

Malnutrition places children at increased risk of morbidity and mortality and has also been shown to be related to impaired mental development. Anthropometry provides one of the most important indicators of children’s nutritional status.

Nationally, nearly 28 percent (27.6 percent) of all children under age of five are moderately or severely underweight--30.4 percent of boys and 24.5 percent of girls under age five are classified as moderately or severely underweight, while 14.3 percent of boys and 9.9 percent of girls under age five are classified as severely underweight. In Western Equatoria State 18.2 percent of children under age five are moderately or severely underweight, while 5.9 percent are severely underweight (SHHS II).

The survey used in Nzara County used the Mid Upper arm Circumference (MUAC to) assess the nutritional status of children. Out of the children from Nzara County measured as part of this survey, 22 percent in rural areas and 10 percent from peri-urban areas were

found to be suffering from malnutrition or at risk of malnutrition. About 3 percent of the children in rural areas and one percent from peri-urban areas from Nzara County included in this survey were found to have severe acute malnutrition (defined as those children whose MUAC is less than 110mm), while 7 percent from rural areas and 5 percent from peri-urban areas had moderate acute malnutrition (defines as those children whose MUAC is between 110- 125mm). Generally, the risk of acute malnutrition in Nzara (defined as those children whose MUAC is between 125 mm and 135mm) in rural areas is 12 percent and 4 percent in peri-urban areas. The prevalence of edema is 48 percent in peri-urban areas and 17 percent in rural areas. Children in polygamous families are more likely to suffer from severe acute malnutrition (12 percent) then are children from monogamous families (2 percent), are more likely to suffer from moderate acute malnutrition (27 percent) compared to children from monogamous families (4 percent), and are at more risk (31 percent) of malnutrition than children in monogamous families (7 percent). Over three- quarters (78 percent) of children from polygamous families whose MUAC was measured were found to be suffering from, or at risk of, malnutrition, compared to 12 percent of children from monogamous families.

Further, differences were found within polygamous families—where some children in polygamous families belonging to one wife were not suffering from or at risk of malnutrition, children belonging to a co-wife in numerous instances were suffering or at risk, which points to discrepancies in treatment of wives and children, as well as poor health outcomes, in polygamous families.

FIGURE 16 PREVALENCE OF MALNUTRITION OF CHILDREN IN NZARA

SAMPLE SIZE: N=485 (PERI-URBAN=95; RURAL=190)

3.6.2 BREASTFEEDING AND SUPPLEMENTATION

Breastfeeding practices and introduction of supplemental foods are important determinants of the nutritional status of children, particularly those under the age of two years. With improved nutritional status, the risk of mortality among children under five years can be reduced and their psycho-motor development enhanced. It is widely reported that breast milk is uncontaminated and contains all the nutrients needed by children in the first six months of life. Supplementing breast milk before six months of age is unnecessary and discouraged because of the likelihood of contamination, which may result in the risk of diarrheal diseases.

3.6.2.1 INITIATION OF BREASTFEEDING

Early initiation of breastfeeding is characterized as putting the infant to the breast within one hour of birth and is measured using the indicator: timely initiation of breastfeeding. Colostrum, which is contained in the very first breast milk after delivery, has been shown to be highly nutritious and to contain a high concentration of antibodies which protect babies from infection before the child’s immune system has matured. Early initiation of breastfeeding fosters strong bonding between the mother and child in addition to the stimulation of milk production in mothers that facilitate the release of oxytocin that helps in contraction of the uterus and reduces postpartum blood loss and is known to play a significant role Image: Mother breastfeeds child in Nzara County in reducing neonatal and infant mortality.

The majority (40.2 percent) of the mothers surveyed in Nzara initiated breastfeeding within hours after delivery, and 93.6 percent reported that they ever breastfed.

3.6.2.2 EXCLUSIVE BREASTFEEDING FOR 6 MONTHS

UNICEF and WHO recommend that children be exclusively breastfed during the first 6 months of life and that children be given solid or semisolid complementary food in addition to continued breastfeeding from 6 months until 24 months or more when the child is fully weaned. Exclusive breastfeeding is recommended because breast milk is uncontaminated and contains all the nutrients necessary for children in the first few months of life. In addition, the mother’s antibodies in breast milk provide immunity to disease. Early

supplementation is discouraged for several reasons. First, it exposes infants to pathogens and increases their risk of infection, especially disease. Second, it decreases infants’ intake of breast milk and therefore suckling, which reduces breast milk production. Third, in low- resource settings, supplementary food is often nutritionally inferior. Nationally, a little over 45 percent of children who are younger than six months of age are exclusively breastfed in South Sudan, although 72.9 percent are predominantly breastfed (SHHS II). (SHHS II).

Some male and female community members report that once a woman becomes pregnant again, which sometimes happens before the baby is six months old, women “must stop breastfeeding.” In these cases, some men from Sangua observe that the infant who stops nursing “has delays in walking,” which points to potential observations in physical/ mental development delays, possibly due to lack of proper nutrition, for young infants/ toddlers who are no longer breastfeeding.

3.6.2.3 COMPLEMENTARY FEEDING IN CHILDREN

When breast milk is no longer enough to meet the nutritional needs of the infant, complementary foods should be added to the diet of the child. The transition from exclusive breastfeeding to family foods, referred to as complementary feeding, typically covers the period from six to 18-24 months of age, and is a very vulnerable period. It is the time when malnutrition starts in many infants, contributing significantly to the high prevalence of malnutrition in children under five years of age world-wide.

Complementary feeding should be timely, meaning that all infants should start receiving foods in addition to breast milk from six months onwards. It should be adequate, meaning that the complementary foods should be given in amounts, frequency, consistency and using a variety of foods to cover the nutritional needs of the growing child while maintaining breastfeeding. Foods should be prepared and given in a safe manner, meaning that measures are taken to minimize the risk of contamination with pathogens. And they should be given in a way that is appropriate, meaning that foods are of appropriate texture

for the age of the child and applying responsive feeding following the principles of psycho- social care.

In Nzara County, 19 percent of children from families surveyed in rural areas ate foods from only one to two food groups the day prior, compared to 20 percent of children from peri-urban areas who were reported to have eaten foods from only one to two food groups. Only 16 percent of children from peri-urban areas were reported to eat foods from all seven to eight food groups, compared to 23 percent of children from rural households were reported to eat from the same number of food groups.

During focus group discussions many community members report that frequently children only eat cassava leaves once or twice per day, and once in a while a family may also serve the child roasted potatoes with the leaves. Many families are engaged in subsistence farming and grow a variety of foods, including cassava, maize, rice, beans, and vegetables. However, there are some families who “do not want to cultivate,” and have little access to food. Families that are cultivating typically have more food, and more variety, during the rainy season than during the dry season. The household survey was conducted during the dry season, which may reflect less food variety and quantities than at other times of the year.

FIGURE 17 PERCENTAGE OF CHILDREN EATING FOOD FROM EIGHT FOOD GROUPS

Percentage of Children Who Ate From Eight Food Groups 40% 34% 35% 30% 31% 30% 27% 25% 23% 19%20% 20% 16% 15% Peri-urban Percentage 10% Rural 5% 0% 1-2 Types 3-4 Types 5-6 Types 7-8 Types Number of Food Groups Consumed

SAMPLE SIZE: N=483 (PERI-URBAN=94; RURAL=388)

The baseline survey identified the other foods are given to children in Nzara County as part of their complementary feeding in children. The baseline established that the majority of both rural (66 percent) and peri-urban (69 percent) children are eating “other solid or soft foods,” which could be potatoes or cassava, which are main staple foods in the area. The most commonly used foods given to children under the age of five include bread, rice, noodles, or other foods made from grains (74 percent) in peri-urban and 59 percent in rural), grains in the form of porridge (30 percent in rural and 48 percent in peri-urban), and dark leafy greens rich in Vitamin A (53 percent in rural and 58 percent in peri-urban). Notably, many more children from peri-urban areas (57 percent) than from rural areas (21 percent) were reported to eat sugary foods.

FIGURE 18 PERCENTAGE OF CHILDREN IN NZARA WHO ATE FOODS YESTERDAY

Percentage Under Fives who ate Specific Foods the Previous Day

Sugary foods Tea/Coffee Legumes (Beans, peas, lentils, nuts) Meat (beef, pork, lamb, chicken, goat) Eggs Vit A (Palm Oil/Palm Nut Sauce) Vit A Veg /Fruit (Dark green leafy)

Grain (Potato/Cassava) Food GroupsFood(Types) Grain (Porridge) Diairy (Cheese/Yogurt) Diairy (Formula)

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% Percentage

Rural Peri-urban

Out of the mothers who were surveyed in Nzara County, they reported that one-third (33 percent) of their children under the age of five ate no meals the day prior to the survey during the day or night (e.g., solid, semi-solid, soft foods other than liquid). Just over one- quarter (27.5 percent reported that their child ate one meal the day prior, and 20.7 percent reported that their child ate two meals the day prior, while only 18 percent reported that their child ate three or more meals the day prior. The majority of families surveyed in Nzara in both rural areas (65 percent) and peri-urban areas (74 percent) report that their family ate two meals together the day prior to the survey.

FIGURE 19 PERCENTAGE OF FAMILIES IN NZARA WHO ATE MEALS TOGETHER YESTERDAY

Meals Eaten as a Family the Previous Day

80% 74% 70% 65% 60% 50% 40% Peri-urban

Percentage 30% Rural 18% 20% 15% 15% 11% 10% 0% 0% 0% 3% 0% None One Meal Two Meals Three Meals Four Meals Meals

SAMPLE SIZE: N=496; (PERI-URBAN=96, RURAL=400)

3.6.3 MICRONUTRIENT INTAKE AMONG CHILDREN

A serious contributor to childhood morbidity and mortality is micronutrient deficiency. Children can receive micronutrients from foods, food fortification, and direct supplementation. Vitamin A is an essential micronutrient for the immune system and plays an important role in maintaining the epithelial tissue in the body. Severe vitamin A deficiency (VAD) can cause eye damage. VAD can also increase severity of infections

such as measles and diarrhea diseases in children and slow recovery from illness. Vitamin A is found in breast milk, other milks, liver, eggs, fish, butter, red palm oil, mangoes, papayas, carrots, pumpkins, and dark green leafy vegetables. The liver can store an adequate amount of the vitamin for four to six months. Periodic dosing (usually every six months) of vitamin A supplements is one method of ensuring that children at risk do not develop VAD.

Nearly two-thirds of women (64 percent) surveyed in Nzara County reported that their child between six to 59 months were given vitamin A supplements in the six months before the survey. Mothers from peri-urban areas were more likely (77 percent) than mothers from rural areas (61 percent) to report Vitamin A supplementation. Nationally, 39.8 percent of children age six to 59 months received vitamin A supplements in the six months preceding the SHHS II survey (SHHS II).

3.6.4 MICRONUTRIENT INTAKE AMONG MOTHERS

Adequate micronutrient intake by women has important benefits for both women and their children. Breastfeeding children benefit from micronutrient supplementation that mothers receive, especially vitamin A. Iron supplementation of women during pregnancy protects the mother and infant against anemia, which is estimated to cause one-fifth of perinatal mortality and one-tenth of maternal mortality. Anemia also results in an increased risk of premature delivery and low birth weight. Finally, iodine deficiency is also related to a number of adverse pregnancy outcomes.

With regard to iron supplementation during pregnancy, 79.4 percent of women in Nzara County reported taking iron folate tablets during the pregnancy of their most recent birth. Women living in peri-urban areas were more likely to report iron supplementation (89 percent) compared to women in rural areas (77 percent).

3.7 MALARIA

Malaria is among the leading causes of death of children under age five in South Sudan (SHHS II). Research shows that preventive measures, especially the use of insecticide treated mosquito nets (ITNs), can dramatically reduce malaria mortality rates among children (SHHS II). In areas where malaria is common, research suggests treating any fever in children as if it were malaria and immediately giving the child a full course of internationally recommended anti-malarial tablets. The best available treatment is Artemisinin-based combination therapy (ACT), adopted by the Ministry of Health in South Sudan and as a protocol for related treatment (SHHS II). Intermittent Preventive Treatment (ITP) of malaria is a key strategy to reduce the burden of malaria in pregnancy and has been adopted by the system and are included in the Antenatal Care protocol: pregnant women in South Sudan are advised to receive at least 2 doses of Sulfadoxine- Pyrimethamine (SP) and all women known to be infected with HIV should receive at least three doses (SHHS II).

Community members in Nzara County cite malaria as a main cause of death among children who are exposed by spending frequent time outside and have low immunity. However, some community members report that malaria is especially a problem in more remote areas, and is especially a problem during rainy season. Particularly in more remote areas parents fear traveling very far to a clinic where they will have to wait a long time and that there may be stock-outs of treatment. Community members report frequency of illness of children under five with complications such as anemia.

3.7.1 OWNERSHIP AND USE OF LONG LASTING INSECTICIDE TREATED NETS (LLITNS)

Long Lasting Insecticide Treated Nets (LLITNs) are shown to significantly reduce the incidence of malaria in endemic areas.

All sampled women in Nzara County were asked if they have a long lasting insecticide treated net LLITN within their households. Most households (81.6 percent) in Nzara

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County were observed to have LLITNs. With regard to sleeping under LLITNs during last night before survey, women in Nzara County reported that 75.4 percent of the children and 76.7 percent of the mothers slept under a net last night. Nationally, household survey results indicate that, 52.3 percent of all households own at least one mosquito net, out of which only 34.2 percent of them are a long lasting, treated net (SHHS II).

Community members and key informants report that many families have received two nets, but complain that it is not enough for all the family members for many homes where there are more than 10 family members, joint family systems, or many children. Some key informants report that this may be an excuse, and many people do not hang their nets, but rather leave it in the package, or misuse the nets for fishing or other purposes.

3.8 HIV AND AIDS

The high levels of HIV transmission through sexual intercourse make negotiating safer sex indispensable. This is especially the case in marital unions, where women’s status is compromised by societal expectations, thereby increasing their vulnerability to HIV transmission. This is further compounded by the high prevalence of polygamous households where condom use is low, further increasing the risk of HIV transmission.

Comprehensive knowledge of HIV prevention methods among women aged 15-49 years remains fairly low (8.6 percent) in South Sudan. Comprehensive knowledge of HIV transmission is defined as knowing one has a monogamous relationship with an uninfected partner, is using a condom every time one has sex, knowing that healthy looking people could still have HIV, and knowing that mosquito bites, supernatural means and sharing food do not transmit the HIV. Close to 9 percent of the respondents report comprehensive knowledge of HIV/AIDS and only 15 percent of the respondents have knowledge encircling three means of mother-to-child HIV transmission (SHHS II).

In Western Equatoria State, 91 percent of survey respondents report having heard of HIV, while 70.4 percent knew that having only one partner can reduce risk, and only 50.6 percent knew that using a condom every time they had sex could reduce their risk (SHHS II).

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An overwhelming majority (99.2 percent) of the women surveyed in Nzara County have heard of an illness called AIDs and out of these, 83.4 percent know that people can reduce their chances of getting the AIDS virus by having just one sex partner who is not infected and who has no other partners.

With regard to management of HIV/AIDS, 51.7 percent of women in Nzara County have heard of the special drugs used in management for HIV/AIDS and 49.6 percent know that the food taken can affect how well the HIV/AIDS drugs work in an HIV-infected person.

With regard to testing for HIV, 28.5 percent of women surveyed in Nzara County tested for HIV within the past three months. Only 9.4 percent of women surveyed in Nzara County have never been tested for HIV. Slightly more women from rural areas (9.94 percent) have never been tested than women from peri-urban areas (7.3 percent), and a much greater proportion of women from rural areas (32.7 percent) have been tested in the past three months than have women from peri-urban areas (11.6 percent).

FIGURE 20: PERCENTAGE OF WOMEN TESTED FOR HIV HIV Tested 35% 33%

30% 28% 28%

25% 23% 21% 19% 20% 15% 15% 12%

Percentage 10% Peri-urban 10% 7% Rural 5% 1% 2% 0% <3 MONTHS 3-6 6 MONTHS >1 YEAR DON’T NEVER AGO MONTHS – 1 YEAR KNOW AGO HIV Tested

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SAMPLE SIZE: N=477 (PERI-URBAN=95; RURAL=382)

Community members and key informants in Nzara report that HIV/AIDS is one of the main health concerns for men, women, married couples, adolescents, children, and babies in Nzara County.

Key informants in the area report that co-infection is also a concern, particularly with syphilis among women and men. Community members and key informants also note that there is a concern about sexually transmitted infections such as syphilis, gonorrhea, and chlamydia. Community members also observe increase in syphilis among young women and men, and particularly among married couples, as well as re-infection (e.g. a woman is treated and partner is not, and she becomes re-infected). Women also have frequent and recurrent yeast infection. TBAs in the area report that people do not want to disclose that they have STIs, or discuss it, so they need to be convinced to get treatment. Although men are supposed to come for partner testing and treatment, they do not typically come, and re-infection of a treated woman often occurs.

Community members and key informants in Nzara note the following as key risk factors driving the spread of HIV in the area: - Low condom use/ men refuse to use condoms - Women have little negotiating power in the bedroom-they are “not allowed” to say no to sex with their husband - Women and men, married and unmarried, have multiple sexual partners (men reportedly out of desire, and women out of revenge if she suspects husband is cheating) - Increased use of alcohol among men which results in poor decision-making among sexual partners and promiscuity - Poor economic situations resulting in high numbers of women and girls exchanging sex for money - Increase of population movement (e.g., military camps with male soldiers from other parts of the country; immigrants from DRC, Uganda, and other places). - Sharing of razor blades

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Community members report “MEN JUST SAY WE WERE DYING that there is high knowledge BEFORE AND WE ARE STILL DYING and education about HIV, how NOW, SO WHO CARES? EVEN IF A to prevent it, and about testing WOMAN TELLS HIM SHE IS HIV POSITIVE, HE WILL JUST SAY, ‘YOU and treatment. They also report ARE SO BEAUTIFUL. SO SEND ME TO increased openness to discuss MY GRAVE.’” - Female community member from Nzara HIV. However, many community members also report that many community members, particularly men, do not wish to be tested. More women than men are reported to get tested, as it is mandatory during ANC; although men are supposed to also be tested at this time some refuse. Many men, in particular, wait to get tested and treated until they are very sick.

ART is free in South Sudan, and there are increased numbers of people in Nzara County receiving treatment. Children and babies that are tested typically adhere to treatment. However, there is still lack of knowledge about adherence to ARVs, and some do not take medicine. Some people stop taking the treatment if they begin to feel better. Most importantly, ART is not available in most payams and at most PHCCs and PHCUs—the only way for clients to receive treatment is to travel to Nzara PHCC, which for many is prohibitive due to the distance and lack of money for transport. For some who live long distances via difficult, and sometimes impassable roads (e.g. Basukangbi Payam), traveling to Nzara PHCC for ART is not a viable option so they go without treatment.

There are reportedly many orphans who live within Nzara County, orphaned due to one or both parents dying of HIV/AIDS. Although some grandmothers care for orphaned grandchildren, there are also many children who are left without homes or care.

3.9 NON COMMUNICABLE DISEASES

Just over half (54.9 percent) of the respondents have heard about non-communicable diseases such as cancer, diabetes and hypertension. When asked about whether there is any member of the family who has suffered this diseases, 11.6 percent said they have members

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diagnosed with diabetes while 12 percent of the respondents have been positively diagnosed for cardiovascular disease, hypertension or high blood pressure. Similarly, 12.7 percent of the respondents have a member of their family suffering from or have ever been positively diagnosed for cervical cancer while six percent have a member of their family suffering from or have ever been positively diagnosed for prostate cancer. Those who are currently suffering from or have ever been positively diagnosed for breast cancer were reported to be 16.6 percent.

Some community members in Nzara County noted that women sometimes suffer from “pain in the lower abdomen,” which they call “hernia of women,” and can lead to miscarriage or infertility. This could be indication of the presence of conditions such as endometriosis or cervical cancer.

On average, less than nine percent of the respondents have information on early diagnosis and early treatment of these non-communicable diseases and only 8.5 percent know where one can receive diagnosis and treatment for these diseases.

Community members and key informants in Nzara cite alcoholism as a key health concern in the area. Many women throughout the county in both peri-urban and rural areas brew a homemade beer from cassava which they sell for profit. It is identified, in particular by female community members, as a driving factor behind GBV, HIV, and preventing access to nutritious foods, education, and healthcare in the area. Community members note that radio talks and speeches have been held by politicians about alcohol abuse, but that it is not making much of a difference; they note that the real difference will come if the chiefs stop drinking alcohol and lead by example for other men.

There is not common recognition about what cancer is generally among community members, and there is little observed awareness of different types of cancers, if it exists in the community, and testing and treatment available for it. When cervical cancer is brought up, many female community members do not know about it. No screening, testing, or treatment for cervical cancer is offered anywhere in Nzara County, and many

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health workers at PHCCs and PHCUs are also not aware of what cervical cancer is, or how to test for it.

Other non-communicable diseases mentioned by community members as a problem in the community include: - Asthma, coughing, and other respiratory ailments reported by community members to be caused by “bad air.” - Blood pressure and stroke. - Glaucoma. - Skin rashes. - Toothache (leading to serious infection and death). - Hernia (for which many community members report there is no treatment).

3.10 WATER AND SANITATION

Human health is inextricably linked to a range of water-related conditions such as access to safe drinking water, sufficient sanitation, minimized burden of water-related disease and healthy freshwater ecosystems. It is thus vital that the ways in which water use and sanitation are managed are improved in order to increase progress towards meeting the Millennium Development Goals (MDGs) related to human health. Apart from the MDG that is linked to Water, Sanitation and Hygiene (WASH): 'Reduce by half, by 2015, the proportion of people without sustainable access to safe drinking water,’ hygiene is also linked to the health of women and children who are most vulnerable and who bear the burden of the disease in many parts of Sub-Saharan Africa.

Nationally, only 2.1 percent of South Sudanese households have water on the premises (SHHS II). For households without improved drinking water facilities onsite, some members of these households travel far distances to collect water; on average 33 percent of individuals travel at least 30 minutes to get to the nearest site with safe, drinking water, while 33.5 percent travel more than 30 minutes to collect it (SHHS II). Nationally, 68.7 percent of the household population has access to improved drinking water sources (SHHS II).

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Image: Girl pumps water from community borehole in Nzara County

3.10.1 ACCESS TO SAFE AND ADEQUATE DRINKING WATER

The survey sought to establish the availability and access to safe and adequate water supply to the communities in the intervention areas. In so doing, the conventional indicators of availability and access were assessed, including: source of water, distance to water source; time spent to collect water from the source and quality of water used by the households.

3.10.1.1 MAIN SOURCES OF WATER

The survey looked at access to improved water sources. “Improved” sources of drinking- water is defined using the UNICEF/WHO guideline which included any of the following sources: piped water into dwelling, piped water to yard/plot; public tap or standpipe; tube well or borehole; protected dug well; protected spring. Although three-quarters (77 percent) of households in peri-urban areas of Nzara County report using boreholes as their

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main water source, the majority (68 percent) of rural households surveyed in Nzara County use unimproved water sources such as unprotected dug well (50 percent), surface water (13 percent), or unprotected spring (3 percent).

FIGURE 21: DRINKING WATER SOURCES IN NZARA Drinking Water Sources 90% 77% 80% 70% 60% 50% 50% 40%

Percentage 30% 17% 20% 13% 15% 13% 10% 4% Peri-urban 1%3% 0%0% 1%0% 0%1% 2%3% 0%1% 0% 0% Rural

Water Source

SAMPLE SIZE: N=492 (PERI-URBAN=95; RURAL=397)

Community members and key informants throughout Nzara County report that the main source of water is from surface water, including streams, ponds, and other small stagnant pools. There are very few boreholes, and any fewer that are functioning. In most communities throughout all payams in Nzara County, lack of access to clean water is noted as a primary concern, and very few communities have access to a functioning borehole—there are very few to begin with, and many communities noted that the ones that exist are broken. In the area surrounding Sangua II PHCU, for example, community members report that they primarily use standing water in the form of unmoving streams

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with contaminated with animal and human use; the water is very cloudy and smells bad, yet people do not treat it as they believe that if they boil it the water will lose its taste.

There is a private hand pump in Nzara Payam where users must pay collectively if it breaks down; many who are not able to pay such fees do not use it, and collect water from Ndere Stream or Nzara River. Many PHCCs and PHCUs also do not have piped water or a functioning facility borehole, and health facility staff must walk some distance to the nearest community borehole for water for facilities.

3.10.1.2 DISTANCE AND TIME TO WATER SOURCE

Distance to the household’s water sources and time spent collecting water, are some of the critical indicators used to determine water availability and access. The WHO recommends the source to be within a 1km walking distance, or 30 minutes per roundtrip. The 30 minutes is inclusive of walking to the source, cuing and walking back home without rest.

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FIGURE 22 AVERAGE DISTANCE TO WATER SOURCE IN NZARA Distance to Water Source 60% 49% 50% 39% 38% 40% 30% 17% 20% 14% 12% Percentage 9% 11% 8% 10% 2% 0% Within the Less than 1 1kms – 2 kms 2 - 5 kms Over 5 kms compound km Distance

Peri-Urban Rural

SAMPLE SIZE: N=497 (PERI-URBAN=96; RURAL=401)

Community members in Nzara County report that women and girls are primarily responsible for fetching water. This is consistent with national household survey findings, which found that in South Sudan, water collection for households is often carried out by young women, and specifically that nearly 86 percent of those collecting water for households are women aged 15 and older, while 9 percent are young women 15 or under (SHHS II). However, in some places, such as in Sangua, women report that all family members (female, male, girls, and boys) take turns in shifts fetching water due to the distance to water source (e.g. it takes some over two hours to walk to fetch water), so families share the burden. Community members from across Nzara County in rural areas report that it can often take anywhere from two to five hours to fetch water.

3.10.1.3 WATER TREATMENT AND STORAGE

The findings revealed a majority (85 percent) of the households in Nzara County took no action to make their water safe while only 14 percent reported that they treat their water. Significantly more households from peri-urban areas (96.7 percent) report that they take no action to make their water safe compared to 82.1 percent of rural households.

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With regard to storage of water, the majority of respondents (51 percent) in Nzara County do not have a special container for storing water in their households. Far more rural households (62 percent) do not have a special container for storing water than do peri- urban households (9 percent).

Community members in Nzara County report that many families collect drinking water directly from surface water sources that may be contaminated by human and animal feces and from washing. Some community members report that during rainy season there are more problem with rain draining waste into water sources, and as a result more incidences of diarrhea.

However, most community members interviewed reported that treating water is not widely practiced in the area. Community members note the following reasons for not treating drinking water: - They have no chlorine (e.g. there are reports of organizations providing to community but they quickly run out of stock), and/or they do not like the way that the tablets change the smell/ taste of the water. - It takes too much time to boil water, or they do not have a pot for boiling water. - Treated water (e.g. via boiling) loses its taste and people don’t like to drink it. - Many people believe that if it looks clear it is safe to drink. - Lack of education about why to treat water, how to treat water, and little public discussion about hygiene and sanitation.

3.10.2 ACCESS TO SANITATION FACILITIES AND PRACTICES

3.10.2.1 HOUSEHOLD LATRINE COVERAGE AND USAGE

Nationally, only 7.4 percent of household population use improved sanitary facilities, compared to 64 percent who use open air spaces to dispose of human wastes (SHHS II).

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Only 8 percent of women in Nzara County report that their family has no access to a latrine and uses the bush outside their homes to relieve themselves. The majority (91 percent) of households from rural areas report having access to a latrine as compared to 96 percent of households in peri-urban Nzara Payam. Among those who do not have a latrine, the reasons cited for lack of a latrine were mainly attributed to the high cost of construction (46 percent), while 23 percent did not respond, 11.5 percent don’t see the need to have one, and 11 percent reported it is due to poor soils.

There have been many recent efforts by various INGOs operating in Nzara County to improve sanitation throughout the area, with several “Open-Defecation Free” bomas. Many communities report that every household has a latrine, although there are many households that remain without latrines. In Sangua, men reported that the community held open community meetings where they publicly shamed several families into building a latrine for their homes. As a result many families were prompted to also build their own latrines to avoid similar public shaming. This was considered by the men in the community to be successful. However, communities report that some households remain without latrines.

In addition, due to poor latrine conditions, or no latrines, and no running water at school facilities, most girls, once they are menstruating, do not attend school when they expect to menstruate and through their menses. They do this because there is no way to clean themselves and do not want “feel ashamed.”

3.10.2.2: DISPOSAL OF CHILD’S STOOL

In terms of disposal of children’s fecal matter the majority of mothers from both peri-urban households (95 percent) and rural households (87 percent) report that the child’s stools are thrown away into the latrine. Nationally, fewer than 16 percent of households practice safe disposal of children’s waste (SHHS II).

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FIGURE 23 CHILD STOOL DISPOSAL PRACTICES

Disposal Practices in Nzara 100% 95% 87% 90% 80% 70% 60% 50% 40% Percentage 30% 20% Peri-urban 10% 2% 2%5% 2%5% 0% 1%1% 0%0% Rural 0% Child's Child’s Child’s Child’s Child’s Others stools are stools are stools are stools are stools are (specify) always buried in thrown in thrown rinsed thrown the yard the yard outside the away while into the yard washing latrine Disposal Practices

SAMPLE SIZE: N=492 PERI-URBAN 95; RURAL 397

3.10.2.3 HAND WASHING PRACTICE

More women from peri-urban areas (84 percent) in Nzara County report using soap to wash their hands than do women from rural areas (56 percent). One-quarter (25 percent) of women from rural areas report that they use nothing to wash hands, compared to 8 percent of peri-urban women who reported the same. Women from rural areas also use ash (10 percent), mud/sand (4 percent), and detergent (4 percent) to wash their hands.

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FIGURE 24 HANDWASHING PRACTICES Hand Washing 90% 84% 80% 70% 60% 56% 50% 40%

Percentage 25% 30% Peri-urban 20% 10% 8% Rural 4% 5% 4% 10% 3% 0% 0%1% 0%

Handwashing Practice

SAMPLE SIZE: N=256 (PERI-URBAN=38; RURAL= 218)

Hand washing practice at critical times is important in the prevention of diarrhea, especially amongst children. Out of the 376 respondents who answered this question, 99.7 percent reported that they know the times it is important to wash hands.

This is consistent with qualitative findings where female and male community members reported that they have received ongoing information regarding the importance of washing hands via workshops and radio campaigns. Men in Sangua Payam, for example, report that this has been effective and families are now washing hands, perhaps in their desire to provide the “correct” answer. However, female community members from the same area in Sangua Payam report that despite increased knowledge, most people still typically do not wash their hands frequently, one citing, “It’s our own fault.” The following reasons the female community members provided for lack of hand washing include: - Many people do not want to bother; despite having the information they do not have the direct tangible connection between hand washing and illness.

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- Many people believe that “God has created everything pure so we cannot be dirty,” so they do not see the real value in hand washing, despite the knowledge. - Many people cannot afford to buy soap.

3.11: HEALTH SEEKING BEHAVIOUR

In an attempt to assess the health seeking behavior of the respondents, the women surveyed in Nzara were asked how often they have come in contact with health care providers. The most frequently ever seen health care provider for rural women (38 percent) was community health workers, compared to only 9 percent of peri-urban who reported the same. The most frequently ever seen health care provider for peri-urban women (36 percent) was a nurse/ mid-wife, compared to only 14 percent of women from rural areas. A much higher proportion of women from peri-urban areas (17 percent) reported seeing a doctor compared to only three percent of women from rural areas. Slightly more rural women (8 percent) reported seeing a TBA compared to peri-urban women (4 percent), although five percent of both peri-urban and rural women reported seeing a traditional healer.

FIGURE 25 FREQUENCY OF EVER SEEING HEALTH CARE PROVIDERS

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Health Service Provider Seen 45% 38% 40% 36% 35% 30% 25% 20% 17% 14%

Percentage 15% 9% 8% 10% 5% 5% 3% 3% 5% 4% 5% 2% 3% 0%

Health Provider

Peri-urban Rural

SAMPLE SIZE: 490= (PERI-URBAN=95; RURAL=395)

The majority of both peri-urban (82 percent) and rural (76 percent) women in Nzara County surveyed walked to reach the clinic, followed by 16 percent of rural women and six percent of peri-urban women who used a bicycle and nine percent of peri-urban and four percent of rural women who used a motorcycle. Out of the few women surveyed who report using private car, women report paying an average of 10.6SSP (equivalent to 11SSP) for public transport (boda boda, bus).

Community members in focus group discussions also report that although TBAs are often key actors in referring patients in emergency or in complicated cases to Yambio State Hospital or Nzara Mission Hospital, there is a perception that sometimes TBAs delay referring patients because they fear they may not get paid if they refer the patients.

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FIGURE 10 MODE OF TRANSPORT TO CLINIC Mode of Transport to Health Facility

90% 82% 80% 76% 70% 60% Peri-Urban 50% Rural 40%

Percentage 30% 20% 16% 9% 10% 6% 4% 0% 1% 1% 3% 1% 0% 1% 0% 0% Wheel Walked Donkey Bicycle Motorcycle Matatu Bus barrow / cart Transport

SAMPLE SIZE: N=482 (PERI-URBAN=93; RURAL=389)

As expected, the majority of women (97 percent) from peri-urban areas need to travel less than 10km to the nearest health facility, presumably to Nzara Mission Hospital, Nzara PHCC, or Good Samaritan PHCC, compared to 86 percent of women from rural areas who travel less than 10km to reach the nearest facility, while 13 percent of women from rural areas must travel between 11 to 30 km to reach the nearest health facility.

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FIGURE 11 DISTANCE TO NEAREST HEALTH FACILITY

Distance to Nearest Health Facility 120% 97% 100% 86% 80% Peri-urban 60% Rural

Percentage 40%

20% 13% 1% 2% 1% 0% 1% 0% 0% 0% 0-10km 11-30km 31-60km 61-100km 100+km Distance

SAMPLE SIZE: N=483 (PERI-URBAN=91; RURAL=392)

Community members and key stakeholders identified multiple factors that influence health-seeking behavior, some of which have been mentioned previously. Some of these factors identified include: - Too far of distance on bad roads to Nzara hospital and Nzara PHCC where services such as ART, vaccines, and emergency obstetric care can be performed discourages people from seeking care: Most roads are sandy and difficult to pass, particularly for those who may be traveling by foot. Some roads are impassable during the rainy season; Basukangbi has one of the worst roads, and also does not provide essential services at the PHCC or PHCUs, such as vaccines, TT, or management of complicated or abnormal births. Further, many of the PHCCs and PHCUs do not have adequate treatment, drugs, and many are not equipped to handle emergency cases, which requires additional travel from the PHCC to Nzara MH. None of the PHCCs have a vehicle to transport a client to Nzara MH, so they must rely upon tying emergency patients to the backs of bicycles, finding a hired boda boda, or identifying a vehicle from the Diocese or an INGO for transport.

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Image: Feeder track road (sand/ dirt) from Yambio to Nzara

- Lack of 24 hour care, inadequate staff and supplies at PHCCs and PHCUs discourages people from making long journeys: If people are able to travel long distances, typically by foot or bicycle, to reach a PHCC or PHCU, many are skeptical that they will be able to receive the care or treatment that they seek. In addition, poor phone network (e.g. phone signal) in the area prohibits many people from calling a facility before traveling. Many community members report that because most PHCCs and PHCUs are not open on nights and weekends, they typically do not visit the clinic in an emergency with a sick child as they will be referred to Nzara, so they stay at home instead. Community members report that this sometimes can lead to a child dying. However, in the case of a woman delivering a baby, clinic staff are typically available on-call after hours. Nevertheless, many community members report that the treatment they receive from midwives, in particular, from Nzara PHCC is very poor, with stories of neglect and verbal abuse of women in labor; for this reason, many women prefer to deliver

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at home. In addition, there are frequent drug stock-outs, so, if for example, someone walks with a sick child for malaria drugs or ORS, they may arrive to the facility to find the drugs not available. Improper temperatures to keep drugs, refrigeration issues, lack of batteries/ maintenance results in ongoing challenges for keeping adequate supplies. Lastly, facilities themselves are not all appealing with poor environmental hygiene, lack of clean, water, etc., which discourages facility use.

- Lack of a functioning referral system and emergency vehicles. As one official concisely stated it, “People are dying before reaching Yambio State Hospital.” The referral system is noted by many stakeholders and providers as the most challenging aspect of providing health care services. IMC currently uses private vehicles in emergencies, but no vehicles or motorbikes are equipped, on-call or used exclusively for emergency services. Compounding this problem, the keeping of data registers at facilities is poor, and data quality is generally poor. Few staff have received training on monitoring, reporting, or HMIS. Many facilities do not record, for example, cases that were referred or outcomes of referred cases, so it is largely unknown if a referred patient attempts to reach the referral facility, made it to the facility, or what the health outcome was. The lack of a reliable referral system and vehicles discourages many patients from embarking on journeys, and many anecdotes were reported about cases of maternal or neonatal death due to client refusal to act upon a referral.

- Lack of education/ awareness regarding the importance of seeking health care services to treat specific ailments prevents many people from seeking services: Many people simply do not know cause of certain disease and the warning signs to look for to prompt them to seek formal medical treatment. For example, an “ill child” suffering from malnutrition may not be identified as needing medical attention or nutrition supplementation; rather, mothers may believe that the child has an unknown ailment that is not treatable. Further, many parents whose children have diarrhea wait until the condition has worsened to seek care. Additionally,

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TBAs and facility midwives are reported to not always be aware of early danger or warning signs of complications in pregnancy that requires referral.

- Cost of receiving care at Nzara Mission Hospital and cost of transportation to reach the hospital (for complicated cases/ referrals) is prohibitive for many people: To receive routine OPD care for children at Nzara Mission Hospital it currently costs 2 South Sudanese pounds, and for adults between 10-20 pounds depending on the service. Nzara Mission Hospital will be slightly raising these prices soon in 2015. Although this cost is very low, for many it is enough that they delay seeking care until the health condition of a child or adult is severe, or sometimes do not seek care, especially in cases of orphans or marginalized children within households. Further, the cost of transport to reach Nzara Mission Hospital from many payams is prohibitive—it often includes the family paying for a boda boda for hire, with payment required in advance, which may cost up to 150-200 pounds. Many anecdotes were told from the community of women in childbirth or children who were sick and were referred to Nzara Mission Hospital, but their families could not afford the transport fees and chose not to travel to the hospital, leading to the death of a child, neonate, or mother.

- Gender inequality and gender-based violence prevent many women and girls from accessing health services: As discussed in previous sections, systemic and ingrained gender inequalities and GBV in the area prevent many women from accessing and controlling family resources. This may prevent women from seeking care for themselves or children, for example, due to the cost of transport or time required to reach clinics due to home and family obligations they must meet. Further, no facility in Nzara County is equipped with procedures or trained staff to handle cases of SGBV, nor do many SGBV survivors seek assistance from a health facility.

- Beliefs in traditional healing and non-medical reasons for illness: Some people believe that if a child falls ill with fever, for example, that it is caused by witchcraft

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and does not warrant a medical visit, but rather traditional healing through a traditional healer or through other non-medical means. One common belief/ misconception among the population in Nzara County is that when babies begin to bud teeth they believe worms are trying to emerge from their gums; the traditional approach to cure the “worms” is by digging them out of the child’s gums with a heated bicycle spoke. This practice is still widely practiced throughout many bomas in Nzara County. Other common conditions that people are reported to seek advice from healers for include jaundice (yellowing of the skin), malaria, epilepsy or convulsions, or poor eating/ wasting.

- Use of traditional birth attendants (TBAs) for home births is familiar and has been practiced for generations. TBAs are well-known to families and communities. Changing the practice of using TBAs and encouraging facility use is challenging, particularly because the service at the facilities and environment may very well be worse than delivering a baby at home in familiar, private, and relatively clean conditions, as mentioned above.

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CHAPTER FOUR - FINDINGS FROM HEALTH FACILITY ASSESMENT

In order to capture the capacity of the health facilitates in the Nzara catchment area to meet the MNCH need in the community, a health facility assessment tool was used to undertake an inventory of MNCH-RH services provided in Nzara County. The assessment tool also captured information for each facility related to staffing; took inventory of equipment and supplies; recorded MNCH-RH service statistics; and other information related to community involvement and funding.

4.1: DESCRIPTION OF HEALTH FACILITIES AND MANAGEMENT

There are a total of 22 health facilities (PHCUs or PHCUs) in Nzara County, excluding the Nzara Mission Hospital. A total of eight health facilities were sampled, which includes the only hospital in the catchment area (Nzara Mission Hospital, a private faith-based facility run by the Camboni Sisters), all five primary health care clinics (PHCCs) in Nzara County, four of which are government facilities which serve four out of the five payams in the county (Nzara, Basukangbi, Ringasi, and Sakure), one faith-based PHCC (Good Samiratan) run by the Catholic Dioecese located in Nzara Payam, and three out of the 17 government primary health care units (PHCUs), Sangua II in Sangua Payam, Nakpazigi PHCU in Ringasi Payam, and Nangirimo PHCU in Sakure Payam. There is no PHCC located in Sangua Payam. All facilities sampled are located within Nzara County of Western Equatoria State.

Although Yambio State Hospital is outside of the catchment area in Nzara County and a facility assessment was not conducted specifically for the hospital, some information is included here as it is identified as a critical care provider for the residents of Nzara County, and serves as a primary referral facility for all complicated cases, such as maternity cases requiring C-section, severe malnutrition, etc.

Yambio State Hospital is a fast growing hospital which is becoming a South Sudan medical training institution, and serves as a referral facility not only for Nzara County, but for all

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of Western Equatoria State. Yambio State Hospital provides integrated maternal, newborn, and child healthcare services with a growing focus of strengthening comprehensive emergency obstetrics and neonatal care [CEMONC] services, and works with Community Health Care Workers and facility-based skilled health providers to address the ‘three delays’ in obstetric care that are often decisive in saving the lives of both the mother and child: 1) the delay in deciding to seek care; 2) the delay in reaching a health facility; and 3) the delay in receiving adequate care and treatment at the facility.

Yambio State Hospital has a capacity of 38 maternity beds, 53 IPD pediatric beds, 28 surgical ward beds, and 10 female and 37 male medical ward beds. Yambio State Hospital is the main referral hospital for complicated cases in Nzara. Yambio State Hospital has 18 beds in ICU where they treat severe malaria, sepsis, and cases of malnourishment. During malaria season they also expand the ICU with two tents and use the General Ward for more mild cases; during peak seasons, such as in September 2014, they peaked at 800 admissions at once. Typically, the hospital handles about 25 cases per month in the ICU, primarily due to chronic malaria, HIV, and TB.

Yambio State Hospital, in addition to providing routine ANC and maternity services, also provides emergency obstetric care, including management of obstructed labor, ectopic pregnancy, and other complications that may require management and C-section. Yambio State Hospital receives referrals from Nzara County for cases of obstructed labor, eclampsia, malpresentation, and at-risk underage girls. It is the only facility in the area with an operating theater to provide these services. Additionally, Yambio State Hospital has a brand new mother waiting shelter with 30 bed capacity. This may be managed by WHO, although it is not yet determined at this time.

Yambio State Hospital sees approximately 1,500 HIV patients per month at the HIV clinic. Official HIV morbidity is 6.8 percent, although it is expected to be higher. They provide ARV treatment and Option B+ to patients. However, they handed over this program to MOH as of May 1.

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Yambio State Hospital also has a psychosocial room, which is also used a health education room. Twice weekly the room is used for stimulation in cases of malnourishment. SGBV victims also use the room to receive psychosocial support. Yambio State Hospital assists SGBV victims with medical care, medical certificate, and psychosocial support.

During the period of 2012- 2014, MSF assisted the hospital to improve the quality of medical practice, which resulted in reducing mortality in half during that period. Recent improvements to the hospital include a recently renovated IPD, HIV, and maternity wards (MSF), a new laboratory and female ward building (UNDP/ Global FUND), brand new operating theater and mother waiting home (WHO), and improved WASH and electrical systems (MSF and UNICEF).

For this reason, Yambio State Hospital is a critical asset in providing life-saving medical services to Nzara County residents. Strengthening and improving the referral processes and identifying realistic transport solutions for emergency cases to Yambio State Hospital are critical. Yambio State Hospital used to have a motorbike for referrals but it has stopped since the MOH donated an ambulance in December 2014. However, the ambulance is not working well due to lack of fuel and funding for operation and maintenance costs. The ambulance only serves Yambio County, and does not serve Nzara County. The referral system is not working well. There are no referrals between facilities and communities, and counties each have their own separate referral system. This is particularly ineffective in the case of Nzara County since the county has no facility or staff to handle many emergency cases and utilize Yambio State Hospital as its main referral facility. However, there are current efforts to standardize referrals with Standard Operating Procedures (SOP) and referral criteria. The Director General of Health for Western Equatoria State who is leading this effort, however, is ill and thus these efforts have come to a halt.

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However, in 2015 MSF is closing its activities and is seeking partners to continue this critical facility that currently is the only option for Nzara County residents for critical care, such as surgery and emergency obstetric care. MOH is taking over with support from various partners, including WHO, UNICEF, UNFPA, and CMMB. Partnerships are still in the process of being managed, as MOH cannot manage alone without external support. UNICEF has taken an active role, and UNDP is bringing doctors and specialists for capacity building. Limitations include a decrease in funding for primary health care due to USAID strategy that excludes primary health care funding. However, there has been good interagency coordination to date in the transition. Challenges expected in the transition, though, include logistical challenges and funding that no one has yet claimed, including cost of generator and water pump, or hygiene cleaners to ensure ongoing cleanliness and hygiene at the hospital.

4.2: ESTIMATED POPULATION IN HEALTH FACILITY CATCHMENT AREA

The entire estimated population in the Nzara Mission Hospital catchment area is 79,995 people, although this is assumed to be an underestimate due to lack of formal birth registration. The following population estimates are provided for each Payam: - Nzara Payam (37,438) - Sangua Payam (12,950). - Basukangbi Payam (8,716). - Ringasi Payam (2,695). - Sakure Payam (18,195). - Sangua II PHCU estimates that before the LRA the catchment area was 5,028 people, but that number has increased since there has been an influx of people following the LRA movement. Sangua is the only payam without a PHCC, and so the catchment area is split between PHCU I and II.

TABLE 8: ESTIMATED CATCHMENT POPULATION, BY PAYAM

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Facility name Estimated Men Women Pregnant Children Pregnant population Women under 5 Women (5.2%) years and (21%) Children under 5 Nzara 79,995 41,854 38,141 4,160 16,799 20,959 County Nzara Centre 37,438 19,246 18,192 1,947 7,862 9,809 Payam Basukangbi 8,716 4,592 4,124 453 1,830 2,284 Payam Sakure 18,195 9,848 8,346 946 3,821 4,767 Payam Sangua 12,950 6,737 6,213 673 2,720 3,393 Payam Sangua II 5,028 NA NA NA NA NA PHCU Nangarimo 655 NA NA NA NA NA PHCU Nakpazigi 4,862 NA NA NA NA NA PHCU

4.3: FACILITY CAPACITY (BEDS)

Nzara Mission Hospital has the most number of beds (135 total), with 60 designated in the pediatric ward, and none designated explicitly for maternity, but at any given time 8-10 are used from the general ward for maternity. There are also two beds designated for delivery in a separate room. Currently, there are 88 beds being used for children at the time of the assessment, which is over the pediatric bed capacity of 60. The beds are in generally okay condition, although the mosquito nets have been removed in the pediatric ward, were the majority of patients are being treated for malaria. The nets were removed due to poor net structures which were falling down and need to be reconfigured.

Nzara PHCC has no general beds and no pediatric beds. There are seven maternity beds and also two delivery beds, all of which are new and in good condition. One was occupied at the time of the facility assessment.

Basukangbi PHCC has a total of six beds, three of which are general beds and the other three which are designated for maternity beds. There are no designated pediatric beds. All

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beds are in good condition. Additionally, there are two new delivery beds in a separate room attached to an ANC exam room.

Good Samaritan PHCC in Nzara Payam has a total of five beds, 3 of which are general examination beds, and two of which are maternity beds with one of those designated as a delivery bed. All beds are functional but with old and much worn mattresses.

Ringasi PHCC has a total of 11 beds, 9 of which are general beds and 2 of which are designated maternity beds; there are no pediatric beds. There is also one delivery bed. Most beds are new and in good condition.

Sakure PHCC has 6 general beds, none of which are designated pediatric beds. One designated maternity bed is placed with another delivery bed in one small room for both ANC and deliveries. The other five beds are placed in one common area. Staff note that this is a problem as men and women are combined together. They noted that recently there was an incident where a woman who just delivered a baby stayed overnight, and another male patient “went to her be during the night,” indicating a serious sexual assault violation.

Sangua II PHCU functions much like a PHCC in the absence of a PHCU. There are a total of five beds, two of which are for general examinations and three of which are for maternity and in very good condition. One of the maternity beds is designated as a delivery bed.

Most PHCUs, like Nakpazigi PHCU and Nangarimo PHCU, do not admit patients and therefore do not have beds, although Nakpazigi PHCU does have a new bed (currently not yet in use).

TABLE 9: FACILITY CAPACITY (BEDS) Facility name Number of Number of Number of Number of Maternity Number of general pediatric pediatric beds in beds delivery beds beds beds maternity currently in beds currently in use currently in use facility Nzara Mission 135 60 88 0 8 2 Hospital

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Nzara PHCC 0 0 NA 7 1 2 Basukangbi 3 0 NA 3 0 2 PHCC Good 3 0 NA 1 0 1 Samaritan PHCC Ringasi PHCC 11 0 NA 2 0 1 Sakure PHCC 6 0 NA 1 0 1 Sangua II 2 0 NA 3 0 1 PHCU

4.4: FACILITY STAFF RESOURCES AND TRAINING

The presence of qualified staff may greatly impact delivery and client utilization of services in a health facility. At all health facilities in Nzara County there is noted understaffing, with no clinical officers or physicians available at any PHCC or PHCU outside of Nzara Payam. There is generally no more than 1-3 trained staff, typically nurses and/or midwives, who are managing and operating each PHCU or PHCC.

Nzara Mission Hospital has the largest number of staff, including 2 medical officers, 16 enrolled nurses, 2 registered nurses, 3 clinical officers, 1 pharmacy assistant, two laboratory assistants, 3 laboratory technicians, and 3 data clerks (3 for HIV and one other). There is also one community health worker. Nzara PHCC has 14 staff consisting of one clinical officer, two certified nurse midwives, four registered nurses, five community nurses, and one laboratory assistant. Additionally, there are two watchmen, five cleaners, and five EPI volunteers. Good Samaritan PHCC has 10 total staff, include two enrolled nurses (one of which serves as the In-Charge), two community midwives, one pharmacy dispenser, one lab technician, two dentists for tooth extraction, one cleaner, and one watchman. Basukangbi PHCC has one nurse midwife, who serves as the In-Charge at the facility, and has one lab technician, one pharmacist, one watchman, and one cleaner. Their positions are funded by the International Medical Corps (IMC). Ringasi PHCC has a total of seven staff comprising one registered nurse (the In-Charge), two registered nurse midwives, one pharmacy assistant, and two community health workers, as well as a watchman and cleaner. Sakure PHCC has the most limited staff with a community health worker who serves as an In-Charge, a Maternal and Child Health worker (MCH) with one

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year of midwifery training, a lab assistant, two watchmen, and four cleaners. Sangua II PHCU has four staff total, consisting of the Nurse In-Charge, a community midwife, a watchman, and a cleaner. PHCUs generally have very few staff—Nangarimo only has one community health worker and no cleaner, watchman, or midwife (although TBAs bring patients to the PHCU for deliveries), and Nakpazigi PHCU has only two staff, a registered nurse working as a Community Health Worker (CHW) and a cleaner.

TABLE 10: FACILITY STAFF POSITIONS Position Nzara Nzara Basuk Good Ringasi Sakure Sangua Mission PHCC angbi Samar PHCC PHCC II PHCU Hospita PHCC itan l PHCC Registered nurses 2 4 0 0 1 0 0 Registered nurse 0 2 1 0 2 0 0 midwives Enrolled nurses 16 0 0 2 0 0 1 Enrolled nurse midwives 0 0 0 0 0 0 0

Enrolled community 0 5 0 0 0 0 0 nurses Medical officers 2 0 0 0 0 0 0 Physicians 0 0 0 0 0 0 0 Obstetrician/Gynecologis 0 0 0 0 0 0 0 t Pediatricians 0 0 0 0 0 0 0 Radiologists 0 0 0 0 0 0 0 Radiographers 0 0 0 0 0 0 0 Cytologists 0 0 0 0 0 0 0 Maternal Child Health 0 0 0 0 0 1 0 Worker (with some midwifery training) Anesthesiologists 0 0 0 0 0 0 0 Clinical officers 3 1 0 0 0 0 0 Clinical officer 0 0 0 0 0 0 0 anesthetists Nurse anesthetists 0 0 0 0 0 0 0 Pharmacists 0 0 1 0 0 0 0 Pharmaceutical 1 0 0 1 1 0 0 dispenser/ assistant Lab technicians 3 0 0 0 0 0 0 Lab assistant 2 1 1 1 1 1 0 Nutritionists 0 0 0 0 0 0 0 Nutrition field workers 0 0 0 0 0 0 0

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Health education officers 0 0 0 0 0 0 0

Public health officers 0 0 0 0 0 0 0 Record clerks 4 0 0 0 0 0 0 Occupational therapists 0 0 0 0 0 0 0 Physiotherapists 0 0 0 0 0 0 0 Public health technicians 0 0 0 0 0 0

Community Health 1 0 0 0 2 1 0 Workers Community midwife 0 0 0 2 0 0 1 (with 1 year, 6 month training) Cleaner NA 5 1 0 1 4 1

Watchman NA 2 1 1 1 2 1

Community volunteers 0 5 0 0 0 0 0 (EPI for immunizations) TOTAL (EXCLUDING 34 13 3 9 8 3 2 CLEANERS/ WATCHMEN/ VOLUNTEERS)

Trained staff are also a critical aspect of quality health care delivery. Despite limited staffing, many of the In-charges (nurses) and some other staff at all five PHCCs received training, most frequently in EMOC, PMTCT, and HIV counseling and testing. However, none of the staff at Nzara MH have received EMOC training, despite being the main referral site for obstetric emergencies for other PHCCs and PHCUs throughout the county.

Although low on staff, the PHCUs only CHWs do have some training: midwifery, leprosy, TB, and HMIS at Nangirimo and HIV C&T, TB, NCDS, and HMIS at Nakpazigi.

TABLE 11: FACILITY STAFF TRAINING Position & Nzara Nzara Basukangbi Good Ringasi Sakure Sangua Training Mission PHCC PHCC Samaritan PHCC PHCC II PHCU Hospital PHCC Nurses- 0 1 1 0 2 NA 0 EMOC Clinical 0 0 NA NA NA NA 0 Officers- EMOC Nurses- 6 5 1 0 2 NA 0 Midwifery

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Community 0 NA NA 2 NA NA 1 Midwives- Midwifery Maternal NA NA NA NA NA 0 NA Child Health Worker- Midwifery Community 0 NA NA 2 0 NA 0 Midwives- PMTCT Nurses- 6 1 0 2 0 NA 0 PMTCT Clinical 0 1 NA NA NA NA 0 officers- PMTCT Community NA NA NA NA NA 1 NA Health Worker- PMTCT Lab 1 0 0 0 0 0 0 Assistant- PMTCT Nurses- HIV 4 2 0 2 0 NA 0 C&T Clinical 0 1 NA NA 0 NA 0 Officer- HIV C&T Community 0 N A NA 2 NA NA 0 Midwives- HIV C&T Community NA NA NA NA NA 1 0 Health Worker- HIV C&T Lab 1 0 0 0 0 1 0 Assistant- HIV C&T Clinical 0 1 NA NA NA 0 Officer- IMCI Nurse- IMCI 0 1 1 2 0 1 Nurse- TB 10 0 2 0 0 Clinical 2 1 NA NA NA 0 officer- TB Community 0 NA 0 2 1 1 0 Health Worker- TB Clinical 0 1 NA NA NA NA 0 Officer- HMIS Nurse- 0 1 0 1 0 NA 1 HMIS

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4.5: FACILITY CAPACITY TO PROVIDE SERVICES

4.5.1 OVERVIEW OF FACILITY SERVICES

The availability of a basic package of health services, the frequency with which these services are offered, the presence of qualified staff for their delivery, and the overall ease of access to the health care system all contribute to client utilization of services in a health facility.

Nzara MH focuses on providing services for the care and treatment for those with HIV, TB, and leprosy. Routine services including ANC, TT immunization, postpartum checkup, family planning, and immunizations are not offered at Nzara MH. The facility, however, is a referral facility for emergencies throughout the clinic due to its larger facility and staffing, which includes medical officers and clinical officers. As a result, they see more complicated deliveries, cases of postpartum sepsis, and attend to cases of pediatric malaria, and severe cases of diarrhea, anemia, etc. However, the facility is not equipped with an operating theater or equipment to perform procedures including C-sections, vacuum delivery, or nutrition supplementation. These cases all must be referred to Yambio Hospital.

The five PHCCs are intended to provide basic primary health care services and attend uncomplicated births with basic equipment, staff, and supplies. However, absolute minimum equipment for delivery is missing at most PHCCs, including suture materials, resuscitation tray for both mothers and neonates, and episiotomy scissors. Staffing is limited at all PHCCs, both in skill set and manpower.

ANC and post-partum care is provided by all five PHCCs, but is not provided by Nzara MH. At Nzara PHCC ANC care and post-partum care is provided all days of the week; however, they noted that no clients return for post-partum checkups, unless there is an emergency, such as sepsis, in which case they typically are seen at Nzara MH for this instead. At Basukangbi PHCC, for example, one post-partum check-up is conducted two

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weeks after delivery. Antenatal care is typically offered on Wednesdays, although a woman will still be reviewed at any other time during the week, and during emergencies.

Under-5 clinics are offered at Nzara Basukangbi PHCC, as well as child health services at any time. A World Vision-funded EPI team of five provide immunizations at Nzara PHCC and throughout the community. However, due to a non-functioning refrigerator the clinic does not keep any vaccines on site. Instead, a World Vision-funded EPI team provides mobile immunization services throughout the community.

Good Samaritan PHCC provides antenatal care, post-partum check-ups, basic obstetric care, and management of STIs. The facility is staffed by two community midwives (who receive one year, 6 month training), and also allows TBAs to bring women to assist in their delivery at the facility. This PHCC does not provide under-5 clinic and immunization services or HIV counseling and treatment, although the In-Charge noted that these are frequently requested services.

Ringasi PHCC under-5 clinic and immunization services, ANC including TT immunizations, basic OB care, postpartum checkup, family planning services and management of STIs, and HIV services.

Sakure PHCC provide ANC including TT immunizations, management of STIs, basic OB care, HIV counselling, and complete child immunizations. Because staffing is limited to only one community health worker (the In-Charge) and a maternal and child health worker with one year of midwifery training, the facility also allows TBAs to assist women in birth at the facility.

Sangua II PHCU provides child immunization services, ANC including tetanus toxoid immunization, basic OB, postpartum checkup, and family planning services. However, the care is all very basic, and the lack of family planning supplies (e.g. only limited supplies of pills and condoms while clients demand injectables), and shortage of vaccines limits

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their ability to provide these services. All HIV counseling, testing, and treatment is referred to Nzara PHCC.

Nakpazigi PHCU provides very basic services, including complete child immunization, TT immunization, and family planning services. Nangirimo PHCU does not provide complete immunization, but does provide TT immunization, and although formal ANC services are not available, TBAs bring clients to the PHCU where the TBAs provide ANC.

All complicated maternity cases or other complicated health problems are referred by the five PHCCs to Nzara Mission Hospital or Yambio Hospital if they cannot be managed at the PHCC. However, with the exception of Nzara PHCC which is directly next to Nzara MH, the cost (financial and time) for patients to arrange transport in non-emergency situations sometimes results in delayed patient care, or with failure of the patient to follow- through to receive referred care. Further, sometimes difficult cases that should be referred are sometimes managed at PHCCs due to impossible transport. To reach Nzara Mission Hospital from Basukangbi PHCC the road is difficult to traverse and some patients who need to go to Nzara MH for HIV treatment and drugs, for example, are not able to make the journey. Similarly, the most common mode of transport from Sangua II PHCU to Nzara is by bicycle or boda boda and may sometimes take up to five hours to reach by bicycle, especially during the rainy season. To reach Nzara MH from Sakure PHCC, the road is comparably better (due to recent USAID-funded road improvements), but still takes one to two hours by boda boda, which is sometimes the personal boda boda of the community health worker. There is no ambulance in Nzara County, but facilities rely upon calling NGOs such as IMC, or in the case of Good Samaritan PHCC the Diocese, in an emergency to see if an available vehicle can be sent. In addition, some areas, such as the Basukangbi PHCC, do not have phone network and have no way to communicate an emergency—their primary mode of communication with Nzara Mission Hospital is via letter.

The PHCCs refer cases of malnutrition to Nzara MH, but many families wait until the child is extremely malnourished due to lack of transport. Extreme cases of malnutrition are typically referred to Yambio Hospital for management, as Nzara MH does not have a

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nutrition supplement/ feeding capability as does Yambio Hospital (which provides two meals daily to all admitted children and women). At Yambio Hospital it is noted that the cases of malnourishment are typically not due to lack of food but due to complications in illness such as HIV.

Nangirimo PHCU makes referrals to Nzara Mission Hospital, although it is six miles away, which takes approximately one hour by vehicle, but most people use bicycle to transport their family member if required. Nakpazigi PHCU is approximately 9 kilometers from the nearest referral facility, although it takes three hours by car and the most common form of transport is also a bicycle. In both cases family members are responsible for arranging for transport for referrals in an emergency, and are also responsible for any associated expenses.

There is no facility in Nzara County that currently conducts routine PAP smears or screening for cervical cancer. Further, this is also not provided at Yambio Hospital— cervical cancer screening and routine pap smears are therefore completely unavailable to women in Nzara County. This is also the case at all five PHCCs and the PHCUs sampled.

Further, no facility offers targeted youth or adolescent services such as “youth corners,” and no one provide services to assist SGBV survivors or to assist in management of an SGBV survivor’s physical, emotional, and social care, with the exception of Nzara MH who provides medical care for survivors. Basukangbi PHCC refers identified SGBV cases to a nearby church. However, at all facilities they report that it is rare that an SGBV survivor seeks care at a health facility.

TABLE 13: SERVICES PROVIDED AT HEALTH FACILITY Services offered Nzara Nzara Basukangbi Good Ringasi Sakure Sangua II MH PHCC PHCC Samaritan PHCC PHCC PHCU PHCC Antenatal Care No Yes Yes Yes Yes Yes Yes Tetanus Toxoid No Yes Not No Yes Yes Yes Immunization currently (refrigerator broken)

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Management of Yes Yes Yes Yes Yes Yes No STIS Normal Yes Yes Yes Yes Yes Yes Yes Obstetric Delivery Care Vacuum No No No No No No No Extraction Delivery “Rooming In” No Yes Yes (woman No Yes No (may No For Postpartum (for 24 can stay, but (for 24 stay Care of Mother hours) no cooking hours) longer but and Baby facilities, typically etc.) leaves within an hour or two after delivery) Postpartum No Yes Yes Yes Yes Yes Yes Check Up Family Planning No Yes No No Yes No Yes Services Management for Yes Yes Yes No No No No Incomplete Abortion Termination of No No Yes No No No No Pregnancy on Medical Ground Blood Yes No No No No No No Transfusion or Replacement Caesarean No No No No No No No Section HIV Counseling Yes Yes Yes No Yes Yes No at facility HIV Care and Yes Yes No No No No No Treatment Care for Sexual Yes No No No No No No or Gender- Based Violence Complete Child No Yes No (EPI No Yes Yes Yes Immunization team in field, not at facility) Adolescent No No No No No No No Health Services Cervical Cancer No No No No No No No Screening Nutrition No No No No No No No Supplementation Diabetic Yes No No No No No No Management

4.5.2 SERVICES AVAILABLE DAILY

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Nzara Mission Hospital operates 24 hours a day and is able to provide emergency care every day throughout the day. Further, they offer services on a daily basis, including care and treatment for patients with severe malaria, severe anemia, HIV, TB, leprosy, etc.

Nzara PHCC also operates 24 hours per day and has a three-shift rotating schedule as well as phone numbers for other staff for on-call needs. The other PHCCs do not operate 24 hours per day, and typically have hours from 9 or 8am to 3 or 5pm. However, many facilities, according the surrounding communities, open later than the official opening time and can often be found during open hours to be closed or staff not present.

The in-charge or a midwife at each PHCC is always on-call and will attend to a delivery after-hours.

Although ANC is designated for Wednesdays at Good Samaritan PHCC, women will also be seen any other day of the week, and all other services are provided on a first-come, first- serve basis during clinic hours M-F, 9am- 3pm. Midwives are on-call to open the delivery room in the event of an after-hours delivery.

Although ANC is designated on Wednesdays and post-partum care on Thursdays at Basukangbi PHCC, women will also be seen on a first-come first-serve basis any other day of the week; all other offered services are offered all days of the week that the clinic is open.

Sakure PHCC is open 8am-5pm Monday through Friday, and provides all services every day that the clinic is open. At Ringasi PHCC all services are integrated and offered any day the clinic is open, except that ANC is typically offered on Wednesdays (unless there is an emergency).

Sangua II PHCU offers services Monday through Friday, and the nurse and midwife are on-call for after-hours emergencies or deliveries at any time. Although antenatal care is specifically offered on Wednesdays, ANC clients will be seen any other day they are open.

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Family planning services and child health services are offered every day that they are open, and all services are offered on a first-come first-serve basis.

At Nakpazigi PHCU family planning services and child health services are offered every day that the facility is open, and although ANC is not officially offered, TBAs provide ANC at the facility. At Nangirimo PHCU no service provided is available every day of the week. Neither PHCU has availability after-hours, or someone that is available on-call in an emergency.

TABLE 14: SERVICES PROVIDED EVERY DAY Services offered Nzara Nzara Basukangbi Good Ringasi Sakure Sangua MH PHCC PHCC Samaritan PHCC PHCC II PHCC PHCU Antenatal Care NA No No No No Yes Yes Family Planning NA Yes NA NA Yes NA Yes Services Child Health Yes Yes Yes Yes Yes Yes Yes services Pre and Post Yes Yes NA NA Yes Yes No Counseling for HIV Test STI Management Yes Yes Yes Yes Yes Yes No Post natal Care NA Yes Yes Yes Yes Yes Yes Integrated service Yes Yes Yes Yes Yes Yes Yes on first come, first serve basis

4.5.3 LABORATORY SERVICES PROVIDED

Other elements that support quality antenatal and postnatal care services include diagnostic capacity and medicines to treat common infections. Pre-eclampsia and eclampsia (hypertensive disorders of pregnancy), anemia, and sexually transmitted infections (STIs) can directly affect both maternal and newborn health. Basic essential obstetric care (BEOC) requires that a facility provide early treatment for complications of pregnancy to prevent them from progressing to more serious conditions. Standards for treatment may vary depending on ANC guidelines and policies and the qualifications of the service provider. The study assessed whether facilities have the capacity to test ANC and PNC clients’ blood

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for anemia, urine for protein, and urine for glucose; to determine blood group; and to diagnose and treat syphilis.

Nzara Mission Hospital has laboratory services available to perform all testing, except for an acetic acid test, unaided visual inspection of the cervix, and pap smears. There are no facilities in Nzara County that provide these laboratory services at present, and a general lack of awareness about cervical cancer screening among staff at facilities. Nzara PHCC has an affiliated PMTCT and VCT clinic run by CMMB which provides voluntary HIV testing after confidential testing; the PHCC also provides syphilis testing, pregnancy testing, and hemoglobin measurement. The only testing provided by Good Samaritan PHCC is pregnancy testing. The only testing provided by Basukangbi PHCC is syphilis and pregnancy testing. Ringasi PHCC offers voluntary HIV testing after confidential counseling and pregnancy testing. Sangua II PHCU offers no testing due to lack of test supplies. Neither of the other two PHCUs (Nakpazigi and Nangirimo) have a lab nor do they offer any laboratory services.

TABLE 15: LABORATORY SERVICES ARE PROVIDED AT FACILITY Laboratory Nzara Nzara Basukangbi Good Ringasi Sakure services provided MH PHCC PHCC Samaritan PHCC PHCC PHCC Syphilis testing Yes Yes Yes No No Yes Hemoglobin Yes Yes No No No No Measurement Urine Testing – Yes No No No No Yes Protein Measurement Voluntary HIV Yes Yes No No Yes No Testing after Confidential Counseling Pregnancy test Yes Yes Yes Yes Yes Yes Sugar testing Yes No No No No No Blood Group and Yes No No No No No X Match Acetic Acid Test No No No No No No Unaided Visual No No No No No No Inspection Of The Cervix Pap Smear No No No No No No

4.5.4 EMERGENCY SERVICES AND REFERRAL

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Not all types of health facilities are expected to provide 24-hour care; however, it is useful to assess their capacity to provide emergency services 24 hours a day. For this assessment, a facility is said to have basic 24-hour emergency services if it offers emergency on-site treatment and has the capacity to monitor a seriously ill client overnight until it is possible to refer the client to an inpatient setting or another facility. This means that the facility must have at least two qualified providers, a duty schedule indicating that providers are on-site or on call 24 hours a day, available overnight beds, a client latrine, 24-hour emergency communication, and an on-site water source.

Nzara Mission Hospital is the only facility in the area that provides true 24-hour emergency services, although it is limited in the emergency services provided and must refer complicated cases to Yambio Hospital. With the exception of Nzara PHCC open 24 hours, the other four PHCCs are generally closed after normal business hours, although the midwife/ in-charge can potentially be reached in emergency or in cases of a woman in labor (either by cell phone in areas with coverage, or by the watchman fetching the in-charge where there is no phone network).

Emergency cases are generally referred from the PHCCs to Nzara Mission Hospital, or to Yambio Hospital for more complicated cases where there is an operating theater and ability to perform, for example, caesarian sections. The Nzara PHCC is located directly across the road from the Nzara Mission Hospital, and so it may be reached on foot within minutes without a problem. The Nzara PHCC operates 24 hours per day with three assigned shifts and a midwife always present and/or on-call to handle deliveries at any time. Good Samaritan PHCC in Nzara payam is located 15 minutes by car from Nzara Mission Hospital, and in cases of emergency the Diocese is called and provides a vehicle if one is available, and the patient is typically sent with the driver as the midwife needs to remain at the facility in case her services are required. In cases where referral to Yambio is required, it may take approximately 30-40 minutes by road in a vehicle. In those cases, assistance is requested from a partner for transport, such as IMC or MSF, who provide transport to Yambio at the INGO’s own expense. Patients typically reach the Nzara PHCC by foot, bicycle or motorbike (boda boda).

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However, for the PHCCs located further away, such as Basukangbi and Ringasi, because there is no ambulance in Nzara County and the roads are too difficult, some emergency cases that should be referred are instead managed at PHCCs. During the dry season, it may take 1.5 hours to reach Nzara from Basukangbi over a very difficult road by car, and 3 hours in the rainy season if the car can pass through; however, that would require the in- charge to make arrangements with the payam administrator to identify a way of transport. In Ringasi, it may take one hour by vehicle during the dry season by car or three hours by boda boda to reach Nara MH, and in the rainy season it could take up to eight hours to travel the 24 kilometers to Nzara MH. Patients typically walk to reach the Basukangbi or Ringasi PHCC, although in emergency obstetric situations a TBA attending a woman may tie the woman in labor to a bicycle to transport her to the PHCC for care. The In-Charge at Basukangbi PHCC has not made any emergency referrals in the past year, and says that there never has been an emergency referral case; if there is an emergency case she surmises that she and the payam administrator would try to identify a way to transport the patient at the cost of the PHCC/ payam. In Ringasi in 2014 there was a fresh still birth that occurred due to obstructed labor; the midwife at Ringasi PHCC referred the case to Yambio, but there was no emergency vehicle available, and the family could not pay for a boda boda to transport the mother.

Sangua II PHCU has no access to an ambulance. The community midwife advises women to bring with them some savings in case they have an emergency and need to hire a boda boda (motorbike) to take her to Nzara. Most women walk to the facility to deliver, but bicycle and boda boda is the most common form of transport used in an emergency. Even though Sangua II PHCU is located only 6 kilometers from Nzara, it may take two hours by boda boda or five hours by bicycle to reach Nzara in an emergency due to the roads conditions and the need to drive carefully; during the rainy season it takes longer. Typically a TBA will accompany a woman to Nzara in case of emergency; the one community midwife at the facility must remain at the facility.

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TABLE 16: EMERGENCY AND REFERRAL SERVICES Emergency Nzara Nzara Basukangbi Good Ringasi Sakure Sangua services and MH PHCC PHCC Samarita PHCC PHCC II referral n PHCC PHCU Type of Adminis Administe Administer: Active Admini Admini Admini Emergency ter: r: parenteral managem ster: ster ster OB services parenter parenteral oxytocic ent of third parenter parenter parenter available al oxytocic drugs; stage labor al al al antibioti drugs, Perform oxytoci antibioti oxytoci cs, parenteral manual c drugs, cs, c drugs; parenter anticonvul removal of anticon perform manual al sants; placenta or vulsants manual removal anticonv Perform retained ; removal of ulsants; manual products; Perform of placenta Perform removal of Active manual placenta ; active manual placenta or management removal and manage removal retained of third stage of retained ment of of products; labor placenta product; third placenta Active or other Active stage or manageme retain manage labor retained nt of third product; ment of products stage labor Active third ; Active manage stage manage ment of labor ment of third third stage stage labor labor Maternity Yes Yes Yes Yes Yes Yes Yes Services Available at Night and Weekends Staff Member No Yes (staff No No Yes No No Reside at the quarters Site for two staff on shift work) On-Call Yes Yes Yes Yes Yes Yes Yes Services for Care Of Complicated

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Deliveries Available at Night and Weekends On Call No No No No No No No Services For Caesarian Section available At Night And Weekends Access to fully No (use No No No No No No equipped car from ambulance IMC or other available ) In Case Of No- Yes Yes (but has Yes Yes No (In- Yes Obstetrics medical (Clinical not yet charge Emergency officer officer referred any does, Does The makes makes case) who is a Midwife referral referral commu Make during nity Transport regular health Arrangement working worker) s To The hours, Referral Site midwife after) Most common INGO or INGO Tied to back Vehicle Boda Boda Bicycle mode of church vehicle of bicycle called boda boda or boda transport for vehicle; (IMC or from (hired boda a patient with if family MSF) Diocese by obstetric arranges family emergency boda or boda or commu own nity transport health , church worker’ reimburs s es their personal expense bike) Time it takes 45 5 minutes No 15 1 hour 1 hour 2 hours for patient minutes to Nzara emergency minutes by car by boda by boda with OB to 1 hour MH; 40 cases yet (1.5 by car to or 3 boda in boda 5 emergency to to minutes to hours dry Nzara hours by dry hours be referred Yambio Yambio season/ 3 MH, 45 boda season by and receive Hospital Hospital hours rainy minutes y boda in or 2 bicycle care by car by car season by car car to dry hours in to Nzara to Nzara MH, Yambio season; rainy during and another Hospital up to 8 season dry 30- 40 hours in season minutes to rainy Yambio) season

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Distance to 22KM .10 KM to 30km to 2km to 24 km 67km to 6km to nearest Nzara MH Nzara MH Nzara MH to Nzara Nzara referral Yambio MH MH facility (KM) Hospital Who typically Nurse/ Nurse Driver of Driver Driver TBA or accompanies midwife midwife/ In- vehicle of of boda boda driver in case charge will if vehicle boda, boda of OB this happens commu driver emergency nity referral health worker often does Responsible INGO Referring Diocese Family/ Family/ Family party for cost providing PHCC patient patient (mother of transport transport (mother (mother needs to in case of needs to needs to pay for referrals pay for pay for boda boda boda boda at boda at boda at time of time of time of transpor transpor transpor t) t) t) or commu nity health worker uses own vehicle at own expense

4.5.5 INFRASTRUCTURE AND EQUIPMENT

Relatively good health services can be provided even in minimal service delivery settings. However, both clients and providers are most likely to be satisfied with a facility if basic amenities and infrastructure components, such as a constant supply of clean water, a comfortable waiting area, and a clean latrine for clients, are available. These components also help staff to provide better services.

Nzara Mission Hospital has infection prevention in place. The five PHCCs have varying levels of very basic infection prevention; however, lack of equipment in resources at some PHCCs results in inability for all facilities to follow infection prevention guidelines. Lack

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of water at health facilities is a key constraint in practicing proper infection prevention. For example, at Basukangbi PHCC they have in the delivery room three separate colored and labeled plastic buckets for washing utensils, but they have run out of cleaning supplies, such as JIK. Good Samaritan PHCC has no JIK or other cleaning supplies.

Nzara Mission Hospital sits on a compound with numerous building, including a building with outpatient examination rooms, a pediatric in-patient ward, general in-patient ward, and separate buildings for treatment of HIV and TB patients. Many patients and families sit on blankets in the grass outside the wards. There is a covered waiting area on a veranda that is not entirely protected during the rainy season. Pit latrines are generally available, but in poor condition due to poor hygiene practices. Water is available for the facility on site with a water tank and two boreholes. There is a functional solar-powered electric system. The hospital also has a telephone (but no radio transmitter), and a cell phone. There is no ambulance available, but the facility relies upon an INGO or church vehicle to bring referral cases to Yambio Hospital.

At Nzara PHCC the building consists of two separate structures, one with multiple exam rooms (but no beds), and a relatively spacious indoor covered waiting area with seating. The other building consists of additional exam rooms and offices for ANC, family planning, and other services. Another building near the site, run by CMMB, provides maternity services and PMTCT and VCT. Infection prevention is generally in place with adequate supplies. However, the piped water supply does not function, so cleaners must fetch water from the nearby borehole to bring into the facility. A flushable toilet inside the building is not utilized due to the lack or water supply, although one latrine located outdoors is being used. Nzara PHCC has reliable solar power and a functioning refrigerator used to store vaccines. However, it lacks a telephone or radio transmitter. There is a placenta pit but it is uncovered.

Good Samaritan PHCC consists of an older building with a large protected waiting area. Two small rooms, each with one bed, are located in one area of the building, which is the designated ANC exam room and delivery room. On the other side of the waiting area is a

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general exam room area and the lab and pharmacy, as well as a storage area. Solar power is the primary source of electricity, but is insufficient to provide light or operate the small refrigerator that they have; battery-operated lanterns are utilized by midwives at night for deliveries. The facility has no running water; the cleaner must walk 2km to fetch water from a community borehole. There is a functioning latrine (2 stalls), and one almost full rubbish pit; there is no separate placenta pit.

At Basukangbi PHCC a new building has just been erected, funded by IMC. It consists of an ANC examination room, a separate room with two delivery beds, and another building with two rooms—a maternity ward and a general ward. New solar power has been installed with well-functioning batteries and is fully operational. A new borehole with above-ground storage tank pumps water into the facility. A structure has been newly built with four new latrines; however, three were padlocked and the open latrine appeared to be filled/ unusable, the wash basin for hand washing at the latrine was already broken, and someone apparently cut the water line from the new borehole to the latrines. There is a pit used to throw placentas and an incinerator which is not in use as the staff are not trained to use it. The refrigerator is not working (it does not get cold enough), and so is not currently storing any vaccinations.

Sangua II PHCU has a relatively new structure with a protected waiting area and two small rooms (one for ANC and delivery, and the other for general examination), in addition to a store room and vaccination room. There is also a functioning pit latrine that is in use. However, lighting is poor—the solar power is effectively running the refrigerator holding vaccines, but the inverter is broken and so no other electricity for lighting throughout the facility is available. The community midwife utilizes a flash light to assist women delivering babies during the night. Water supply is also a significant problem—there is a rain water catchment system with a tank, but during the dry season they have no running water. They must walk a long distance (not specified) to fetch water from a community pump. Beyond hand washing, infection prevention is not in place; equipment is not sterilized.

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Ringasi PHCC consists of one building that includes an open veranda as an opening area and examination rooms, including one private ANC examination room. There is also a room dedicated to family planning that includes posters on information related to family planning and HIV. There is a functioning pit latrine, but there is no functioning water source. Water must be brought by a tank from Nzara Payam, and if that runs out then water needs to be collected form a community borehole three kilometers from the facility. The facility runs on solar power, but often finishes (it doesn’t last past five hours), so a torch is typically used for lighting for deliveries during the night. The solar-powered refrigerator is functioning, however, with its own solar battery source. No radio or telephone is available at the facility, and there is poor network coverage in the area. Infection prevention is in place, and equipment is regularly sterilized.

Sakure PHCC has the worst infrastructure of all five PHCCs. This is likely due to the fact that Sakure PHCC was previously operated by MSF until March 2013, after which the government took over management. All other PHCCs, except for Sakure, are currently supported by IMC through a USAID-funded ISDP project which includes upgrading and renovation of facilities. As such, Sakure PHCC has crumbling, cratered cement floors, no electricity for any lighting, including in the delivery room (torches are used at night), and no water source. The facility uses water collected from a stream located two miles from the facility. A functioning solar-powered refrigerator is located on the premise, and currently holds vaccines in-stock. The condition of the exam rooms are very poor, with lack of light, visible dirt and dust on all surfaces, including on the examination beds, and the space of the exam room is quite small (close-sized) and can only fit a bed. The ANC room is also small, with a bed for ANC exams, as well as a delivery bed—both ANC patients and those delivering are seen in the same room, often at the same time. Postpartum recovery takes place in a general ward mixed with men, women, and general (in a larger room with five beds). There is no landline, radio, or facility cell phone. There is a functioning latrine and a placenta pit. However, there is an SPLS military camp directly neighboring the PHCC, and there are significant problems with the military utilizing the latrines and health facility equipment; a rainwater tank they have was broken through use by the military.

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Both smaller PHCUs, Nakpazigi and Nangirimo, are very small basic structures that contain an examination room and a veranda for a waiting area. Neither have ANC rooms with privacy, although at Nangarimo the general examination room is used for TBAs to examine ANC clients (without privacy screen).Both have functioning pit latrines, but lack electricity, telephone or radio transmitter, or any type of referral vehicle. Nangirimo PHCU does have water supply that it receives from a tank where rain water harvest is reserved, while Nakpazigi does not have a direct water sources; the guard/ cleaner fetches water from a nearby unprotected spring.

TABLE 17: INFRASTRUCTURE COMPONENTS BY FACILITY NAME

Infrastructure Nzara Nzara Basukangbi Good Ringasi Sakure Sangua II Mission PHCC PHCC Samaritan PHCC PHCC PHCU Hospital PHCC Functional NA NA NA NA NA NA NA theatre Protected Available Available Not Available Available Available Available waiting area and in and in available and in and in and in and in working working working working working working condition condition condition condition condition condition Examination Available Available Available Available Available Available Available room and in and in and in and in and in but not in and in working working working working working working working condition condition condition condition condition condition condition ANC Available Available Available Available Available Available Available examination and in and in and in and in and in but no in but not in room or area working working working working working working working providing condition condition condition condition condition condition condition client privacy (no light, (no light at privacy) night) Gynecological Available Not Not Not Not Not Not examination and in available available available available available available couch with working accessories condition Storage area or Available Available Available Available Available Available Available cupboards for and in and in and in and in and in and in and in drugs working working working working working working working condition condition condition condition condition condition condition (but too small) Toilet Available Available Available Available Available Available Available facilities or pit and in but not in but not in and in and in and in and in latrine working working working working working working working condition; condition condition condition condition condition condition poor hygiene conditions Delivery or Available Available Available Available Available Not Available labor room and in and in and in and in and in available and in working working working working working (delivery working condition condition condition condition condition bed placed condition

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(but lacks (but lacks (but lacks in ANC minimum minimum minimum room) supplies) supplies) supplies) Lighting of the Available Available Available Not Available Not Not labor room but not in and in and in available but not in available available working working working working condition condition condition condition (single lightbulb and poor light) Refrigerator Available Available Available Available Available Available Available and in and in but not in but not in and in and in and in working working working working working working working condition condition condition condition condition condition condition (no power) Water supply Available Available Available Not Not Not Not and in but not in and in available available available available working working working condition condition condition (piped (except no water not water to working- latrine use area) borehole) Electricity Available Available Available Available Available Not Available and in and in and in but not in but not in available but not in working working working working working working condition condition condition condition condition condition Telephone or Telephone Not Not Not Not Not Not radio available available available available available available available transmitter and in working condition (no radio) Placenta Available Available Available Not Not Available Available pit/Incinerator and in but not in and in available available and in and in working working working (mothers working working condition condition condition bring condition condition (medical (but staff home to waste pit) not trained bury) to use) Facility cell Available Not Not Not Not Not Not phone and in available available available available available available working condition

Ambulance or Not Not Not Not Not Not Not vehicle to refer available available available available available available available an obstetric (relies on (relies on (relies on (relies on emergency INGO INGO Diocese INGO vehicle by vehicle by vehicle by vehicle request) request) request) request)

The table below provides a summary of basic equipment available at all of the health facilities in Nzara. Most basic equipment is available and satisfactory at Nzara Mission Hospital except for items required for emergency obstetric care, such as a functioning

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autoclave and vacuum aspirator, forceps, amniotic hook, assembled delivery kit, and episiotomy scissors. Basic equipment is generally lacking at the PHCCs with the exception of Nzara PHCC that has most basic equipment, including lack of stethoscope, clinical oral thermometer, and other essentials for providing basic primary health care and for delivery.

Both PHCUs have very limited equipment. Nangirimo PHCU only has a stethoscope and some protective clothing, but lacks basic equipment to provide primary health care, such as a thermometer, weighing scale for adults or children, or a blood pressure apparatus. Nakpazigi PHCU also lacks most basic equipment, although it does have a blood pressure apparatus, stethoscope, infant weighing scale, and an unassembled delivery it (some supplies for deliveries.

TABLE 18: BASIC EQUIPMENT Equipment State Name of facility

Blood pressure apparatus Not available Basukangbi PHCC, Sakure (Sphygmomanometer) PHCC Available but not satisfactory Available and satisfactory Nzara PHCC, Good Samaritan PHCC, Sangua II PHCU, Ringasi PHCC, Nzara MH Stethoscope Available and satisfactory Nzara PHCC, Good Samaritan PHCC, Sangua II PHCU, Nzara MH Available but not satisfactory Basukangbi PHCC, Ringasi PHCC Not available Sakure PHCC Adult weighing scale Not available Basukangbi PHCC Available but not satisfactory Available and satisfactory Nzara PHCC, Good Samaritan PHCC, Sangua II PHCU, Ringasi PHCC, Nzara MH, Sakure PHCC Infant weighing scale Available and satisfactory Basukangbi PHCC, Nzara PHCC, Good Samaritan PHCC, Sangua II PHCU, Nzara MH, Sakure PHCC Available and not satisfactory Not available Ringasi PHCC Fetal stethoscope Available and satisfactory Basukangbi PHCC, Nzara PHCC, Good Samaritan

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PHCC, Sangua II PHCU, Ringasi PHCC, Nzara MH, Sakure PHCC Not available Autoclave Not available Basukangbi PHCC, Good Samaritan PHCC, Sangua II PHCU, Sakure PHCC Available but not satisfactory Nzara MH Available and satisfactory Nzara PHCC, Ringasi PHCC Sterilizer Not available Basukangbi PHCC, Good Samaritan PHCC, Sangua II PHCU, Ringasi PHCC, Nzara MH Available and satisfactory Nzara PHCC, Sakure PHCC Obstetric calculator Not available Basukangbi PHCC, Sakure PHCC Available and satisfactory Nzara PHCC, Good Samaritan PHCC, Sangua II PHCU, Ringasi PHCC, Nzara MH Clinical oral thermometer Not available Basukangbi PHCC, Nzara PHCC, Sangua II PHCU, Ringasi PHCC, Nzara MH, Sakure PHCC Available and satisfactory Good Samaritan PHCC Urine catheter (Plastic) Not available Basukangbi PHCC, Nzara PHCC, Good Samaritan PHCC, Sangua II PHCU, Ringasi PHCC, Sakure PHCC Available and satisfactory Nzara MH Urine catheter (Metal) Not available Basukangbi PHCC, Nzara PHCC, Good Samaritan PHCC, Sangua II PHCU, Ringasi PHCC, Nzara MH, Sakure PHCC Urinometer Not available Basukangbi PHCC, Nzara PHCC, Good Samaritan PHCC, Sangua II PHCU, Ringasi PHCC, Sakure PHCC Available but not satisfactory Nzara MH Manual vacuum aspirator Not available Basukangbi PHCC, Nzara PHCC, Sangua II PHCU, Ringasi PHCC, Sakure PHCC Available but not satisfactory Nzara MH Available and satisfactory Good Samaritan PHCC (but not trained to use) Protective clothing Not available Basukangbi PHCC, Good Samaritan PHCC, Sangua II

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PHCU, Ringasi PHCC, Sakure PHCC Available but not satisfactory Nzara PHCC, Nzara MH Speculum (any kind) Available and satisfactory Nzara PHCC, Good Samaritan PHCC, Nzara MH Not available Basukangbi PHCC, Sangua II PHCU, Ringasi PHCC, Sakure PHCC Vacuum extractor Not available Basukangbi PHCC, Nzara PHCC, Good Samaritan PHCC, Sangua II PHCU, Nzara MH, Ringasi PHCC, Sakure PHCC Obstetric forceps Not available Basukangbi PHCC, Sangua II PHCU, Ringasi PHCC, Nzara MH, Sakure PHCC Available and satisfactory Nzara PHCC, Good Samaritan PHCC Tongue blade or spatula Not available Basukangbi PHCC, Good Samaritan PHCC, Sangua II PHCU, Sakure PHCC Available and satisfactory Nzara PHCC, Nzara MH

No facility in Nzara County, including Nzara Mission Hospital, has an operating theater, and therefore no facility has equipment for operation. All cases that require operation, including caesarian section, are referred to Yambio Hospital, which is outside Nzara County, and about a 40 minute drive by car during dry season from Nzara MH.

In addition to basic infrastructure that assures privacy and supports infection control, several types of equipment and medicines are needed to support safe deliveries. Minimum equipment is lacking from the five PHCCs, including an assembled delivery kit and resuscitation kit. Basic supplies such as blankets, baby clothes, and sanitary pads are expected by all facilities, including Nzara MH, to be brought by the mother prior to delivery—the facilities do not have these items available. The PHCUs do not provide obstetric care, and therefore do not have equipment necessary for delivery, although Nakpazigi PHCU does have an unassembled delivery kit.

TABLE 19: ABSOLUTE MINIMUM EQUIPMENT FOR DELIVERY

Equipment State Name of facility

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Assembled delivery Available but not satisfactory Basukangbi PHCC, Nzara PHCC, Ringasi kit PHCC Not available Good Samaritan PHCC, Sangua II PHCU, Nzara MH, Sakure PHCC Scissors Available and satisfactory Basukangbi PHCC, Nzara PHCC, Sangua II PHU, Ringasi PHCC, Nzara MH Not available Good Samaritan PHCC, Sakure PHCC Suture needles Not available Basukangbi PHCC, Sangua II PHCU, Sakure PHCC Available and satisfactory Nzara PHCC, Good Samaritan PHCC, Ringasi PHCC, Nzara MH Suture materials Available and satisfactory Nzara PHCC, Nzara MH Not available Basukangbi PHCC, Good Samaritan PHCC, Sangua II PHCU, Ringasi PHCC, Sakure PHCC Needle holder long Available and satisfactory Nzara MH Not available Basukangbi PHCC, Nzara PHCC, Good Samaritan PHCC, Sangua II PHCU, Ringasi PHCC, Sakure PHCC Forceps-assorted Available and satisfactory sizes Not available Basukangbi PHCC, Nzara PHCC, Good Samaritan PHCC, Sangua II PHCU, Ringasi PHCC, Nzara MH, Sakure PHCC Amniotic hook Not available Basukangbi PHCC, Nzara PHCC, Good Samaritan PHCC, Sangua II PHCU, Ringasi PHCC, Nzara MH, Sakure PHCC Complete Not available Basukangbi PHCC, Nzara PHCC, Sangua resuscitation tray II PHCU, Ringasi PHCC, Sakure PHCC for mother Available and satisfactory Good Samaritan PHCC, Nzara MH Sanitary pads Not available Basukangbi PHCC, Nzara PHCC, Good Samaritan PHCC, Sangua II PHCU, Ringasi PHCC, Nzara MH (uses orthopedic cotton), Sakure PHCC Sterile 4x4 gauze Available and satisfactory Nzara PHCC, Ringasi PHCC, Nzara MH, pads Sakure PHCC Not available Basukangbi PHCC, Good Samaritan PHCC, Sangua II PHCU Umbilical cord tie Available and satisfactory Basukangbi PHCC, Nzara PHCC, Good Samaritan PHCC, Sangua II PHCU, Ringasi PHCC, Nzara MH, Sakure PHCC Episiotomy scissors Not available Basukangbi PHCC, Good Samaritan PHCC, Sangua II PHCU, Ringasi PHCC, Nzara MH, Sakure PHCC Available and satisfactory Nzara PHCC Surgical gloves Available but not satisfactory Sangua II PHCU Available and satisfactory Basukangbi PHCC, Nzara PHCC, Ringasi PHCC, Nzara MH, Sakure PHCC Not available Good Samaritan PHCC Oxygen cylinder Not available Basukangbi PHCC, Nzara PHCC, Good Samaritan PHCC, Sangua II PHCU, Ringasi PHCC, Sakure PHCC

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Available and satisfactory Nzara MH (oxygen concentrator) Cloth or towel to Not available Basukangbi PHCC, Good Samaritan dry baby PHCC, Sangua II PHCU, Ringasi PHCC, Nzara MH, Sakure PHCC Available but not satisfactory Nzara PHCC Blanket to wrap Not available Basukangbi PHCC, Nzara PHCC, Good baby Samaritan PHCC, Sangua II PHCU, Ringasi PHCC, Nzara MH, Sakure PHCC Bag and mask for Not available Basukangbi PHCC, Nzara PHCC, Sangua neonatal II PHCU, Ringasi PHCC, Sakure PHCC resuscitation Available and satisfactory Good Samaritan PHCC, Nzara MH Complete neonatal Not available Basukangbi PHCC, Nzara PHCC, Sangua resuscitation tray II PHCU, Ringasi PHCC, Nzara MH, Sakure PHCC Available and satisfactory Good Samaritan PHCC Mucous extractors Not available Basukangbi PHCC, Sangua II PHCU, Ringasi PHCC, Sakure PHCC Available and satisfactory Nzara PHCC, Good Samaritan PHCC, Nzara MH Ultraviolet Source Not available Basukangbi PHCC, Nzara PHCC, Good Samaritan PHCC, Sangua II PHCU, Ringasi PHCC, Nzara MH, Sakure PHCC Incubator Not available Basukangbi PHCC, Nzara PHCC, Good Samaritan PHCC, Sangua II PHCU, Ringasi PHCC, Nzara MH, Sakure PHCC

4.5.6 REGISTERS AND RECORD KEEPING

Nzara MH does not provide some services, such as ANC, family planning, postpartum check-up, and immunizations; thus, the hospital does not keep such registers. Nzara PHCC has most necessary registers such as ANC, delivery, family planning, partographs, and immunization registers, but does not have clinical management guidelines. Good Samaritan PHCC only has an ANC register and partographs. Basukangbi PHCC does not have clinical management guidelines/ flow charts; partographs; ANC cards, or family planning registers. Sangua II PHCU has ANC, family planning, delivery, and immunization registers; ANC and under-5 cards, and partographs, but no clinical guidelines and they frequently run out of unfilled partograph. Include data here for registers at all facilities. Ringasi PHCC has everything with the exception of unfilled partograph.

The other smaller PHCUs do not have many registers, although they also provide limited services. Nakpazigi PHCU has a family planning register and tally sheets for

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immunizations. Nangirimo PHCU has a family planning register and an immunization register which is used by an outside immunization team, and not by the facility.

Nzara PHCC has one clinical officer and one nurse trained in HMIS, and Good Samaritan PHCC and Sangua II PHCU has a nurse trained in HMIS. They utilize their registers to track data, but no other HMIS or software tools. Sakure PHCC has an ANC, delivery, and immunization register, as well as under-5 immunization cards, but lacks partographs, ANC cards, and clinical management guidelines.

TABLE 20: REGISTERS AND CHARTS FOR RECORD KEEPING Register chart State Name of facility

Clinical management Not available Basukangbi PHCC, Nzara PHCC, Good guidelines / flow charts for Samaritan PHCC, Sangua II PHCU, maternal health care Sakure PHCC Available and satisfactory Ringasi PHCC, Nzara MH ANC cards Available and satisfactory Nzara PHCC, Sangua II PHCU, Ringasi PHCC, Nzara MH Not available Basukangbi PHCC, Good Samaritan, Sakure PHCC ANC register or log book Available and satisfactory Basukangbi PHCC, Nzara PHCC, Good Samaritan, Sangua II PHCU, Ringasi PHCC, Sakure PHCC Not available Nzara MH (kept at Nzara PHCC) Partograph Not available Basukangbi PHCC, Ringasi PHCC, Sakure PHCC Available and satisfactory Nzara PHCC (but not used- just trained), Good Samaritan PHCC, Sangua II PHCU, Nzara MH Delivery register or log Available and satisfactory Basukangbi PHCC, Nzara PHCC, Sangua book II PHCU, Nzara MH, Sakure PHCC Not available Good Samaritan PHCC, Nzara MH (kept at Nzara MH) FP register Not available Basukangbi PHCC, Good Samaritan PHCC, Nzara MH, Sakure PHCC Available and satisfactory Nzara PHCC, Sangua II PHCU, Ringasi PHCC Child welfare cards Not available Basukangbi PHCC, Good Samaritan (Under-5 cards) PHCC, Nzara MH (at Nzara PHCC), Sakure PHCC Available and satisfactory Nzara PHCC, Sangua II PHCU, Ringasi PHCC Immunization registers Available and satisfactory Basukangbi PHCC, Nzara PHCC, Sangua II PHCU, Ringasi PHCC, Sakure PHCC Not available Good Samaritan PHCC, Nzara MH

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HMIS tools utilized Not available Basukangbi PHCC, Nzara PHCC, Good Samaritan PHCC, Sangua II PHCU, Ringasi PHCC, Nzara MH, Sakure PHCC

4.5.7 INFORMATION EDUCATION COMMUNCATION (IEC)

Information and Education Communication (IEC) is a critical component to providing health service delivery. When used through various channels such as health talks, posters, leaflets, radio, and other mediums it can provide critical information to individual sand communities to make informed decisions about when health care should be sought (e.g., warning signs in pregnancy, signs of dehydration or malnutrition in children, proper breastfeeding and nutrition instruction, etc.). Most facilities in Nzara have some type of IEC displayed via posters, but is typically limited to a few posters regarding breastfeeding, HIV testing, and measles/ polio vaccine. Sakure PHCC and Nangirimo PHCU has no IEC materials available, and Nakpizigi PHCU only has a poster on family planning displaced.

TABLE 21: IEC USED AT FACILITIES

IEC Material Type IEC Availability Name of facility

Types of educational Health talks Nzara PHCC, Ringasi PHCC teaching aids or methods Posters Basukangbi PHCC, Nzara PHCC, Good used in the health facility Samaritan PHCC, Sangua II PHCU, for MNCH Ringasi PHCC, Nazara MH Warning signs of Displayed NONE complications in Not available Basukangbi PHCC, Nzara PHCC, Good pregnancy Samaritan PHCC, Sangua II PHU, Ringasi PHC, Nzara MH, Sakure PHCC Newborn Care or Displayed Basukangbi PHCC, Nzara PHCC, Good Breastfeeding Samaritan PHCC, Ringasi PHCC Not available Sangua II PHCU, Sakure PHCC Family Planning Displayed Basukangbi PHCC, Sangua II PHCU, Ringasi PHCC Not available Nzara PHCC, Good Samaritan PHCC, Nzara MH, Sakure PHCC HIV/AIDS and/or STIs Displayed Basukangbi PHCC, Nzara PHCC, Ringasi PHCC, Nzara MH Not available Good Samaritan PHCC, Sangua II PHCU, Sakure PHCC Antenatal nutrition or Not available Basukangbi PHCC, Nzara PHCC, Good anemia Samaritan PHCC, Sangua II PHCU, Ringasi PHCC, Nzara MH, Sakure PHCC Displayed NONE

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Non-communicable Not available Basukangbi PHCC, Nzara PHCC, Good diseases Samaritan PHCC, Sangua II PHCU, Ringasi PHCC, Nara MH, Sakure PHCC Other infectious diseases Displayed Nzara PHCC (mosquito nets, hand washing), Sangua II PHCU (measles and vaccinations), Ringasi PHCC (diarrhea, malaria, polio), Nzara MH (TB, leprosy) Not available Basukangbi PHCC, Good Samaritan PHCC, Sakure PHCC

4.5.8 VACCINES AVAILABLE

Nzara MH does not administer vaccines—this is done at Nzara PHCC. Nzara PHCC is fully stocked with vaccines required for under-5 immunization requirements, as well as Sangua II PHCU (although in very low quantities—the refrigerator only stocked, for example, one vial of DTP and one of polio) and Ringasi PHCC. Good Samaritan PHCC does not currently stock any vaccinations or have any affiliated vaccination program. Basukangbi PHCC does not currently stock any vaccinations or anything requiring refrigeration due to a non-functioning refrigerator; however an EPI team provides vaccines throughout the community (volunteers with World Vision). Before the refrigerator broke, vaccines were available, including tetanus toxoid injections; however, no child received BCG/polio last year when the drug was in stock because the person administering it did not want to open one vile for only one child so did not administer any.

Neither of the smaller PHCUs (Nakpazigi and Nangirimo) had any immunizations in stock, although at Nangirimo PHCU they report that BCG, DPT, polio, and measles are available by an outside outreach team in the community, and TT injections are available at Sakure PHCC.

TABLE 22: IMMUNIZATIONS STOCKED AND AVAILABLE, BY FACILITY

Immunization Nzara Nzara Basukangbi Good Ringasi Sakure Sangua II / Injection Mission PHCC PHCC Samaritan PHCC PHCC PHCU Hospital PHCC Tetanus NA Yes No No Yes Yes Yes toxoid Anti-tetanus NA No No No No No No serum (ATS) BCG vaccine NA Yes No No Yes Yes Yes

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DPT NA Yes No No Yes Yes Yes Polio NA Yes No No Yes Yes Yes Measles NA Yes No No Yes Yes Yes Pneumonia NA No No No No No No

4.5.9 CONTRACEPTIVES AVAILABLE

No facility in Nzara County provides longer lasting contraceptive options such as IUDs or Norplant—this is only provided at Yambio Hospital. Nzara MH does not provide any family planning services—all patients are referred to Nzara PHCC. Nzara PHCC stocks injectables (Depo-Provera), pills (high dose estrogen and progesterone only), and male and female condoms (but says they do not distribute the unpopular female condoms). Sangua II PHC only stocks low dose pills and some condoms in low supply, and reports that women would prefer injectables but they do not stock injectables as an option. Good Samaritan, Sakure (except for some condoms), and Basukangbi PHCCs stock no family planning options, although Basukangbi PHCC in the past sometimes distributed condoms. Nakpazigi PHCU only has male condoms available and in stock, while Nangirimo had no family planning options available.

TABLE 23: CONTRACEPTIVES STOCKED AND AVAILABLE, BY FACILITY

Contraceptive Nzara Nzara Basukangbi Good Ringasi Sakure Sangua II Mission PHCC PHCC Samaritan PHCC PHCC PHCU Hospital PHCC High dose NA Yes No No No No No pills Low dose pills NA No No No Yes No Yes Progesterone NA Yes No No Yes No No only pills Depo provera NA Yes No No Yes No No Noristerat NA No No No No No No Diaphragm NA No No No No No No Male NA Yes No No No Yes Yes Condoms Female NA Yes No No No No No Condoms Plain IUCD NA No No No No No No Copper NA No No No No No No loaded IUCD

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Progesterone NA No No No No No No loaded IUCD Norplant NA No No No No No No implant Morning NA Yes No No No No No After Pill

4.5.10 DRUGS AND LAB SUPPLIES AVAILABLE

Nzara Mission Hospital is well-stocked in terms of drugs and lab supplies, including all standard drugs and supplies, with the exception of those required for operating theater (in the absence of an operating theater). They are the only facility within Nzara County that offers insulin and diabenes for patients with diabetes. They receive drug kits and supplies from the government, although they also receive drugs and supplies from other donors in the event of stock-outs.

All PHHCs, with the exception of Good Samaritan PHCC, receive a drug kit supply that is distributed by the government. Good Samaritan PHCC anticipates that it may begin receiving drug kits from the government in 2015. However, shortages are common. For example, Basukangbi PHCC usually runs out of or has too limited supply of: oxytocin, paracetamol, diazepam, diclofenac, amoxicillin, anti-worm medication, magnesium, and Vitamin A. They also never stock, but could use, quinine and hydrogen peroxide. Nzara PHCC frequently runs out of erythromycin, amoxicillin, ampicillin, and cirpofloxacin. Good Samaritan PHCC has many shortages, as well as many expired drugs; shortages include: cord ties, zinc tablets, hydrocortisone, lidocaine, paracetamol, procainepenicillin, ciprofloxacin, amoxicillin, atenolol (hypertensive), magnesium sulphate, epinephrine, and promethazine. Sangua II PHCU frequently runs out of Panadol, amoxicillin, and multi- vitamins. Ringasi PHCC frequently runs out of paracetamol, amoxicillin, Cipro, zinc, ORS, and JIK. Sakure PHCC frequently runs out of paracetamol, amoxicillin, erythromycin, and ampicillin.

The two smaller PHCUs have a very limited and basic drug supply, and do not have a store room for drugs. Nangirimo PHCU stocks: zinc tablets, paracetamol, ciprofloxacin, gentamycin eye ointment, sulfamethoxozole + trimethoprim, amoxicillin, tetracycline

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ointment, fansidar and artesunate anodiaquine for malaria, and ferrous sulphate. Nakpazigi PHCU stocks disposable syringes and needles, IV giving set, partographs, zinc tablets, sulfamethoxzole + trimethoprim, tetracycline ointment, amoxicillin syrup, fansidar and artesunate anodiaquine for malaria, ferrous sulphate, chlorohexidine, and JIK.

TABLE 24: DRUGS AND LAB SUPPLIES STOCKED AND AVAILABLE, BY FACILITY

Drugs/ Supplies Nzara Nzara Basukangbi Good Ringasi Sakure Sangua II Mission PHCC PHCC Samaritan PHCC PHCC PHCU Hospital PHCC Disposable Yes Yes No No No No No syringes and needles IV giving set Yes Yes No No Yes No No Blood giving set Yes No No No No No No Syphilis test kits Yes Yes Yes No No Yes No Urine dipstick Yes No No No No Yes No Misoprostol Yes No No No No No No Zinc tablet Yes Yes Yes Yes Yes Yes No VCT kit Yes Yes No No No No No Nitrous oxide No No No No No No No Diazepam Yes Yes Yes Yes No No No (injection or tablets) Ketamine Yes No No No No No No (injection) Atropine Yes No No No No No No Hydrocortisone Yes Yes Yes Yes Yes Yes No Lidocaine (2%) Yes Yes Yes Yes Yes Yes No Acetylsalicylic Yes No Yes No No No No acid Paracetamol Yes Yes Yes Yes Yes No Yes Pethidine Yes No No No No No No Morphine No No No No No No No Ampicillin Yes No No No No No No Benzathine/ Yes Yes Yes No Yes Yes No Benzyl penicillin Procaine Yes No No Yes No No No penicillin Ceftriaxone Yes Yes Yes Yes Yes Yes No (injection) or ciprofloxacin (capsule) Gentamycin Yes Yes Yes No Yes Yes No (injection) Kanamycin No No No No No No No (injection) Sulfamethoxazole Yes Yes Yes Yes Yes Yes No + trimethoprim (400mg + 80 mg tablets) Chloramphenicol Yes No No No No No No Erythromycin Yes No No No No No No

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Amoxycillin Yes Yes Yes Yes Yes Yes Yes tablet Antenatal No No No No No No No steroids Tetracycline Yes Yes Yes No Yes Yes Yes (ointment) Silver nitrate (eye No No No No No No No drops) Chloroquiine No No No No No No No (tablets/ injection) Quinine Yes Yes No Yes Yes Yes Yes (injection) Metakelfin No No No No No No No Meflaquine No No No No No No No Proguanil No No No No No No No Fansidar Yes Yes No No Yes Yes Yes (pyrimethamine and sulphurdoxine) Artesumate- Yes No Yes Yes Yes Yes Yes amodiaquine Ferrous sulfate Yes Yes Yes No Yes Yes No Folic acid Yes Yes No No Yes Yes No Digoxcin Yes No No No No No No Calcium Yes Yes No No No No No gluconate Sodium Yes No No No No No No bicarbonate Methyldora Yes Yes Yes No Yes Yes No Propranolol Yes No No No No No No Hydralazine Yes No No No No No No (injection) Atenolol No No No Yes No No No Phenobarbitone Yes No No No No No No Magnesium Yes Yes No No Yes Yes No sulphate (injection) Ergometrine Yes No No No No No No (injection) Oxytocin Yes Yes Yes Yes Yes No Yes (injection) Chlorhexidine Yes Yes No No Yes No Yes Surgical spirit Yes No No No No Yes No Betadine Yes No No No No No No JIK (Sodium Yes Yes No No Yes No No hypochlorite) Normal Saline Yes Yes No No Yes Yes No Sodium lactate Yes Yes No No No No No Dextrose (5%, Yes Yes No No Yes Yes No 10%, 50%) Water for Yes Yes No No No Yes No injection Epinephrine Yes No No No No No No Promethazine Yes Yes No No Yes Yes No Chloromethiazole No No No No No No No Insulin Yes No No No No No No Diabenes Yes No No No No No No

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4.6: FACILITY MATERNAL HEALTH SERVICES COVERAGE

4.6.1 MATERNAL HEALTH SERVICES COVERAGE JANUARY- DECEMBER 2014

Maternal health services are not a primary service provided at Nzara MH. More complicated cases that they are able to manage with limited equipment are referred to them, although complicated cases that require surgery or more advanced management are referred to Yambio Hospital. Thus, the total number of deliveries at Nzara MH is only 60 for 2014, and they saw no ANC clients. They do not see patients for postpartum checkup (unless there is an emergency such as postpartum sepsis).

At Nzara PHCC, out of the 960 women who went for ANC care, 332 went to deliver their babies at the facility (or were referred), and none returned for postnatal checkup (the PHCC cited that mothers go to Nzara MH for that). At Good Samaritan PHCC, out of the 199 women who went for ANC care, 166 women (83.4 percent) went to deliver their babies at the facility, and 78.9 percent of those who delivered at the facility returned for a postnatal checkup (131 women total). At Basukangbi PHCC, 53 out of 144 women (36.8 percent) who went for ANC care delivered their babies at that facility. Only 26.4 percent (14 out of 53) of women who delivered babies at Basukangbi PHCC returned for their two week postnatal checkup. At Sangua II PHCU, out of 110 women who visited for ANC care 109 women delivered their babies at the facility; post-partum checkups are “not frequent.” At Sakure PHCC, there were 84 ANC clients in 2014, out of which 23 delivered at the facility, with no record of postpartum checkups.

Although the smaller PHCUs provide no official ANC or obstetric care, they still reported some ANC or deliveries in the area supported by TBAs. Nakpazigi PHCU, for example, reported 45 ANC clients in the area that were attended to at home by TBAs, and 20 home births that were recorded at the facility (although supported at home by TBA). At Nangirimo PHCU, the facility recorded 124 ANC clients in 2014, attended to at the facility by a TBA. The facility also recorded 26 births that occurred at the facility, attended to by

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a TBA, in addition to one miscarriage. No other pregnancy-related or delivery-related complications were documented at either PHCU.

TABLE 25: MATERNAL HEALTH SERVICES COVERAGE RATES, BY HEALTH FACILITY (JANUARY- DECEMBER 2014) Coverage Rates Nzara Nzara Basukangbi Good Ringasi Sakure Sangua II MH PHCC PHCC Samaritan PHCC PHCC PHCU PHCC Antenatal NA NA 32% NA NA 9% 42% Coverage Total Deliveries 60 332 53 166 58 23 109 Delivery NA 960 36.8% 83.4% 67.4% 27.4% 99% Coverage Rate- Percentage of those receiving ANC who came to deliver Percentage of 100% 100% 100% 31% 100% 0% 83.5% (91 Deliveries (community (mostly performed attended by midwife), by MCH by skilled 69% (TBA) worker community professional with some wife and midwifery others by training nurse of and TBA) TBAs) Total Number of 0 0 14 131 0 0 NA Women who received postnatal care Postnatal Care NA 0% 26.4% 78.9% 0% 0% NA Coverage Rate- Percentage of those who delivered baby who received postnatal care Total number of NA 24 0 0 46 0 13 women using Family Planning methods

4.6.2 FACILITY FAMILY PLANNING SERVICES COVERAGE (OCTOBER- DECEMBER 2014)

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In the quarter preceding this facility assessment (October- December 2014), Nzara PHCC and Ringasi PHCC provided birth control, primarily inform of injectables, male condoms, and oral pills. Sangua II PHCU provided limited stock of male condoms and low dose pills. Nzara MH, Good Samaritan PHCC, and Sakure PHCC and Basukangbi PHCC provide no family planning services or contraceptives. Sakure PHCC does stock some condoms, but only recorded giving a total of 15 condoms to two separate women in the fourth quarter of 2014. Although Nakpazigi PHCU has condoms available, they do not have any record of providing condoms or any other contraceptive during the indicated time period.

TABLE 26: TOTAL NUMBER OF CLIENTS RECEIVING CONTRACEPTIVES, BY HEALTH FACILITY (OCTOBERBER- DECEMBER 2014) Type of Nzara MH Nzara Basukangbi Good Ringasi Sakure Sangua contraceptive PHCC PHCC Samaritan PHCC PHCC II PHCC PHCC Low dose oral NA 0 0 0 10 0 14 High dose oral NA 0 0 0 0 0 0 Progesterone only NA 0 0 0 1 0 0 Injectable NA 24 0 0 17 0 0 Norethisterone NA 0 0 0 0 0 0 Male condoms NA 0 0 0 18 2 20 Female condoms NA 0 0 0 0 0 0 Diaphragms NA 0 0 0 0 0 0 IUCD NA 0 0 0 0 0 0 Subdermal implant NA 0 0 0 0 0 0 Spermicide (foam, NA 0 0 0 0 0 0 jelly) Male sterilization NA 0 0 0 0 0 0 Female NA 0 0 0 0 0 0 sterilization Morning After Pill NA 0 0 0 0 0 0

4.6.3 FACILITY MATERNAL HEALTH INDICATORS (JANUARY- DECEMBER 2014)

All facilities track key maternal health indicators, including number of births, maternal deaths, and neonatal deaths. All facilities are supposed to report data regularly to Nzara County, but there are challenges in record keeping. For example, not all facilities record if there was a complicated case that requires referral—many simply refer the case without

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recording or following-up. Nzara MH does not see ANC clients. Nzara PHCC saw the most clients (960) in the time period January- December 2014, followed by Good Samaritan (199), Basukangbi (144), and Sangua II PHC (110). However, the most births were recorded at Nzara PHCC (332) and Good Samaritan PHCC (166). The fewest ANC clients for a PHCC was 84 at Sakure PHCC, which also recorded the fewest births for a PHCC (23) in all of 2014, in an area with an estimated population of over 18,000 people, which is indicative of low facility us; community members report that this is due to several factors: poor facilities; staff not always present; preference to birth at home with TBAs.

In the case of maternal or neonatal death, all facilities are supposed to report deaths and engage in a maternal death audits as they occur. In facility monthly reports this should also be reported. However, none of the facilities in Nzara County recorded a maternal death at the facility in 2014.

There was one fresh stillbirth reported in 2014 at Ringasi PHCC. According to the midwife, the baby was large (4kg) and the delivery was obstructed. She referred the woman and the family to Nzara MH, but there was no emergency vehicle available, and the family did not have money to pay for a boda. The midwife reports that the family chose to ignore the referral and remained at the facility. Eventually the baby came out, but had been separated from the placenta. It was reported to IMC and the county, and an investigation followed.

Another fresh still birth was reported in 2014 at Sakure PHCC. The mother was delivering twins, the first which was presenting abnormally (hand first). The mother was referred to Nzara MH during the delivery, but was unable to arrange transport there. One of the twins survived and one died.

Although unofficial deliveries do take place with TBAs at Nangirimo PHCU, there are no records of any maternal or neonatal deaths that may have occurred at the facility. Nangirimo did record that 22 babies were vaccinated with BCG immunization in 2014.

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TABLE 27: MATERNAL HEALTH INDICATORS, BY HEALTH FACILITY (JANUARY- DECEMBER 2014) Coverage Nzara Nzara Basukangbi Good Ringasi Sakure Sangua Rates MH PHCC PHCC Samaritan PHCC PHCC II PHCC PHCU Total number NA 960 144 199 86 84 110 of antenatal clients Total number 60 332 53 166 58 23 109 of births Total number 60 307 53 166 57 22 109 of spontaneous vaginal deliveries Total number 137 1 0 1 0 2 0 of abortions Total number 0 0 0 0 0 0 0 of instrumental deliveries (forceps or extraction) Total number 2 25 (all 0 0 1 1 (twins, 0 of abnormal referred) (obstructed- first was vaginal stillbirth) hand deliveries- first, 1 breech, face, twin shoulder stillborn) Total number 0 0 0 0 0 0 0 of C-sections Total number NA 839 0 0 79 19 NA of babies receiving BCG and polio immunizations at facility Total number 0 0 0 0 0 0 0 of maternal deaths Causes of NA NA NA NA NA NA NA maternal deaths Total number 2 0 0 0 1 1 0 of fresh still births Total number 0 0 0 0 0 0 0 of macerated still births Frequency of As As they As they As they As they As they As reporting on they occur (but occur (but occur (but occur occur they maternal occur no deaths) no deaths) no occur deaths to (but deaths) (but no District health not deaths) team deaths)

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Frequency of As As they As they As they As they As they As reporting on they occur (but occur (but occur (but occur occur they maternal occur no deaths) no deaths) no occur deaths from deaths) (but no health facilities deaths) in catchment area to district Does a No No No No No No No standard maternal death notification form exist Frequency of Never Never Never Never Never Never Never maternal death audits Frequency of Never Never Never Never Never Never Never peri-natal death audits

4.6.4 COMPLICATIONS SEEN/ MANAGED AT FACILITY (JUNE- DECEMBER 2014)

The assessment identified prevalence of some major and fatal child illnesses and pregnancy-related complications attended to at the selected facilities in the last 6 months. In the majority of cases at Nzara Mission Hospital, complications including anemia, malaria, and pregnancy-related complications including obstructed labor and breech presentation were managed at the hospital. More complicated cases for delivery or pregnancy that require surgery were referred to Yambio Hospital PHCCs and PHCUs, for the most part, referred most complicated cases.

As mentioned previously, most PHCCs and PHCUs have very poor record keeping of complicated cases; often for these cases they refer without recording the client’s complication, and there is also no follow-up. Thus, for some they do not know/ did not recall complications for last year. For other PHCC In-charges, they were able to recall specific numbers of cases. This reflects generally on the poor referral system and data keeping currently in place. Thus, relatively low reported cases of most complications are not indicative of actual prevalence or incidence seen at facilities. For example, community members report a common problem, and often cause of death, for women in Nzara County is infection following labor, or bleeding following labor.

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TABLE 28: COMPLICATIONS SEEN/MANAGED AT FACILITY (MARCH- SEPTEMBER 2014) Complications Nzara Nzara Basukangbi Good Ringasi Sakure Sangua MH PHCC PHCC Samaritan PHCC PHCC II PHCC PHCU Severe Anemia 250 0 1 0 1 NA 0 total Anemia managed 250 0 0 0 0 NA 0 Anemia referred 0 0 1 0 1 NA 0 Severe Malaria 1,781 10 21 14 NA NA 0 total (under 5), 263 (above 5) Malaria 1,322 0 21 0 NA NA 0 managed (under 5), 571 (above 5) Malaria referred NA 10 0 14 NA NA 0 Antepartum 3 NA 0 0 1 NA 0 hemorrhage total Antepartum 0 NA 0 0 1 NA 0 hemorrhage managed Antepartum 3 NA 0 0 0 NA 0 hemorrhage referred Preeclampsia 1 0 0 0 0 NA 0 total Preeclampsia 0 0 0 0 0 NA 0 managed Preeclampsia 1 0 0 0 0 NA 0 referred Eclampsia total 1 0 0 0 0 NA 0 Eclampsia 0 0 0 0 0 NA 0 managed Eclampsia 1 0 0 0 0 NA 0 referred Postpartum 1 NA 2 0 0 NA 0 hemorrhage total Postpartum 0 NA 2 0 0 NA 0 hemorrhage managed Postpartum 1 NA 0 0 0 NA 0 hemorrhage referred Abortion 32 NA 0 1 1 NA 0 complication total

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Abortion 30 NA 0 1 0 NA 0 complication managed Abortion 12 NA 0 0 1 NA 0 complication referred Retained 12 NA 0 0 1 NA 0 placenta total Retained 8 NA 0 0 1 NA 0 placenta management Retained 4 NA 0 0 0 NA 0 placenta referred Breech 2 NA 0 0 0 NA 1 presentation total Breech 1 NA 0 0 0 NA 0 presentation managed Breech 1 NA 0 0 0 NA 1 presentation referred Postpartum 15 0 0 0 0 NA 0 sepsis total Postpartum 15 0 0 0 0 NA 0 sepsis management managed Postpartum 0 0 0 0 0 NA 0 sepsis referred Ectopic 7 0 0 0 0 NA 0 pregnancy total Ectopic 0 0 0 0 0 NA 0 pregnancy managed Ectopic 7 0 0 0 0 NA 0 pregnancy referred Obstructed labor 2 NA 0 0 1 NA 1 total Obstructed labor 0 NA 0 0 0 NA 0 managed Obstructed labor 2 NA 0 0 1 (but NA 1 referred patient remained and stillbirth) Ruptured uterus 0 0 0 0 0 NA 0 total Raptured uterus 0 0 0 0 0 NA 0 managed Raptured uterus 0 0 0 0 0 NA 0 referred

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4.7: MANAGEMENT PRACTICES

4.7.1 SUPPORTIVE SUPERVISION

Supervision by external managers has many benefits. It can help ensure that system-wide standards and protocols are followed at the facility level and promote an organizational culture that expects such standards and protocols to be implemented. It provides an opportunity to expose staff to a wider scope of ideas and relevant experiences, including on-the-job training for some providers. It can also motivate service providers, especially if the supervisor is supportive.

The Nzara County Health Management Team conducts support supervision at all five PHCCs and the three PHCUs sampled and at Nzara Mission Hospital in partnership with INGO, IMC. Support supervision visits are intended to be conducted on a quarterly basis, and the mission hospital and the four government PHCCs report that support supervision visits are typically conducted as such. However, Good Samaritan PHCC reports receiving support supervision only twice last year in 2014. The four PHCCs have documentation supporting these visits, including documentation in a visitors’ book.

Nzara MH is supposed to receive supervision visits from Yambio State Hospital but reports that it has never received visits, nor does it report receiving visits from the Nzara County Health Management Team.

4.7.2 QUALITY IMPROVEMENT PROGRAMMING

None of the five PHCCs or PHCUs sampled, nor Nzara MH, report having a quality improvement program, and were not aware of what quality improvement programming was at the time of the interview in February 2015. None of the facilities in Nzara County

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reported that they conduct patient/ client satisfaction surveys on a quarterly basis or regularly over another time period.

4.7.3 FUNDING MECHANISMS AND FEES FOR SERVICES

User fees may have a positive effect on the use of health facilities by increasing the funds available to the facility; they may also have a negative effect by deterring poor clients from using services. User fees with exemption schemes for vulnerable people often help to augment inadequate facility budgets. However, providing exemptions or discounts for poor clients can result in budget shortages if there is no system for reimbursing the facility for these exempted or discounted costs.

Some other approaches also encourage appropriate use by poor clients and reimburse facilities for client services. These approaches include insurance plans, credit plans (delayed payment for services received today), and charity or equity funds that reimburse the costs of certain clients (thus increasing access to care by reducing out-of-pocket payments at the time of service utilization). In any case, health facilities should clearly display their fees for service, if they charge for any services. This improves accountability, reduces the likelihood of corruption, and helps clients calculate the costs they will incur in seeking services.

All PHCC and PHCU facilities located in Nzara County provide all services free of charge, including for all delivery, ANC and postpartum services. Nzara MH provides delivery services free of charge; however, there is a small user fee of 2 South Sudanese pounds for OPD children under 5, which will increase to 4 pounds for children under 5, and 5 SSP for inpatients. Fees for adults are slightly higher, and depends on the service (ranging from between 2 SSP for admission or consultations to 25 SSP for drugs). Additionally, although no services are paid for formally at Nangirimo PHCU, the TBAs that assist women to deliver babies at the facility are typically paid by the women, such as 50 South Sudanese pounds, or in-kind items such as soap, chicken, or meat.

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Although there is no fee for mothers in labor, and there is no charge for delivery or care for mother and baby at any facility in Nzara, the mother is expected to bring her own supplies for the delivery, which includes a baby blanket, baby clothes, towel, clothes for the mother, plastic, JIK (cleaner), razor blade, basin for washing the baby, nappies, sanitary pads, food, and anything else the mother or baby requires during and after labor. Women who deliver at Sangua II PHCU are advised to also save money and bring some in case there is an emergency to pay for a boda boda (motorbike) to go to Nzara Mission Hospital. Although there are mother waiting areas at each facility where an expectant woman may come in anticipation of delivering, she is also expected to provide her own food and all personal items while she is there. This may be prohibitive for many women who may need to travel some distance; if she runs out of food and supplies she may not continue her stay, or she may choose not to travel to the waiting area if she is not able to travel with adequate amounts of food and supplies in advance.

The PHCCs in Nzara generally do not receive any regular funding for operation. Rather, MoH provides in-kind supplies (drugs and equipment) while IMC pays staff salaries. Good Samaritan PHCC receives all of its in-kind supplies and staff salaries via the Diocese, and does not receive any government or INGO support via funding or supplies.

4.7.4 COMMUNITY INVOLVEMENT IN MANAGEMENT

Encouraging community input into a facility’s functions makes the facility more accountable to the community it serves; it also helps the facility to better understand the community’s needs. This increases the probability of better health-seeking behavior, may facilitate advocacy and outreach activities, and in turn may improve the health of the population.

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All health facilities should have a Village Health Committee (VHC) that is closely involved with each PHCC and PHCU. Sakure PHCC was the only PHCC that reported an active VHC that meets monthly and provides monthly meeting minutes to the facility. Basukangbi PHCC reports that there is a Village Health Committee in the area that meets; however, the PHCC does not appear to interact regularly with the committee and the PHCC was not able to describe its functions, number of volunteers, or any further details. Nzara MH, Nzara PHCC, Good Samaritan PHCC, and Sangua II PHCU reported

Image: Woman in Nzara County participating in FGD that they do not have a Village Health Committee. Ringasi PHCC reports that there is an active Village Health Committee that meets monthly, and the community health worker runs approximately two community health talks each month.

Both Nakpazigi PHCU and Nangarimo report that there are community linkages in place, with community units attached to the facility which meet monthly. At Nangarimo PHCU there is a women’s group run supported by Red Cross.

However, both Ringasi PHCC and Basukangbi PHCC note that there is not a set procedure for linkages and referrals between the community and facility.

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“THE COMMUNITY HEALTH WORKERS WHO ARE VOLUNTEERS DO NOT WORK PROPERLY. VOLUNTARY WORK DOESN'T SUCCEED IN AFRICA. MAYBE IN EUROPE IT WORKS, BUT NOT HERE." Nzara County Primary Health Center In-Charge

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CHAPTER FIVE – CAPACITIES AND ANTICIPATED CHALLENGES

This section provides a brief overview of:

1) Identified capacities and opportunities that exist within the project area that the CHAMPS project may anticipate as a key resource for leveraging.

2) Identified challenges, barriers, or obstacles that exist within the project area that the CHAMPS project may anticipate to be important to consider during CHAMPS project design in order to create appropriate mitigation measures.

5.1 CAPACITIES AND OPPORTUNITIES

Community members and key stakeholders in Nzara County identified the following capacities and opportunities listed below that exist within the project area that the CHAMPS project may anticipate as a key resource for leveraging. This may include specific influential individuals within the community, existing organizations of people or institutions, or existing financial resources or infrastructure in the area.

Existing institutional/ organizational capacities that may be leveraged include: - County Coordination Meetings comprises of the County Health Director, payam administrators, ISDP workers, and health workers. They meet monthly, where each member presents issues relevant to health problems in each payam and bomas, and other issues such as lack of water or staffing issues (such as a lack of staffing; midwives). A report is made and recommendations are followed-up by responsible parties. State coordination meetings also take place, involving all payam administrators, the County Commissioner’s Office, the women’s group in Nzara Payam, and other stakeholders.

- RRC coordinates all INGO efforts. It is a government wing responsible for overseeing humanitarian interventions at different levels. RRC has a national office, State Offices and county representatives including Nzara. County RRC offices helps

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coordinate NGO activities in Nzara through facilitating monthly coordination meetings in collaboration with the county authorities.

- Diocese plays an important role within Nzara County, with particular emphasis within Nzara Payam where they are located. They fully support one of the PHCCs, Good Samaritan PHCC, and also support other initiatives such as a Women’s Development Group in Nzara Payam.

- International Medical Corps (IMC) operates under USAID-funded ISDP throughout Nzara County supporting 17 out of the 22 PHCCs and PHCUs. They provide salary to health facility staff, and also support operations of facilities, including provision of rehabilitated infrastrucutre, equipment, and supplies. There is a focus on reproductive healthcare and quality of deliveries, with efforts in place to ANC, and family planning. IMC is also distributing misoprostol through HHPs and community health workers in communities to reduce maternal deaths as a result of post-partume hemorrhage. They are also working to increase curative consultations and improve child health by providing Vitamin A, growth monitoring, and increased immunizations (implemented under the Core Group). Lastly, IMC has been successful in promoting behavior change through use of the Community Action Cycle (CAC), observed in four facilties. IMC will be a key partner in developing and implementing institutional/ facility improvements to ensure efficiency and collaboration and to avoid duplication of work. IMC faces some limitations in what they can accomplish due to certain restrictions. For example, they are not able to assist in any cases of abortion. Further, IMC cannot engage in any construction—only in rehabilitation. This means that in some cases, such as in Sangua I PHCU which has no existing latrine, they are not able to build a latrine. Lastly, although IMC has a budget to hire more staff at facilities, there is a lack of qualified candidates to fill positions.

- Community Peace Building and Protection Association (COPEBA) is a non- profit, local community based organization (CBO) based in Nzara county which was

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initiated by World Vision with the name Peace and Protection Committee (PPC) targeting work with internally displaced people (IDPs) from all five payams following displacement due to LRA activity in 2007. It’s mission is to fight illiteracy by promoting basic education in the community and building a peaceful co-existence for real and sustainable development by working together and closely with the community members to mobilize the local resources for income earning, advocacy for protection of children, women, and the most vulnerable groups. Its objectives are two-fold: 1) Promote peace, literacy, and development in the community and promote self-reliance within the community through mobilization of local resources; 2) Build the capacity of the community on child protection issues and policies; and 3) Create awareness on women’s rights, empowerment, and GBV.

- Abt is running a Health System Strengthening Project, also supported by USAID, which is a sister project to ISDP. It is tasked with supporting monthly coordination meetings and strengthening health systems throughout the area.

- World Vision runs community vaccination campaigns and funds EPI workers throughout Nzara County to conduct door-to-door vaccinations. World Vision also runs some livelihood programs Food for Assets project by supporting farmers groups, establishing and supporting fish ponds for groups.

- Village Health Committees (VHCs) are a mandatory mechanism that are supposed to be linked to all health facilities. VHCs serve as a communication link between community and hospital. They are important groups in terms of IEC, increasing community access, and ensuring quality health care accountability of facilities; however, in most areas throughout Nzara County they are reportedly not very active, and in some places are not at all operational, presenting challenges (see Section 5.2).

- Community health promoters are attached to each PHCC and PHCU, responsible for conducting IEC and conducting outreach within the community. The government has 24 paid health promoters working throughout the county, going

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house-to-house to check on the welfare of families and link them to health facilities. However, few PHCCs and PHCUs assessed identified active community health workers (see Section 5.2).

- Churches (Catholic, Protestant, and a minority of Muslim) and religious leaders throughout Nzara County are influential in decision-making of individuals, providing individual and family spiritual guidance and counseling. The churches play a key role in setting the moral compass among individuals and families, and are influential in beliefs and behaviors related to reproductive health and family planning, gender equality, and other health issues.

- Nzara Payam Women’s Development Group are a group of women who train women in Nzara Payam on human rights, leadership and business skills, organizing workshops, and economic empowerment (including income-generating activities such as skills building in tailoring).

- Nzara United Youth Peace and Development Organization are a group of male and female youth based in Nzara Payam, primarily operating there. Its mission is to coordinate youth to achieve sustainable development in Nzara County. Their primary activities include: opening of a community school, advocacy on HIV peer awareness and prevention via public performances and drumming, combating GBV, and producing vegetables for the community. The group has members age 18- 45, which it defines as “youth,” aligned with the South Sudanese “age of consent.”

- Nzara Payam Mentor Mothers are HIV positive mothers from the community who provide support, advice, and counseling for other HIV positive mothers, including guidance and support for providing PMTCT.

Existing individuals or influential community members that may be leveraged include: - Traditional chiefs for each payam, sub-chiefs for each boma, and the Paramount Chief for all of Nzara County, who have authority as leaders throughout the area.

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People rely upon chiefs for guidance within communities. They are important gatekeepers as they may influence decisions made by community members, may disseminate information, and make decisions over resources and community behaviors. They are reportedly the most influential, in particular, over men’s behaviors in the community (more than are religious leaders).

Existing resources or services that may be leveraged include: - Existing PHCCs and PHCUs exist throughout Nzara and are crucial in connecting community members to health care services. Despite some challenges that exist, discussed throughout this assessment, these facilities are for many families the only existing critical points for health care service delivery that can be leveraged and mobilized with improved resources and capacity.

- National strategies related to maternal health and children’s health are in place with policy and implementation frameworks, including the Health Strategic Plan (2011- 2015) for the Government of Southern Sudan Ministry of Health (September 2010); the Republic of South Sudan MOH Health Sector Development Plan 2012-2016; the Basic Package of Health and Nutrition Services in Primary Health Care Update (South Sudan July 2011); guidelines on HIV accepted fully by the Republic of South Sudan; distribution of kits with anti-malaria drugs and focus on prevention and treatment of malaria; and efforts to increase TB case findings, including more training and supervision workshops.

- The MOH is opening a new training institute for midwives and nurses. However, there is no current plan in place to implement the training.

5.2 CHALLENGES AND BARRIERS

Community members and key stakeholders in Nzara County identified the following challenges, barriers, or obstacles that exist within the project area that the CHAMPS project may anticipate to be important to consider during CHAMPS project design in

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order to create appropriate mitigation measures. These challenges are focused not on health outcomes and service already explored in this assessment, but rather on challenges that may impede project design or implementation.

Institutional challenges include: - Poorly resourced and funded government health facilities and institutions have lack of adequate numbers of trained staff and supplies. The government is not able to run the facilities, and so IMC is providing salaries for the staff (which is very low—around 200 South Sudanese pounds monthly), and the government provides drug kits which are often inadequate. The sustainability of dependence on INGOs for operation of health facilities is questionable. No ambulance exists in all of Nzara County, nor any facility for performing emergency procedures for C-sections, for example; all such cases must be referred to Yambio Hospital outside the hospital.

- Insufficient coordination between various government, private, and community actors prevents effective planning and service delivery. Some stakeholders point to a lack of coordination between these different entities and stakeholders.

- Weak government institutions due to poor funding. There is great dependence, particularly due to lack of funding and recent conflict/ instability on INGOs. The County Health Department is supposed to be staffed with 20 people but they currently only have one county medical officer, one health surveillance officer, an EPI coordinator, and a data clerk. They also face logistical challenges in conducting support supervision due to lack of a vehicle. Government institutions are largely unable to provide basic services such as training and salary provision to health facility staff. Further, because of the poor staff pay for health workers (about 200 pounds monthly), many leave to work for INGOs with better pay opportunity; this does not support a sustainable system for a skilled medical staff in Nzara County.

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- Weak human resources, including lack of cadre to recruit as health workers. Due to political instability and war there is generally low education of people in the area. However, there are still secondary school graduates that could serve as a potential cadre of trainees as health workers. Further, people are hesitant to take on responsibility of leadership and supervisory roles.

- Weak political will from the top-down. Many people within Nzara County see challenges in the lack of desire of key decision-makers and politicians at state levels and downwards to influence important needed changes, in health care improvement in general, and also in relation to traditional practices such as early marriage, as well as child abuse.

- Division between traditional/ customary legal practices. While government institutions are still weak, there are at the same time government efforts to separate chiefs from the people, which creates a vacuum in authority and power over keeping order among community members. The Paramount Chief, the 8 Executive Chiefs under him, and all of the other chiefs for individual villages/ bomas still retain a great deal of influence, but at the same time are “losing their grasp,” while at the same time formal systems have not yet strengthened to have the capability to play a strong role in people’s lives—particularly in terms of discouraging harmful behavior.

- Despite the importance of Village Health Committees (VHCs), they face numerous obstacles in meeting their full potential as a key agent in health service delivery. First, there are no formal linkages or procedures that seem to exist between the health facilities and VHCs—most stakeholders interviewed, including health facility in-charges, were not able to identify set procedures or processes for working with VHCs and communities. Further, the VHCs are limited in how effective they can be as they have limited or no resources for transport money, communication/ phone credit; some stakeholders report that

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there is low motivation due to lack of lunch allowance, transport allowance, or other types of incentives.

- Insufficient service providers, NGOs, or other organizations that provide psycho-social services for people living with HIV, internally displaced persons, and SGBV survivors.

- Insufficient existing community groups (e.g., women’s groups, youth groups, men’s groups, sports groups) throughout Nzara County results in a vacuum of existing community-based organizations to work through and build upon. Although several groups exist within the peri-urban area of Nzara Payam, not many community-based organizations were identified in other rural payams.

- Insufficient of infrastructure in terms of communication and transport options inhibits efficiency. Most people in the area rely upon cell phones, but there are several problems: 1) health facility staff use their own personal resources to pay for phone credit; and 2) there is poor network, and many areas are out of reach by cell phone, such as in Basukangbi. In addition, transport is a challenge and costly, including expensive fuel costs. Although vehicles from INGO IMC or the Diocese may be called upon, if available, in an emergency for patients within Nzara Payam, there are no options for emergency transport throughout the rest of the county in rural areas—most clients rely upon walking, bicycle, or (if they have personal money) a boda boda (motorbike) if a driver is available. Further, bad roads, and in particular the road to Basukangbi, are in such poor condition that during the rainy season it becomes impassable, and at any time of the year there are many reports of women giving birth on the road or people

Challenges related to community perceptions and beliefs include:

- There exists distrust among community members for promises of a project that may not materialize. Many community members and stakeholders are weary of

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organizations or individuals coming to Nzara County to implement a project since many promises and commitments were made in the past that never materialized. Programming will need to take into consideration the need to build trust with community members over time.

- Some stakeholders from the area surmise that there is a general feeling of “hopelessness” among people in Nzara County, which negatively impacts their health-seeking behavior (including health precautions), as well as motivation to improve their own lives and their communities. Due to the experience of conflict in recent years, both internal within Sudan and from external sources such as the Uganda LRA, most adults and young adults lived through, grew up in, and/or came to age during conflict and suffered from violence, trauma, loss of family members, and displacement. Now the community remains less “on edge” then they were before, with slightly more stability, but because uncertainty remains about their security (particularly in areas such as Sakure Payam where there is still reported LRA attacks), people in the community reportedly have little hope or motivation for the future. This will be particularly important challenge to overcome, especially when discussing behavior change (such as health-seeking behavior, HIV testing and preventive measures), as well as livelihood initiatives that require motivation and personal investment of time and resources. Without addressing underlying attitudes rooted in this conflict mentality of hopelessness to support community members in seeing the value and potential in life, behavior change efforts will likely be fruitless. Lastly, the passage of time, which requires programmatic patience, may also be important to bear in mind when looking for results in behavior change.

- Religious beliefs and the interpretation of the Bible in many communities results in resistance to utilize family planning, devaluation of basic hygiene measures, such as hand-washing, and justifies violence within households (e.g. beating of women and children as God-given right and duty). It must be recognized that religion plays a critical role in the lives of many of the community members; no meetings should start or end without a prayer. This can be a strong

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capacity that be leveraged, but it is important to also recognize where some messages have been interpreted at the expense of the health of community members, and in particular, women and children. Because, for example, “God has made all things pure,” community members place little value in hand washing. It will be critical for IEC and outreach efforts to utilize these beliefs in a way that places value on personal hygiene.

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CHAPTER SIX – CONCLUSIONS AND RECOMMENDATIONS

6.1 CONCLUSIONS

Key underlying challenges in accessing quality health care for maternal and child health care services include: long distances on poor roads that are sometimes impassable, and lack of transport to reach the few available health facilities; understaffed/ poorly staffed health facilities; poor health facility infrastructure, equipment, and supplies; and health seeking behavior including lack of knowledge, and gender inequality; and religious beliefs and practices that discourage the use of family planning and basic hygiene.

6.2 RECOMMENDATIONS

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to guide community-driven design of the CHAMPS project in Nzara County, and are intended not as a prescription, but rather as a starting point for community-driven discussion on the most important objectives and activities to improve the health of women and children in Nzara County.

It is critical to note that the identified capacities and challenges in the previous section may help or hinder implementation of recommended activities. Most importantly, without addressing root causes of poor maternal and child health outcomes—namely systemic poverty and gender inequality,

Image: Woman in Nzara County offering activities will simply be a “Band-Aid.” solutions to identified problems in a FGD Sustainable change to improve the well- being of women in children in Nzara County must, therefore, systematically take on the challenge on addressing systemic poverty and gender inequality.

6.2.1 IMPROVED HEALTH CARE SERVICE DELIVERY

Community members and stakeholders identify the importance of improving the quality and quantity of health care facilities with skilled staff, equipment, and drugs. It will be of great benefit to the Nzara community to support improved health facility infrastructure, equipment, and availability of skilled staff vin close coordination with IMC leading the ISDP effort to ensure complimentary work that does not duplicate existing efforts:

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- Increase skilled staff at all health facilities—particularly skilled midwives (and community midwives), nurses, and clinical officers who have received training in emergency obstetric and newborn care. This will require resources currently not available by the government, in addition to increased/ improved accommodation for health workers, including housing with available water and sanitation facilities. It must be recognized that this will be a long-term effort due to the low educated workforce within Nzara County—efforts will be needed to ensure basic literacy and understanding of competent workers prior to training. Although some great work has already taken place, including formal training of recognized community wives, enhancing referral mechanisms by community health workers and traditional birth attendants (TBAs) to a PHCC or PHCU with a trained midwife will be critical. This could be done, for example, by compensating TBAs for referrals that they make. Female community members further suggest that “paying TBAs would help improve their service.”

- Work with existing cadre of IMC community health workers/ promoters to compliment IMC efforts and conduct critical outreach efforts and provide training in nutrition, under-5 growth monitoring, when to refer a woman for ANC, delivery, or PNC/ child in emergencies, malaria testing, provision of essential drugs (malaria medication, ORS, family planning supplies); hygiene; provision of incentives such as a community-provided allowance for transport/ lunch; and provision of essential supplies and drugs. Ensure each CHW has a bicycle to travel around the community and reach the nearest health post or PHCC/ PHCU in cases of emergency and no phone network.

- Increase number of health facilities to ensure places that currently lack health facilities, such as Babadga in Ringasi, have access to primary health care, and to ensure there are adequate facilities in Nzara Payam to handle all maternity cases.

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- Compliment existing IMC efforts to equip health facilities with appropriate equipment and supplies to provide MNCH services, including emergency obstetric care, cervical cancer screening and infant feeding programs, with a focus on facilities not currently supported by IMC. All PHCCs and PHCUs with trained staff could be provided with basic supplies required to safely deliver babies and provide care for mothers, children, and newborns. This includes regular stocking of basic supplies such as ORS, diagnostic test and treatment for typhoid, drugs such as oxytocin, vaccines, malaria tests and treatments, and various family planning methods/ contraceptives. Additionally, there should be available equipment and staff within Nzara County who can perform EMOC and provided PEP to SGBV survivors. All staff require education and training on screening for cancer (including breast and cervical cancer) and equipped with proper supplies and test materials to perform regular tests. “THERE SHOULD BE NO ONE SAYING, ‘THIS MEDICINE IS NOT HERE’ WHEN A Basic infrastructure CHILD IS SICK.” needs could be met - Community member from Nzara including: running water, power/ electricity; and functioning refrigerators. Facility support should focus on those facilities not currently supported through by IMC, such as Sakure PHCC which requires a new admission room, maternity room, separated male/ female ward, clean water, laboratory equipment, and other basic essentials to operate properly.

- Compliment IMC efforts to equip and upgrade health facilities with appropriate equipment, supplies, and trained staff to provide HIV counseling and treatment, and other related services such as PMTCT. Currently, HIV counseling and treatment is only available through the clinic run by CMMB attached to Nzara PHCC in Nzara Payam. HIV testing, treatment, and counseling is not available in any other rural payam, except when there are mobile outreach

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efforts conducted by CMMB. Access to testing, and especially to ART within all payams is critical for successful management of HIV. This could be done by making testing, equipment, trained staff, supplies, and treatment available at each PHCC in each payam, or by providing a regular and reliable mobile community outreach HIV service that provides monthly testing, care and treatment throughout Nzara County, including the more hard-to-reach areas such as Basukangbi. Solutions to continued mobile outreach services throughout rainy season when roads are impassable will be required to make this successful. Because of this mobility challenge during much of the year (April- December), it may be more realistic to ensure ART services are available with trained staff, drugs, equipment, and supplies, particularly in Basukangbi, Sakure, and Ringasi.

- Create an operating theater at Nzara Mission Hospital and train staff to perform lifesaving surgeries, including C-sections to avoid time lapses and delays in referrals from Nzara County to Yambio State Hospital, which may lead to maternal and neonatal deaths.

- Provide HIV counseling and testing at schools for girls and boys.

- Provide an equipped ambulance for Nzara County, as well as an “emergency motorbike” at each PHCC and one PHCU in Sangua where no PHCC exists, to ensure that, in the event of a medical emergency, patients have a reliable method of transport to reach Nzara Mission Hospital or Yambio Hospital in a timely and safe manner. o Allocate an equipped ambulance with ongoing maintenance and fuel allocation to be located at Nzara Mission Hospital and that may travel to pick-up patients in emergencies throughout the county. o Locate emergency motorbikes in each payam at each PHCC and at Sangua I PHCU in Sangua where there is no PHCC (during rainy season vehicles such as an ambulance cannot pass over the roads). o All transport vehicles used (ambulance, motorbikes, or other) for

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emergencies should be equipped with radio in order to communicate, especially in areas without cell phone reception. o Support provision of free transport for SGBV and child abuse survivors to reach critical services.

- Identify potential partners, such as UNOPS, who may assist in road improvement, particularly in areas such as Basukangbi where the road is sometimes impassable by vehicle during rainy season. Failure to improve certain roads will result in a failure to improve access to emergency health care in those areas.

- Support existing efforts to improve referral mechanisms and Standard Operating procedures (SOPs) for referrals throughout Nzara County and to Yambio State Hospital, and support ongoing quality care at Yambio State Hospital.

- Improve communication between PHCCs, PHCUs, Nzara MH, health posts, and the community at large. This could be done by creating a community radio station and distributing solar-powered radios to CHWs, VHCs, PHCCs, PHCUs, and Nzara MH.

- Opening of “youth friendly corners” and safe spaces for girls within schools and clinics to provide them with safe access to information and services related to reproductive health, family planning, and GBV. Link them with community-based child protection committees, and short-and long-term shelter options.

- Create mother shelters, which are husband/ male friendly. Besides the mother’s shelter located outside of Nzara County at Yambio state Hospital, there were no identified mother’s shelters identified at any of the PHCCs or selected PHCUs where a woman may come to wait in anticipation of giving birth, nor are there cooking facilities available to allow for her to sustain herself during this

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waiting period. If waiting areas are provided, it will be important to construct them in a way that encourages their husbands/ partners to accompany women to participate in ANC and delivery.

6.2.2 IMPROVED KNOWLEDGE FOR BEHAVIOR CHANGE

Community members and stakeholders identify the importance of increasing the knowledge and awareness of community members and key community stakeholders and leaders to facilitate behavior change in areas related to health seeking behavior for a variety of health concerns including maternal and child health, gender- based violence, nutrition, hygiene practices, and improved livelihoods. The Nzara County community will benefit from information education communication (IEC) to encourage behavior change among community leaders, community members, and health staff to improve the well-being of women in children.

Image: Mother and child in Nzara County participating in focus group discussion It will be of great benefit to the Nzara County community to support implementation of IEC, in close collaboration and coordination with other stakeholders such as IMC, targeted to specific groups on topics prioritized by the community via: - Parents (mothers and fathers) are taught about harm of early marriage and importance of education for girls. - Parents and chiefs are taught to discourage men from beating their wives and children.

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- Police are sensitized with knowledge on appropriate action to take in cases of abuse, neglect, maternal or child death, etc. - Chiefs are sensitized with knowledge about dangers of early marriage and abuse in order to take action and counsel women and men in the community, including ongoing talks with groups of men in each village. - Community-wide sensitization is held on gender-based violence, including early child marriage, and the negative impacts of alcohol consumption. - Community-wide sensitization is held on essential health package issues, including maternal health, cervical cancer screening, nutrition, family planning benefits and facts, malaria and proper use of mosquito nets, HIV/AIDS, PMTCT, disease prevention, water treatment, sanitation and disposal of solid/ human waste, and personal hygiene. Identify impactful opportunities, such as discussing at a child’s funeral the cause of death and link between poor hygiene and disease (due to earlier failed radio/ community workshop attempts to change behavior on hand washing). - Expectant mothers and their male partners are educated about danger signs in pregnancy, when to seek care, dangers in using traditional care rather than formal care, and breaking down myths and taboos related to pregnancy. - Adolescents and married/ single women and men are targeted for awareness on HIV/AIDS and STI transmission, testing, and treatment. Men, who are more frequently resistant, require extra encouragement from chiefs to get testing and treatment. - “Being faithful” counseling and workshops for couples are held. - Pregnant women and their male partners, parents of newborns and young children, and their elders are targeted for awareness proper nutritious feeding of pregnant women, PMTCT, Option B+, testing and treatment of HIV-exposed babies. - Adolescent girls and boys, and single/ married women/ men, including new parents, are educated about modern FP methods and health benefits/ economic benefits of child spacing, and myths in the community.

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The community members Nzara County indicated that it is critical that the method of IEC be appropriate and effective for their cultural context. The following IEC methods were suggested by community members and leaders: - Face-to-face (e.g., door-to- door) interactions works well, on a one-to-one basis. - Drama/ street theater performed by

people within Image: TBAs in Nzara County participate in focus group discussion Nzara County works well, especially when it includes drumming. - Spreading messages through church (particularly those targeting women, more so than men—women claim that reaching men through church is not effective as the men will view it as “just preaching.”). - Begin changing gender norms and behavior with very young children, from birth on-ward, via community, parenting skills provided to young parents, community theater, and in education outlets (beginning with pre-school and up) and health facilities. Integrate HIV/AIDS awareness into school syllabus early on. Train teachers to talk to children about sex, starting at an early age. - Community meetings (such as strengthened Village Health Committee meetings or others) advocated for by men. However, some community members noted that it will be important for the chief to call meetings for men to attend, but not to inform the men in advance about the topic of the meeting (otherwise they will not come if they know the topic is alcohol or violence, for example). - Leverage existing groups and people as information disseminators such as: teachers in schools; church groups; youth groups, women’s groups, etc.

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- Adolescent girls noted that boys will not listen to their male peers—they will only listen to older men. Thus, for boys, peer-to-peer awareness may be replaced with counseling and talks with older men who are respected within the community. However, in some bomas it was noted that “the payam administrator and chief cannot put the fear in [younger boys] about HIV” and it will be important to identify and train community members that are perceived as able to do that. - Mass communication that requires reading and writing is not effective and should be minimized due to low literacy in the area. Radio is effective, and in-person communication, with some print media only if pictures alone (e.g. no words) are used.

6.2.3 IMPROVED CAPACITY OF COMMUNITY GROUPS AND GOVERNMENT

Community members and stakeholders identify the importance of improving the capacity of community groups and government actors in priority areas via: - Provide leadership skills for women, boys, and girls to improve their ability to contribute to designing and implementing program activities (including designing and implementing dramas, health talks, etc.) to encourage ownership and uptake. - Train community leaders, including church pastors/ preachers, and chiefs strategies to discuss early child marriage and abuse with communities, families, and individuals (men and women), including targeted training to pastors, male elders, and head teachers to teach boys how to be respectful of girls. Identify creative solutions to address challenge of chiefs financially benefiting from early marriages so that they are incentivized to dissuade people via customary law. - Work with churches in a multi-faith effort to work with “one voice” so that Catholics, Protestants, Muslims, chiefs, and government are all sending the same cohesive message about various topics (water and sanitation, HIV, GBV, etc.). Facilitate a formal resolution for all churches to work together with one voice, with tenants of church leaders leading through example; training clergy at weekly round table discussions on various topics, and speaking out at work places, markets, schools, and churches.

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- Provide parenting workshops and mentorship opportunities to families, especially targeting men, including material on the importance of sending children to school and; encouraging positive male behavior and empowering girls. - Train local magistrates on laws related to GBV, early marriage, property rights, and other forms of abuse. Train them on how to handle cases legally and how to harmonize with traditional/ customary law. - Train police on how to handle cases of GBV, including SGBV, to empower them as key community actors and members of community committees addressing GBV. - Support formation and sustainability of various community-based groups to function independently of INGOs in rural payams and, where appropriate, linked to health facilities, including: o Youth groups (e.g., youth friendly corners) for adolescent girls and boys, both in-school and out-of-school, especially around sports clubs to discuss issues such as HIV, GBV, RH, early child marriage, etc. o Women’s savings clubs with support/ training for growing gardens and acquiring inputs (tools, fertilizer, seeds) for cassava; grinder for grinding cassava into flour and equipment to make it into bread; animal husbandry (cattle, chickens, goats) and production of milk products such as cheese; sewing (including purchase of sewing machines), including sewing of school uniforms; selling of fish purchased from DRC; opening of small markets in rural payams to sell basic goods such as salt, sugar, tea, and oil. Particular emphasis should be placed on intensive support in the form of technical training for women participating in clubs, as well as viable linkages to markets so that women are not disenfranchised/ discouraged.

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Nutrition groups, linked to women’s groups that: provide nutrition knowledge and information on food preparation applicable to home environments on how to tend home vegetable gardens, which should be done during the rainy season when they have the most food so they can focus on food preservation. Link to existing IGA efforts to increase livelihoods through agricultural production with a focus on ensuring adequate market demand for produce.

Image: Women in Nzara County participate in focus group discussion o Safe Motherhood groups (SMAG) that provides support and information for women. o Prevention of Positives and Mentor Mothers groups comprised of HIV positive people trained in treatment adherence to run support groups for HIV positive people, including youth, men, women, and women with HIV-exposed babies (separate from the others). o Men’s groups, potentially formed around football clubs or organized by chiefs, to address positive male behavior in relationships, fatherhood (including training on how to feed children and provide other care for children), GBV, HIV, etc.

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- Train CHWs and community groups, such as Safe Motherhood Groups, to introduce the concept of Individual Birth Plans (IBP) to address birth preparedness and childbirth. The IBPs should be based on a card reporting system where the CHWs and community groups / members will collect information from the expectant mothers in villages on: the expected date of delivery, the identified skilled birth attendant, and the health facility for delivery / emergency, danger signs in pregnancy / delivery, transport plans, birth companion partner and basic supplies for the birth. In addition, the project could create linkages between the local TBAs and health facilities to increase skilled attendance and use of health services for deliveries. - Work with the Nzara County Health Office and Nzara MH to build upon the existing HMIS system to promote a unified reporting and referral system that facilitates increased access to information and data throughout Nzara County, including capturing of data on maternal and child health outcomes outside facilities within communities. - Identify partners to provide training (on an ongoing basis with refresher trainings) to Nzara MH, PHCC, and PHCU staff in providing mother baby packages and a wide range of services including maternal, neonatal and child health management, clean delivery care, FP, cervical cancer screening, FANC, youth friendly services, Post Abortion Care (PAC), Basic Emergency Obstetric and New-born Care (BEmONC), and post-rape care and comprehensive GBV response. This should include capacity building for the County Health Office Team on management, support supervision, budgeting, leadership and quality improvement efforts. Quality improvement programs, which are currently not operating in Nzara County, should be rolled out and supported. - Work in partnership with the government and other INGOs to identify priority actions to improve ownership and sustainability of government in operating health facilities.

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6.2.4 IMPROVED ACCESS TO EDUCATION

Community members and stakeholders identify the importance of improving the access of quality, safe education for girls and boys to prevent many identified health problems, including early pregnancies and HIV, among others. The Nzara County community may be supported by improving access to secondary education for boys and girls, and vulnerable children such as adolescent mothers, to help them escape from poverty and abuse via: - Provision of nutritional support to learners and families; provision of school feeding programs. - Provision of educational support to learners and families with a focus on girls, particularly in transition from primary to secondary school. - Support improved structures with protection of rain so that learners may learn uninterrupted throughout the rainy season, including girls’-only primary and secondary schools. - Support improved water and sanitation at schools, including latrine facilities that take into account adolescent girls’ hygiene needs during menstruation. - Provision of materials to school girls to assist them in hygiene during menstruation to allow them to go to school (e.g. soap, underpants, and pads). - Support construction of a boarding facility for girls who are vulnerable to abuse within their homes. - Support improved conditions for teachers and a cadre of teachers to provide quality education throughout all payams. - Strengthen existing efforts in Nzara County to address needs of all vulnerable children, including young girls who are pregnant or have children; and expand support to families of vulnerable children throughout Nzara beyond Nzara Payam in more remote areas.

6.2.4 IMPROVED ACCESS TO CLEAN WATER AND SANITATION

Community members and stakeholders identify the importance of improving access to clean water and improved sanitation/ hygiene conditions in order to prevent diseases that

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are leading causes of death in children under 5, including diarrhea and malaria. Access to clean water was resoundingly the number one priority of most community members and stakeholders. It will be of great benefit to the Nzara community to support improved water and sanitation facilities via:

- Construction of boreholes and well-located (in consultation with men and women within communities) community pumps. - Eliminate shallow water sources and provide IEC on clean water sources and water treatment. - Review existing need for latrines in communities and support communities and families to continue using latrines. - Work in close collaboration with IMC to provide IEC on sanitation, hand washing, and personal hygiene, with ongoing feedback to identify effectiveness and behavior change. Understand what does and does not work (e.g. people have knowledge but still not changing behavior; one community member suggested community-led efforts to discuss need for clean water/ hygiene and children’s funerals who died from preventable diseases due to poor hygiene or bad water). - Identify and implement practical ways to increase consumption of clean, treated, and safe drinking water. Boiling water and chlorine tablets are not effective because: 1) people don’t like to take the time; and 2) chlorine tablets cost money and run out of supply. Look into cost-effective and impactful interventions that have proven to work globally,49 such as providing a pre- installed chlorine treatment tap directly next to the water source (e.g. directly at public water tap/ borehole (or as part of the mechanism) which delivers free water treatment at the water source. This type of intervention has been proven to avert 494 diarrheal incidents per $1,000 spent (Kenya), compared to handwashing promotion with free soap which only averted 71 diarrhea incidents per $1,000 spent (Pakistan).

49 Cost-Effectiveness: Diarrheal Incidents Avoided per $1000, Available at: http://www.povertyactionlab.org/policy-lessons/health/child-diarrhea

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Image: Girls in Nzara Payam carrying pumped water from community water source

6.2.5 IMPROVED COORDINATION MECHANISMS

Community members and stakeholders identify the importance of supporting coordination and linkages among communities, NGOs, and government actors to facilitate ownership, efficiency, and synergy via: - Support existing government efforts to lead coordination among various actors with a community-based response. Ideally, each payam would have a health worker, school representative, and neighborhood watch to bring to police and respond, church, headsmen, traditional birth attendants, and other community leaders who would meet regularly to discuss problems and formulate a multi-sector response to address family needs, including GBV and child protection issues. - Identify existing efforts (INGO, CBO, or government) to link to and leverage. - Support functioning VHCs which may be incentivized through disease-specific or health condition-specific t-shirts and allowance for transport/ lunch. - Support government and INGO efforts to build and sustain effective partnerships at all levels: government, donors and with credible NGOs / CBOs committed to maternal,

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newborn and child health goals. Opportunities should be identified to intensify networking and collaboration in the implementation of the project that leverages strengths of all partners, and mobilizes joint planning and resources efficiently and collaboratively. - Support coordination of a comprehensive and integrated “one-stop shop” at in each PHCC with psycho-social, medical, and legal support for SGBV survivors. - Locate the CHAMPS office in Nzara County and not in Yambio. This will create good-will with the community and build political capital with decision-makers and leaders in the area. “Nzara is it’s own county—not a neighborhood of Yambio.” - CHAMPS should work closely on an ongoing basis with Nzara County government, payam administrators, the Paramount Chief and the 8 executive chiefs under him, and others to be transparent in all actions. Information shared should include implementation activities, monitoring, results, etc. It is important to share this assessment and future assessments and results to also coordinate planning, activities, and gaps with other stakeholders and actors. - Work towards the long-term goal of collaborating with the County government to support ongoing efforts to create a comprehensive development plan, inclusive of a health sector development plan with a clear human resources plan for staffing of all facilities with trained and qualified staff (including doctors), and pre-service and ongoing health facility staff staff training in all areas, including clinical OB care, hygiene, wat/san, early diagnosis of all diseases and ailments, HIV, TB and leprosy; and allocating dedicated full-time staff as a department to engage with community.

6.2.6 CROSS-CUTTING STRATEGIES IN PROGRAM DESIGN AND IMPLEMENTATION

Cross-cutting strategies that will be important in designing and implementing program activities include: - Always include the government (e.g., payam administrators, county officials) and traditional leaders (chiefs) in all processes.

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- Always be respectful of preserving local culture and traditions by making a concerted effort to develop programming that integrates local culture. - In marketing and branding of CHAMPS, it should be presented as a more holistic program that aims to help families, including men, and not just women and children; if it is perceived by men, who are key decision-makers, as targeting only women and children, they may dismiss the program as a “woman’s issue” and choose not to be involved in making it successful (e.g., avoid calling it/ branding it as a “program for women and children’s health”). - Acknowledge and address the challenge of engaging in community-driven activities in an area with a war-affected population and low levels of education. Community-driven and led activities must be simple, incentivized, and complimented with significant efforts to mentor, guide, and supervise community members who are taking leadership roles. - Acknowledge that human beings work on incentives and motivations. o Expecting that community members work on a volunteer basis is not realistic or sustainable, and has led to failed efforts in the past. Health promoters, for example, may be motivated by t-shirts and other in-kind support, including transport refund. o Expecting that community members will be self-motivated to seek preventive health care at expense of their time and transport money (e.g. vaccinations, ANC, etc.) to avert future disease is not realistic. Practical, evidence-based, and effective incentives should be identified that provides immediate rewards for improved health-seeking behavior, such as providing mother and baby delivery kits to women who attend ANC regularly.50

50 Abhjit, et al (2010). Improving immunization coverage in rural India: clustered randomized controlled evaluation of immunization campaigns with and without incentives. Available at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2871989/pdf/bmj.c2220.pdf

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ANNEX 1: HOUSEHOLD SURVEY TOOL

BASELINE SURVEY AND NEEDS ASSESSMENT FOR CHILDREN AND MOTHERS PARTNERSHIPS (CHAMPS) PROJECT IN NZARA COUNTY, WESTERN EQUATORIA STATE- SOUTH SUDAN

HOUSEHOLD QUESTIONAIRE

Identification Cluster Number Household Number Village Name Name of Mother/ care giver Name of Supervisor

Interview date ___/___/____ For Supervisor day/month/year Day Name of Interviewer Month Year District MUTOMO IKUTHA Consent Page INFORMED CONSENT

Hello. My name is ______, and I am working with (MoH and Catholic Medical Mission Board-CMMB ). We are conducting a baseline survey on health issues affecting women, children and mothers in the community and would appreciate your participation. I would like to ask you about your health and the health of your children under the age of five. This information will help (CMMB) to plan on the strategies of implementing a project focusing on improving the health of women and children in this community, to assess the health needs for women, pregnant women and children and to set up a benchmark through which its goal to improve women and children’s health in this community may be measured. The interview will take 40 minutes to complete. Whatever information you provide will be kept strictly confidential. Participation in this interview is voluntary and you can choose not to answer any individual question or all of the questions. You can stop the survey at any time. However, we hope that you will participate in this survey since your views are important. Will you participate in this survey?

At this time, do you want to ask me anything about the survey?

Signature of interviewer: ______Date: ______

RESPONDENT AGREES TO BE INTERVIEWED ...... 1 RESPONDENT DOES NOT AGREE TO BE INTERVIEWED ......

INSTRUCTIONS: (1) ALL QUESTIONS ARE TO BE ADDRESSED TO MOTHERS WITH A CHILD LESS THAN 5 YEARS OF AGE.

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(2) ASK FOR OFFICIAL DOCUMENTATION REGARDING CHILD (ANTENATAL CARDS, IMMUNIZATIONS RECORDS, BIRTH CERTIFICATES, ETC.)

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No. Questions and Filters Coding Categories Skip Section 1 Introduction and Background information AGE……………..………………………… 101. Age of the Respondent DON’T KNOW…………………………………998 Protestant ……………..……………………………….. 1 102. What is your religion Muslim……………..…………………………………. 2 Roman Catholic……………………………………… 3 Adventist…………………………… ………………… 4 Traditional religion…………………………………….. 5 Other (Specify)……………………. ………………… 6 None……………………………….. …………………. 7

Single/never married…………………………………….. 1 103. What is your current marital status Married……………………………………………………..2 Divorced/separated………………………………………..3 Widowed……………………………………………………4 What is the highest level of education completed by you? No formal education ………………………………………1 104. Primary Not Completed …………………………………. 2 Primary Completed ………………………………………..3 Secondary Not Completed ……………………………….4 Secondary Completed …………………………………...5 Tertiary college /University………………………………..6 What is your Main source of household income? No reliable source of HH income…………………………1 105. Salaried employment………………………………………2 Casual labor/wage earner…………………………………3 Assistance (hand-outs) ……………………………4 Business……………………………………………………...5 Crop farming…………………………………………………6 Animal husbandry …………………………………………..7

106. Are you currently pregnant YES ...... 1

NO ...... 2 DON’T KNOW ...... 9

107. How old were you when you gave birth to your first child? AGE……………..…………………………

DON’T KNOW………………………………… 998

Number of Bilogical children 108. How many biological children have you given birth to (Parity )

109. How old were you when you gave birth to your first child? AGE……………..…………………………

DON’T KNOW………………………………… 998

Skip if 110. What is the average spacing among your children in months 0-12 months ...... 1 has only 1 child 12-24 months ...... 2 24-36 months ...... ….……..3 More than 36 Months………………………..……………4

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No. Questions and Filters Coding Categories Skip

111. If less than 12 months, what was the main reason the immediate I planned to have an immediate follow up pregnancy…..1 follow up pregnancy? Was not aware I could get pregnant…………….………..2

Husband decided so………………………………………..3 Decided together with my partner..………………………..4

I don’t like family planning……………………………..……5 112 What is the name, sex, date of birth of your youngest child that you YOUNGEST CHILD gave birth to and that is still alive? NAME ______

SEX MALE ...... 1

FEMALE ...... 2

DATE OF BIRTH DAY MONTH YEAR

113 Have you ever lost a child when aged bellow 5 years YES ...... 1

NO ...... 2 DON’T KNOW ...... 9

114 If YES, what was the cause of death? (Name the disease)…………………………………………… DON’T KNOW ...... 9

115 MAIN MATERIAL OF THE FLOOR. EARTH/MUD/DUNG/SAND...... 1 [RECORD OBSERVATION.] WOOD PLANKS...... 2 PALM, BAMBOO...... 3 PARQUET/POLISHED WOOD...... 4 VINYL OR ASPHALT STRIPS...... 5 CERAMIC TILES...... 6 CEMENT ...... 7 CARPET...... 8 OTHER ………………………………9 (SPECIFY)______116 What type of fuel does your household mainly use for cooking? ELECTRICITY...... 1 LPG/NATURAL GAS...... 2 BIOGAS...... 3 PARAFFIN/KEROSENE...... 4 COAL, LIGNITE...... 5 CHARCOAL FROM WOOD...... 6 FIREWOOD/STRAW...... 7 DUNG...... 8 [FUEL EFFICIENT STOVE]………..9 OTHER ………………………………10 (SPECIFY)______

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117 Does any member of your household own: YES NO A bicycle? BICYCLE ...... 1 0 A motorcycle or motor scooter? MOTORCYCLE/SCOOTER. 1 0 A car or truck? CAR/TRUCK...... 1 0

118 Does your household own the land on which the structure (house, flat, OWNS ...... 1 shack) sits? PAYS RENT/LEASE...... 2 NO RENT, W. CONSENT OF OWNER….3 NO RENT, SQUATTING...... 4

119 In the last 12 months, did you work outside of the home to earn NO OUTSIDE WORK ...... 1 money? HANDICRAFTS ...... 2 [IF NO, CIRCLE “1” (NO OUTSIDE WORK)] HARVESTING ...... 3 SELLING FOODS...... 4 [IF YES:] What kind of work do you do? SHOP KEEPER/STREET VENDOR……………....5 SERVANT/HOUSEHOLD WORKER………………6 SALARIED WORKER……………………………….7 OTHER………………………….…………………….8 SPECIFY______

120 Who mainly decides how the money you earn will be used? RESPONDENT...... ……………………….1 HUSBAND/PARTNER...... ……………2 RESPONDENT AND HUSBAND/PARTNER JOINTLY...... 3 SOMEONE ELSE...... …………….4 RESPONDENT AND SOMEONE ELSE JOINTLY….5 121 How much is the total household income per month (include income from earnings as well as those from outside such as donations etc) Amount………………………………………………

122 What is the size of this house hold ( NB- A household refers to people Number ………………………………………………. who live together and eat from the same pot)

Section 2 Maternal and Newborn Care

201 During your pregnancy with (Name), did you see anyone for DOCTOR/MEDICAL ASSISTANT ...... A antenatal care? NURSE ...... B

IF YES: Whom did you see? MIDWIFE ...... C

Anyone else? TRADITIONAL BIRTH ATTENDANT ...... D

OTHER ______...... X PROBE FOR THE TYPE OF PERSON AND RECORD ALL PERSONS SEEN. (SPECIFY)

NO ONE ...... Y  203 202 4 times or more……………………………………………1 During your pregnancy with (Name), how many times did you receive antenatal care?( Confirm from mother and baby booklet) 2 to 3 times…………………………………………………2 1 times………………………………………………………3 Never……………………………………………………….4

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203 During your pregnancy with (Name) did you receive an injection in YES ...... 1 the arm to prevent the baby from getting tetanus; that is convulsions after birth? NO ...... 2  205

DON’T KNOW ...... 9  205 204 While pregnant with (name), how many times did you receive such ONE ...... 1 an injection? TWO ...... 2

THREE OR MORE ...... 3

DON’T KNOW ...... 9

205 Did you receive any tetanus toxoid injection at any time before that YES ...... 1 pregnancy, including during a previous pregnancy or between pregnancies? NO ...... 2  207

DON’T KNOW ...... 9  207

206 Before the pregnancy with (Name), how many times did you ONE ...... 1 receive a tetanus injection? TWO ...... 2

THREE OR MORE ...... 3

DON’T KNOW ...... 9

207 During (any of) your antenatal care visits, were you told about the YES ...... 1 signs of pregnancy complications? NO ...... 2  209

DON’T KNOW ...... 9  209

208 Were you told where to go if you had any of these complications? YES ...... 1

NO ...... 2

DON’T KNOW ...... 8

209 During pregnancy, woman may encounter severe problems or VAGINAL BLEEDING...... A illnesses and should go or be taken immediately to a health facility. FAST/DIFFICULT BREATHING ...... B

What types of symptoms would cause you to seek immediate care at FEVER ...... C a health facility (right away)? SEVERE ABDOMINAL PAIN ...... D ASK: Anything else? HEADACHE/BLURRED VISION ...... E

CONVULSIONS ...... F

DO NOT READ RESPONSES. RECORD ALL THAT ARE FOUL SMELLING DISCHARGE/FLUID FROM MENTIONED. VAGINA...... G

BABY STOPS MOVING ...... H

LEAKING BROWNISH/GREENISH FLUID FROM THE VAGINA...... I

OTHER ______X (SPECIFY) DON’T KNOW ...... Z

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210 During your pregnancy with (Name), were you given or did you buy YES ...... 1 any iron folate tablets? ( Show sample of Iron follates) NO ...... 2  212

DON’T KNOW ...... 8  212 212 During the whole pregnancy, for how many days did you take the DAYS tablets? DON’T KNOW ...... 9998 IF THE ANSWER IS NOT NUMERIC, PROBE FOR APPROXIMATE NUMBER OF DAYS. 213 Where did you give birth to (Name)? HEALTH FACILITY ...... 1  214

OTHER (SPECIFY) ______2

214 Why did you choose not to deliver at a health facility? DISTANCE ...... A

PROBE AND RECORD ALL MENTIONED REASONS COST ...... B

DISSATISFACTION WITH QUALITY OF

CARE...... C

OTHER (SPECIFY) ______D 215 Who assisted with the delivery of (Name)? DOCTOR ...... A

Anyone else? NURSE ...... B

PROBE FOR THE TYPE(S) OF PERSON(S) AND RECORD MIDWIFE ...... C ALL MENTIONED. AUXILIARY MIDWIFE ...... D IF RESPONDENT SAYS NO ONE ASSISTED, PROBE TO DETERMINE WHETHER ANY ADULTS WERE PRESENT AT OTHER HEALTH STAFF WITH MIDWIFERY THE DELIVERY. SKILLS ...... E

TRADITIONAL BIRTH ATTENDANT ...... F

COMMUNITY HEALTH WORKER ...... G

RELATIVE/FRIEND ...... H

NO ONE ...... I

216 After (Name) was born, did any health care provider check on YES ...... 1 (Name’s) health? NO ...... 2  219

217 How many hours, days or weeks after the birth of (Name) did the HOURS ...... 0 first check take place? DAYS ...... 1 IF LESS THAN ONE DAY, CIRCLE 0 AND RECORD HOURS; IF ONE TO SIX DAYS CIRCLE 1 AND RECORD DAYS; IF MORE THAN 6 DAYS CIRCLE 2 AND RECORD WEEKS. WEEKS ...... 2

DON’T KNOW ...... 998

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218 Who checked ON (NAME’S) HEALTH at that time? DOCTOR ...... A

Anyone else? NURSE ...... B

PROBE FOR THE MOST QUALIFIED PERSON AND RECORD MIDWIFE ...... C ALL MENTIONED. AUXILIARY MIDWIFE ...... D

OTHER HEALTH STAFF WITH MIDWIFERY

SKILLS ...... E

TRADITIONAL BIRTH ATTENDANT ...... F

COMMUNITY HEALTH WORKER ...... G

RELATIVE/FRIEND ...... H

NO ONE ...... I 219 Did a health care provider or a traditional birth attendant check ON YES ...... 1 YOUR HEALTH after the delivery of (Name), either at a health facility, at home, or other location? NO ...... 2  221 220 How long after the delivery did the first check take place? HOURS ...... 0 IF LESS THAN ONE DAY, CIRCLE 0 AND RECORD HOURS; IF LESS THAN ONE WEEK CIRCLE 1 AND RECORD DAYS; DAYS ...... 1 IF MORE THAN 6 DAYS CIRCLE 2 AND RECORD WEEKS

WEEKS ...... 2

DON’T KNOW ...... 998

221 Sometimes children get sick and need to receive care or treatment for LOOKS UNWELL OR NOT PLAYING NORMALLY...... A illnesses. What are the signs of illness that would indicate your child NOT EATING OR DRINKING ...... B needs treatment?

RECORD ALL MENTIONED. LETHARGIC OR DIFFICULT TO WAKE ...... C

HIGH FEVER ...... D

FAST OR DIFFICULT BREATHING ...... E

VOMITS EVERYTHING ...... F

CONVULSIONS ...... G

DIARRHEA ...... H

OTHER ...... X (SPECIFY) DON’T KNOW ...... Z 222 Did you ever breastfeed (Name)? YES ...... 1

NO ...... 2 224

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223 How long after birth did you first put (Name) to the breast? HOURS ...... 0

IF LESS THAN ONE HOUR, RECORD 00 HOURS. IF LESS THAN 24 HOURS RECORD THE HOURS, OTHERWISE DAYS ...... 1 RECORD DAYS WEEKS ...... 2

DON’T KNOW ...... 998

224 Did you give (Name) the first liquid (Colostrum) that came from YES ...... 1 your breasts? NO ...... 2

DON’T KNOW ...... 9

225 Are you currently doing something or using any method to delay or YES ...... 1 avoid getting pregnant? NO ...... 2  301 226 Which method are you (or your husband/ partner) using? FEMALE STERILIZATION ...... 1

DO NOT READ RESPONSES. CODE ONLY ONE RESPONSE. MALE STERILIZATION ...... 2

IF MORE THAN ONE METHOD IS MENTIONED, ASK, PILL ...... 3 What is your MAIN method that you (or your husband/ partner) use to delay or avoid getting pregnant?” IUD ...... 4

IF RESPONDENT MENTIONS BOTH CONDOMS AND INJECTABLES...... 5 STANDARD DAYS METHOD, CODE “12” FOR STANDARD DAYS METHOD. IMPLANTS ...... 6

IF RESPONDENT MENTIONS BREASTFEEDING, CODE “15” CONDOM ...... 7 FOR OTHER AND RECORD BREASTFEEDING.

IF RESPONDENT MENTIONS ABSTINENCE OR ISOLATION, FEMALE CONDOM ...... 8 CODE “15” FOR OTHER AND RECORD RESPONSE IN SPACE PROVIDED. DIAPHRAGM ...... 9

FOAM/JELLY ...... 10

LACTATIONAL AMEN METHOD ...... 11

STANDARD DAYS METHOD/ CYCYLEBEADS ...... 12

RHYTHM METHOD (OTHER THAN STANDARD

DAYS) ...... 13

WITHDRAWAL...... 14

OTHER ______15

(SPECIFY)

Section 3 Breastfeeding/ Infant and Young Child Feeding Now I would like to ask you about liquids or foods (NAME) had 301 yesterday during the day or at night

Did (NAME) drink/eat:

YES NO DK READ THE LIST OF LIQUIDS (A THROUGH E, STARTING WITH “BREAST MILK”) A. Breast milk? ...... 1 2 9

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B. Plain water? ...... 1 2 9 C. Milk: such as tinned, powered or fresh animal milk? ...... 1 2 9 D. Commercially produced infant formula? ...... 1 2 9

E. Any fortified, commercially available infant and young child ...... 1 2 9 food” [e.g. Cerelac]?

F. Any (other) porridge or gruel? ...... 1 2 9

302 PLEASE FILL OUT THE FOLLOWING TABLE WITH THE ANSWERS TO THE QUESTIONS BELOW: Now I would like to ask you about (other) liquids or foods that (NAME) may have had yesterday during the day or at night I am interested in whether your child had the item even if it was combined with other foods

Did (NAME) drink/eat: GROUP 1:DAIRY YES NO DK

A. CHECK Q 301D – IF YES, CIRCLE YES HERE Commercially produced infant formula? ...... 1 2 9 B. CHECK Q 301C – IF YES, CIRCLE YES HERE Milk such as tinned, powdered, or fresh animal milk? ...... 1 2 9 C. Cheese, yogurt, or other milk products? ...... 1 2 9

GROUP 2: GRAIN YES NO DK D. CHECK Q 301E – IF YES, CIRCLE YES HERE Any fortified, commercially available infant and young Child food (eg Cerelac)? ...... 1 2 9 E. CHECK Q 301F – IF YES, CIRCLE YES HERE ...... 1 2 9 Any (other) porridge or gruel? F. Bread, rice, noodles, or other foods made from grains? ...... 1 2 9

G. White potatoes, white yams, manioc, cassava, or any other ...... 1 2 9 foods made from roots?

GROUP 3: VITAMIN A RICH VEGETABLES YES NO DK H. Pumpkin, carrots, squash, or sweet potatoes that are yellow or ...... 1 2 9 orange inside? I. Any dark green leafy vegetables? ...... 1 2 9

J. Ripe mangoes, papayas or (INSERT ANY OTHER ...... 1 2 9 LOCALLY AVAILABLE VITAMIN A-RICH FRUITS)? K. Foods made with red palm oil, palm nut, palm nut pulp sauce? ...... 1 2 9

GROUP 4: OTHER FRUITS/VEGETABLES YES NO DK L. Any other fruits or vegetables like oranges, grapefruit or ...... 1 2 9 pineapple?

GROUP 5: EGGS YES NO DK M. Eggs? ...... 1 2 9

GROUP 6: MEAT, POULTRY, FISH YES NO DK N. Liver, kidney, heart or other organ meats? ...... 1 2 9 O. Any meat, such as beef, pork, lamb, goat, chicken, or duck? ...... 1 2 9 P. Fresh or dried fish or shellfish? ...... 1 2 9

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Q. Grubs, snails, insects, and other small protein food? ...... 1 2 9

GROUP 7: LEGUMES/NUTS YES NO DK R. Any foods made from beans, peas, lentils, or nuts? ...... 1 2 9

GROUP 8: OILS/FATS YES NO DK S. Any oils, fats, or butter, or foods made with any of these? ...... 1 2 9

T. CHECK 15A – 15S: HOW MANY FOOD GROUPS (GROUPS 1-8 IN ABOVE TABLE) HAVE AT LEAST 1 Number of Groups ...... ‘YES’ CIRCLED?

GROUP 9: OTHER FOODS YES NO DK U. Tea or coffee? ...... 1 2 9 V. Any other liquids? ...... 1 2 9 W. Any sugary foods, such as chocolates, candy, sweets, pastries, ...... 1 2 9 cakes, or biscuits? X. Any other solid or soft food? ...... 1 2 9

303 How many times did (NAME) eat solid, semi-solid, or soft foods NUMBER OF TIMES ...... other than liquids yesterday during the day or at night? DON’T KNOW ...... 9 WE WANT TO FIND OUT HOW MANY TIMES THE CHILD ATE ENOUGH TO BE FULL SMALL SNACKS AND SMALL FEEDS SUCH AS ONE OR TWO BITES OF MOTHER’S OR SISTER’S FOOD SHOULD NOT BE COUNTED

LIQUIDS DO NOT COUNT FOR THIS QUESTION DO NOT INCLUDE THIN SOUPS OR BROTH, WATERY GRUELS, OR ANY OTHER LIQUID

USE PROBING QUESTIONS TO HELP THE RESPONDENT REMEMBER ALL THE TIMES THE CHILD ATE YESTERDAY

IF CAREGIVER ANSWERS SEVEN OR MORE TIMES, RECORD “7” 304 How many meals did you have yesterday as a family ? One meal……………………………………………………1 Two meals…………………………………………………..2 Three meals………………………………………………..3 More than three meals …………………………………..4

No Questions and Filters Coding Categories Skip Section 4 Vitamin A Supplementation- (For children 6-23 months only)

401 Has (Name) ever received a Vitamin A dose (like this/any of YES ...... 1 these)? NO ...... 2  501 SHOW COMMON TYPES OF AMPULES/CAPSULES/SYRUPS DON’T KNOW ...... 9  501

402 Did (Name) receive a Vitamin A dose within the last 6 months? YES ...... 1

NO ...... 2

DON’T KNOW ...... 9 Section 5 : Child Immunizations

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501 Do you have a card or child health booklet where (Name’s) YES ...... 1 vaccinations and Vitamin A (capsules) are written down? NO ...... 2  504 IF YES: May I see it please? DON’T KNOW ...... 9  504

502 COPY VACCINATION DATE FOR VITAMIN A, DTP1, DTP3 DAY MONTH YEAR AND MEASLES FROM THE CARD OR BOOKLET VITAMIN A|___||___|/|___||___|/|___||___|___||___| IF VACCINES ARE NOT RECORDED IN CHILD HEALTH CARD OR BOOKLET, FILL IN 99/99/9999 DTP1………|___||___|/|___||___|/|___||___|___||___|

DTP3………|___||___|/|___||___|/|___||___|___||___|

MEASLES|___||___|/|___||___|/|___||___|___||___|

503 Has (NAME) received any vaccinations that are not recorded on YES ...... 1 this card, including vaccinations given during immunization campaigns? NO ...... 2  601

DON’T KNOW ...... 9  601

504 Has (NAME) received a DTP vaccination, that is, an injection YES ...... 1 given in the thigh, sometimes at the same time as polio drops? NO ...... 2  506

DON’T KNOW ...... 9  506

505 How many times? NUMBER OF TIMES ......

No Questions and Filters Coding Categories Skip

506 Did (Name) ever receive an injection in the arm to prevent YES ...... 1 Measles? NO ...... 2

DON’T KNOW ...... 9 Section 6 : Malaria - Treatment of Fever of Child Does the household have a mosquito net ( Insecticide Treatment ) YES ...... 1 601 OBSERVE NO ...... 2

602 Did the child (Name) sleep under a mosquito net last night? YES ...... 1

NO ...... 2

603 Did you sleep under mosquito net last night YES ...... 1

NO ...... 2

604 Has (Name) been ill with fever at any time in the last 2 weeks? YES ...... 1

NO ...... 2  701

DON’T KNOW ...... 9  701

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605 Did you seek advice or treatment for the fever? YES ...... 1

NO ...... 2  607

606 How many days after the fever began did you first seek treatment SAME DAY ...... 0 for (Name)? NEXT DAY ...... 1

TWO OR MORE DAYS ...... 2

607 At any time during the illness did (Name) take any drugs for the YES ...... 1 fever? NO ...... 2  701

DON’T KNOW ...... 9  701

608 What drugs did (Name) take? ANTI-MALARIAL Any other drugs? RECORD ALL MENTIONED A. SP/Fansidar ...... 0 1 2 9

ASK TO SEE DRUG(S) IF TYPE OF DRUG IS NOT KNOWN IF B. Chloroquine...... 0 1 2 9 TYPE OF DRUG IS STILL NOT DETERMINED, SHOW TYPICAL ANTIMALARIAL DRUGS TO RESPONDENT C. Amodiaquine ...... 0 1 2 9 **COUNTRY SPECIFIC BASED ON NATIONAL MALARIAL PROTOCOL D .Quinine ...... 0 1 2 9

FOR EACH ANTIMALARIAL MEDICINE ASK: How long after E. ACT(Coartem*) ...... 0 1 2 9 the fever started did (NAME) start taking the medicine? OTHER DRUGS CIRCLE THE APPROPRIATE CODES: SAME DAY = 0 A. ASPRIN ...... 0 1 2 9 NEXT DAY AFTER THE FEVER = 1 TWO OR MORE DAYS AFTER THE FEVER = 2 B. PARACETAMOL ...... 0 1 2 9 DON’T KNOW = 9 X Other ...... 0 1 2 9

SECTION 7: Control of Diarrhea

701 Has (Name) had diarrhea in the last one Month? YES ...... 1

NO ...... 2  703

DON’T KNOW ...... 9  703

What was given to treat the diarrhea? NOTHING ...... A

702 FLUID FROM ORS PACKET ...... B

Anything else? HOME-MADE FLUID ...... C

If answer pill or syrup, show local packaging for zinc and ask if the PILL OR SYRUP, ZINC ...... D child received this medicine PILL OR SYRUP, NOT ZINC ...... E

INJECTION ...... F RECORD ALL MENTIONED IV (INTRAVENOUS) ...... G

HOME REMEDIES/HERBAL MEDICINES ...... H

OTHER (SPECIFY) ...... I

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Have you heard of ORS? DESCRIBED CORRECTLY ...... 1

703 IF YES, ASK MOTHER TO DESCRIBE ORS PREPARATION DESCRIBED INCORRECTLY ...... 2 FOR YOU NEVER HEARD OF ORS...... 3 IF NO, CIRCLE 3 (NEVER HEARD OF ORS)

ONCE MOTHER HAS PROVIDED A DESCRIPTION, RECORD WHETHER SHE DESCRIBED ORS PREPARATION CORRECTLY OR INCORRECTLY

CIRCLE 1 [CORRECTLY] IF THE MOTHER MENTIONED THE FOLLOWING:

 USE 1 LITER OF CLEAN DRINKING WATER (1 LITER=3 SODA BOTTLES)

 USE THE ENTIRE PACKET

 DISSOLVE THE POWDER FULLY

SECTION 8: ARI/Pneumonia

801 Has (Name) had an illness with a cough that comes from the chest YES ...... 1 at any time in the last two weeks?

NO ...... 2  901

DON’T KNOW ...... 9  901

802 When (Name) had an illness with a cough, did he/she have trouble YES ...... 1 breathing or breathe faster than usual with short, fast breaths? NO ...... 2  901

DON’T KNOW ...... 9  901

803 Did you seek advice or treatment for the cough/fast breathing? YES ...... 1

NO ...... 2  901

804 Who gave you advice or treatment? DOCTOR ...... A Anyone else? NURSE ...... B RECORD ALL MENTIONED AUXILIARY NURSE ...... C

COMMUNITY HEALTH WORKER ...... D OTHER ...... X

805 How long after you noticed (NAME’s) cough and fast breathing did SAME DAY ...... 0 you seek treatment? NEXT DAY ...... 1

TWO DAYS ...... 2

THREE OR MORE DAYS ...... 3

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Section 9. Water and Sanitation 901 What is the main source of drinking water for members of this household? PIPED WATER INTO DWELLING ...... 1 PIPED WATER INTO YARD/PLOT/BUILDING ...... 2

PUBLIC TAP/STANDPIPE ...... 3 (CHECK ONE) TUBEWELL/BOREHOLE ...... 4 PROTECTED DUG WELL ...... 5

UNPROTECTED DUG WELL ...... 6

PROTECTED SPRING ...... 7 UNPROTECTED SPRING ...... 8 RAIN WATER COLLECTION ...... 9 CART WITH SMALL TANK/DRUM ...... 10 TANKER TRUCK ...... 11 BOTTLED / SACHET WATER ...... 12 SURFACE WATER (RIVER/STREAM/ETC.) ...... 13 OTHER ...... 96 (SPECIFY) 902 Do you treat your water in any way to make it safe for drinking? YES ...... 1 NO ...... 2  904 903 If yes, what do you usually do to the water to make it safer to drink? LET IT STAND AND SETTLE/ SEDIMENTATION ...... A Anything else? STRAIN IT THROUGH CLOTH ...... B ONLY CHECK MORE THAN ONE RESPONSE IF SEVERAL METHODS ARE USUALLY USED TOGETHER, FOR EXAMPLE, BOIL ...... C CLOTH FILTRATION AND CHLORINE. ADD BLEACH/ CHLORINE ...... D

WATER FILTER (CERAMIC, SAND, COMPOSITE) ...... E SOLAR DISINFECTION ...... F OTHER ...... X (SPECIFY) DON’T KNOW ...... Z

904 Do you know the times when it is important to wash hands? BEFORE PREPARING FOOD ...... A

IF FOR WASHING MY OR MY CHILDREN’S HANDS IS BEFORE EATING ...... B MENTIONED, PROBE WHAT WAS THE OCCASION, BUT DO BEFORE FEEDING CHILD ...... C NOT READ THE ANSWERS. AFTER CLEANING CHILD’S BOTTOMS ...... D (DO NOT READ THE ANSWERS, ASK RESPONDENT TO BE SPECIFIC. ENCOURAGE “WHAT ELSE” UNTIL NOTHING AFTER USING THE TOILET...... E FURTHER IS MENTIONED AND CIRCLE ALL THAT APPLY) AFTER EATING ...... F AFTER CLEANING ...... G AFTER TOUCHING SOMETHING STICKY, OILY, SMELLY ...... H OTHER ...... X (SPECIFY)

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905 Does the Household have access to a latrine YES ...... 1 NO ...... 2 906 If NO, Where do you mainly relieve yourself Bush outside homestead…………………………………..1 Neighbour’s latrine…………………………………………...2 School latrine…………………………………………………3 Dig hole for immediate use………………………………...4 In the lake/river ………………………………………………5 907 If no latrine, give reason? Cost of constructing one is high…………………………1 Do not see the need to have one………………………..2 No response…………………………………………………3 Poor soil formation/collapsible soil………………………4 Others (specify)……………………………………………..5

908 How do you handle or dispose off your child’s stool (Children under Child's stools are always thrown into the latrine………. 1 5 yrs)? (Probe for Multiple answers Child’s stools are buried in the yard……………………..2 Child’s stools are thrown in the yard……………………. 3

Child’s stools are thrown outside the yard………………4 Child’s stools are rinsed away while washing…………. 5 Others (specify)…………………………………………… 6

909 Can you show me where you usually wash your hands and what you INSIDE/NEAR TOILET FACILITY ...... 1 use to wash hands? INSIDE/NEAR KITCHEN/COOKING PLACE ...... 2 ASK TO SEE AND OBSERVE ELSEWHERE IN YARD ...... 3

OUTSIDE YARD ...... 4 NO SPECIFIC PLACE ...... 5  911

NO PERMISSION TO SEE ...... 7 910 OBSERVATION ONLY: IS THERE SOAP OR DETERGENT OR SOAP ...... 1 LOCALLY USED CLEANSING AGENT? DETERGENT ...... 2

THIS ITEM SHOULD BE EITHER IN PLACE OR BROUGHT BY ASH ...... 3 THE INTERVIEWEE WITHIN ONE MINUTE. IF THE ITEM IS NOT PRESENT WITHIN ONE MINUTE CHECK NONE, EVEN IF MUD/SAND ...... 4 BROUGHT OUT LATER NONE ...... 5 OTHER ...... 6 (SPECIFY) 911 Within the compound…………………………………….1 How far is the source of your drinking water Less than 1 km…………………………………………….2 1kms – 2 kms……………………………………………..3 2 - 5 kms…………………………………………………..4 Over 5 kms………………………………………………..5 912 Less than 1 hr……………………………………………..1 How long does it take you to collect water from this main drinking 1hr – 2 hrs………………………………………………….2 water source Over 2 hrs……………………………………………….....3 913 1. Yes Do you have a special container for storing drinking water 2. No

Section 10 HEALTH SEEKING BEHAVIOUR NO QUESTIONS AND FILTERS CODING CATEGORIES SKIP During the last month, how often have you come in contact with each FREQUENTLY SOMETIMES NEVER

1001 of the following: (4 or more times) (1-3 times) (0 times)

Doctor 1 2 3

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Nurse/Midwife 1 2 3 Community Health Worker 1 2 3 Health Educator 1 2 3 Growth Monitoring Person 1 2 3 Trained Birth Attendant 1 2 3 Traditional Healer 1 2 3

What form of transport did you use to get to the clinic? Wheel barrow / cart…………………………………….1 Walked…………………………………………………..2 Donkey…………………………………………………..3 Bicycle……………………………………………………4 1002 Motorcycle……………………………………………….5 Matatu…………………………………………………….6 Tick the appropriate Bus………………………………………………………..7 Private car……………………………………………….8 Other. Specify…………………………………………..9 HOW MUCH DID YOU PAY FOR YOUR TRANSPORT TO THE 1003 NEAREST HEALTH FACILITY Enter amount in total currency Amount …………………………………………………..

HOW FAR IS YOUR HOME FROM THE NEAREST HEALTH 1004 FACILITY IN KM ______Kms Enter distance in km HOW LONG DID IT TAKE YOU TO REACH THIS FACILITY? ______minutes 1005 Enter response in minutes (for example, enter 1 hr 30 minutes as 90 minutes)

What is the total amount you paid for all services or treatments you received at this facility? Please include any money you paid for 1006 laboratory tests, supplies, and consultation fee. Amount …………………………

NON COMMUNICABLE DISEASES- ADULT WOMEN Have you ever heard of Non Communicable diseases? (MENTION 1007 THE NAMES: CANCERS, DIABETES, and YES……………………………………………………1 HYPERTENSION…) NO……………………………………………………. 2

Are you currently suffering from or have ever been positively YES……………………………………………………1 1004 diagnosed for cervical cancer NO……………………………………………………. 2 Is there a member of your family suffering from or have ever been 1005 positively diagnosed for cervical cancer YES……………………………………………………1 NO……………………………………………………. 2

1006 Are you currently suffering from or have ever been positively YES……………………………………………………1 diagnosed for breast cancer NO……………………………………………………. 2

1007 Is there a member of your family suffering from or have ever been YES…………………………………………………..1 positively diagnosed for breast cancer NO……………………………………………………. 2

1007 Is there a member of your family suffering from or have ever been YES…………………………………………………..1 positively diagnosed for prostate cancer NO……………………………………………………. 2

1008 Are you currently suffering from or have ever been positively YES…………………………………………………….1 diagnosed for diabetes, NO……………………………………………………… 2

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1009 Is there a member of your family suffering from or have ever been YES………………………………………………………1 positively diagnosed for diabetes, NO……………………………………………………… 2

1010 Are you currently suffering from or have ever been positively YES……………………………………………………..1 diagnosed for cardiovascular disease or Hypertension or high blood pressure NO……………………………………………………… 2

1011 Do you have any information about early diagnosis and early Breast Cancer ………………YES……………………1 treatment for any of the above diseases NO……… …………… 2 Cervical Cancer ……………YES………….…………1 NO……… …………… 2 Prostate Cancer……………YES………………………1 NO……… ….………… 2 Hypertension ………………YES…………….….……1 NO……… …………… 2 Diabetes….. ………………YES………………………1 NO……… ….………… 2

Do you know of any facility where one can receive diagnosis and Breast Cancer ………………YES……………………1 treatment for the diseases above? NO……… …………… 2 Cervical Cancer ……………YES………….…………1 NO……… …………… 2 Prostate Cancer…………YES………………………1 NO……… ….………… 2 Hypertension ………………YES…………….….……1 NO……… …………… 2 Diabetes….. ………………YES………………………1 NO……… ….………… 2

NUTRITION STATUS OF CHILDREN

1008 May I weigh (Name)? |___||___| . |___| KILOGRAMS

1009 Height |___||___| . |___| Meters

1010 MUAC |___||___| . |___| CM

1011 Age |___||___| . |___| months

1012 Check for OEDEMA. Does the child have oedema? 1. Yes 2. No

HIV AND AIDS MODULE

1101 Now I would like to talk about something else. NO ...... 0 Have you ever heard of an illness called AIDS? YES……………………………………………..1

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1102 Can people reduce their chances of getting the AIDS virus NO ………………….……………..0 by having just one sex partner who is not infected and who has no other partners? YES ……………………………….1 DON’T KNOW ………………….. 2 1103 Have you heard of special drugs (medicines) for YES ……………………………….1 HIV/AIDS? NO ………………….……………..0 DON’T KNOW ………………….. 1104 For an HIV-infected person, can the foods he or she eats NO ………………….……………..0 affect how well the HIV/AIDS drugs work? YES ……………………………….1 DON’T KNOW ………………….. 12 MONTHS AGO OR LESS….……..1 1105 When was the last time you were tested for the AIDS virus? 13–23 MONTHS AGO ……………….2 2 OR MORE YEARS AGO …………..3 DON’T KNOW ………………………..4 NEVER……………………………….5

Thank the mother for the interview

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ANNEX 2: KEY INFORMANT GUIDE

BASELINE SURVEY AND NEEDS ASSESSMENT FOR CHILDREN AND MOTHERS PARTNERSHIPS (CHAMPS) PROJECT IN NZARA COUNTY, WESTERN EQUATORIA STATE- SOUTH SUDAN

KEY INFORMANTS INTERVIEW GUIDE

1. Availability of health care services in the community

a) Comment on the availability and types of health care services (public, private, traditional, mission, municipality council etc.) within the district.

Probe for capacity, distance, ownership, cost, infrastructure , roads – how do they affect access to health services etc. Specifically, what are some of the general health related services offered by these facilities (public, private, traditional, mission etc)

b) What are the main health concerns facing most of the people in the community, men, women and children below the age of 5 years in this community? Most prevalent diseases among expectant mothers (15-49 years) and children below 5 years; men (15-49 years) and Older women in general Probe for prevalence of diseases such as malaria, HIV/AIDS, pneumonia, sexually transmitted infections, and abortions among men and women. Probe for most prevalent childhood diseases (pneumonia, diarrhea, fever, malaria, chest / respiratory diseases, measles etc). Probe for environmental and sanitation issues (toilets, refuse disposal, access to clean water etc) Probe for specific measures for situations of health insecurity (epidemics, pregnancy) in the district

2. Community perceptions on access and quality of health services

Comment on how the communities in the county perceive access to and the quality of health services in the district? a. Pregnant mothers and children access to: Health care facilities Adequacy of health facilities (Government, NGO, local authorities, Mission etc) Availability of drug supplies and equipment when needed; Proximity to users Affordability and accessibility; Competent health care providers in the area Operational space within the facilities HCW attitudes towards their patients Whose role is it to decide when and where to seek health care

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b. Comment on the type and quality of services as provided by private providers, including traditional practitioners in addressing health concerns of women and children in the district(Explain how these health seeking behaviors) Probe for their knowledge, attitude and competency Cost of receiving health care services Coverage / Distribution among different communities

3. Community structures to support health services and strengthen linkages Capacity of the Village Health committee /Health Facility Management committee to provide required services Have you received any training before? Probe on type of training received and which organizations conducted the trainings Please share with us some of the key issues about the MNCH training received that you can remember? In what ways have you been able to utilize the MNCH training received both for your own benefit as well as the community’s?/How have you and the community benefited from the training that you received? c) What are the views of the community regarding the capacity of the health facilities to meet their MNCH needs / requirements in the district? Probe for the number of health facilities at level 1,2 and 3 and staffing levels? d) What would you say on Community knowledge on Non communicable diseases (NCDs) such as Diabetes, Hernia, Breast cancer, Prostate cancer, hypertension?

4. Capacity of the stakeholders (NGOs/CBOs, HFMC, DHMT and political leadership) to address health issues facing the Women and children below 5 years? a) Comment on the capacity of each of the above institutions in addressing health needs of mothers and children within the district. Probe for the existing gaps and priorities Probe for political commitment to the provision of health care in the district (what has been done: new dispensaries or expansion of the existing facilities etc.)

b) What kind of training is required among to help improve general health in the community. Probe for: Health promotion; Hygiene; Nutrition & Food security Water and Sanitation issues Non Communicable diseases Any other training e.g. ITNs. c) What type of trainings on health promotion, hygiene and sanitation are still needed to help improve men, women, newborn and child health in the district? d) Are you aware of other partners supporting developments within the community including health, wash, education, OVC, agriculture etc.: Name them e)

5. Diseases patterns and health seeking behavior: a) Which are the prevalent diseases in the community among children of less than 1 month, less than 1 year, between 1-5 years? b) Which are the most prevalent? c) Factors that influence one to seek for health seeking services

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d) Comment of the health seeking behavior of the residents of the district: Comment on preference for public vs private health facilities one hand and traditional providers (TBAs, herbalists, witchdoctors etc. and other practitioners). e) Probe for disease prevention, treatment in the district etc. f) Common cancers and other NCDS in the community (probe for more information about the NCDs, people’s awareness, health seeking behaviors, where services are available for the NCDs)

6. Community Structures, Linkages and Partnerships: a) Are there any existing partnerships between organizations working in the area of MNCH matters / concerns and the residents/ communities in the project area? Probe for partnerships with District Health Facilities (knowledge and membership if any), Probe for linkages between the community health systems and the formal health system within this County. Probe for group memberships such as self-help and community development initiatives that deal with health issues, environmental, child and maternal nutrition, HIV/AIDS psycho-social support groups etc. What do you recommend for the improvement of existing partnerships and structures between the community members and agencies working in the district on MNCH matters.

7. MNCH Community Strategy, Policy and programmatic approaches a) What strategies exist at community level to help mitigate men, women maternal, new born and childhood morbidities and mortalities within the district? b) What are the envisaged opportunities and challenges to improve on the existing MNCH and women issues within the district? c) Comment on the existing national policy to reduce maternal, newborn and child morbidities and mortalities d) Comment specifically on the MNCH strategy put in place by the Government. e) Any recommendations for improvement in the delivery of MNCH services in the district.

8. Are the local communities involved in the development of policies and strategies affecting their own health? a) Probe for their participation and representation at all levels of health care systems in the district? b) What recommendations do they have / suggestions on improvement of maternal, new born and child health care and delivery in the district.

9. Are there Community resources that can/are reserved for promoting women and children’s health (mention some of the available resources) Probe if there is land set aside for building the hospital/health facility Community pharmacy/clinic

10. What is your opinion in involving the community in management of projects that affects the health of women and children in the district? Committees for health in the community

11. What is the prevalence of gender based violence and child abuse/labour in this community? Does it usually affect the health seeking behaviors? Does child abuse/labour usually affect school attendance? How does the community deal with the issues of GBV Are there mechanisms put in place to deal with child abuse/labour within the community?

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ANNEX 3: FOCUSED GROUP DISCUSION GUIDE

BASELINE SURVEY AND NEEDS ASSESSMENT FOR Children and Mothers Partnerships (CHAMPS) PROJECT IN NZARA COUNTY, WESTERN EQUATORIA STATE- SOUTH SUDAN

FOCUS GROUP DISCUSION GUIDE

GENERAL ISSUES- I would like us to talk about General Health concerns

1. What are the main health concerns in your community? Probe for specific concerns and problems such as malaria, RH, HIV, Diabetes, Cancers, Hernia, Hypertension, 2. Who suffers these health problems mostly? Are the trends increasing or decreasing? Any evidence? 3. What are the Common childhood illnesses in this community? 4. What is the Prevalence of child mortality-Probe for specific problems mentioned above and groups that are affected most

FAMILY PLANNING

1. What is family planning?  (Probe for knowledge and types of family planning methods)? 2. Do you know where one can get family planning services?  Probe for sources: Government, Missionary and private health facilities. 3. Do women / men in the community use family planning including natural family planning methods ?  Probe for advantages, disadvantages including side effects, perceived fears and barriers to family planning including attitudes, socio-cultural factors and religious reasons etc.  Probe for traditional methods such as breastfeeding, withdrawal etc. 4. Are family planning services available at all the time? Probe for providers availability and supplies within the community / facilities 5. How much does family planning cost? Probe for amounts by facility and type of FP 6. In what ways can utilization of family planning be improved?  Probe for methods and roles of community folk music, barazas and CBDs 7. What are men’s perception on the use of family planning methods by their spouses and partners in the community? (Probe for approval/disapproval, indifference etc.) 8. What are the key barriers on FP uptake /utilization among women in the community? Probe for men, cultural and religious reasons 9. Who should make decisions regarding child spacing and use of contraceptives? Probe for spouse, mother-in-law, woman, friend etc.

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MATERNAL HEALTH

1. Are men and women are educated on the danger signs during pregnancies and post-delivery. What are the danger signs during pregnancy/ delivery and post-delivery? 2. Where do women go for treatment of complications associated with pregnancy / childbirth? Probe for health facilities: Government, Missionary, Private and NGOs 3. Are health facilities within the County capable to treat pregnancy related complications? Probe for specific deficiencies like infrastructure, lack of personnel, skills, equipment, supplies etc.). 4. Where do women in the community mostly go for delivery? Probe for health facilities: Government, Missionary, Private, NGOs and within the homes / TBAs and relatives

ACCESS TO HEALTHCARE

1. What are the main constraints in accessing the nearest health facilities? Probe for witchcraft, Herbal medicine, religion, distance, money, spousal attitude, looking after livestock or children and how can these constraints be reduced? 2. What can be done to access to health care services within the health facilities?

NON COMMUNICABLE DISEASES 1. What are some of the common Non Communicable diseases in the community (probe also to understand the communities understanding of NCDs) give examples of NCDs, 2. Is cervical cancer, breast cancer, diabetes, cardiovascular disease, HIV/AIDS, high blood pressure, prostate cancer and hernias a problem in this community among adult men and women? 3. Do you know of anyone who has suffered from cervical cancer, breast cancer, diabetes, cardiovascular disease related conditions? Probe for major a description of major signs in a woman (cancer of the breast and cervix) / man (cancer of the prostrate, penile etc.). 4. Do women in this community have knowledge about the use of disease prevention practices such as self- breast examinations and periodic pelvic exams (explain) 5. In the recent past, have women in this community made use of disease prevention practices such as self- breast examinations and periodic pelvic exams(explain)

WATER , SANITATION AND HYGIENE(WASH)

1. What is the main source of drinking water for members of this community? Probe for piped water, protected springs,/ borehole, unprotected springs, rain water; surface water (river, dam, lake etc.) and time spent searching for water 2. Where does the community access water for livestock consumption? Probe for time spent searching for water 3. Do the people in this community have latrines? Where do they mainly relive themselves 4. How adequate / inadequate is the community’s water sources and sanitation services? 5. How much time do women in the community spend searching for water? How has the time saved if any been used productively? Has the access to water opened up other livelihood opportunities for the community? Probe for agriculture or water related activities etc. 6. What is the prevalence of water borne diseases in your community? Probe for hand washing during and after food; after visiting toilet; before feeding a child etc.

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7. Water detergents are used to wash hands? Probe for soap and alternatives such as ash 8. Where do the community members go to relive themselves? Probe for toilet coverage in the community and use of bush etc.,

LIVELIHOODS

1. What are the main sources of livelihoods and cash income in the area? 2. Rank the sources of livelihoods in order of importance. 3. What livelihood activities are important sources of cash income? 4. What activities are new and what other changes did farmers observe in the relative importance of the livelihoods? 5. What differences do you observe for women and men (e.g., access to land and livestock, control over production and sale) 6. What are some of the sources of food in this community? If farming, what are some of the crops planted? What are some of the crops considered as cash-crop (name them) and food crop (Name them)?

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