Sudan Health Transformation Project (SHTP) II
FY 2009 Q4 PROGRESS REPORT
Report Type: Quarterly Report Award No. GHS-I-00-07-00006-00 Task Order 4
Period Ending: July 1st – September 30th, 2009
Prepared for Patrick Kollars September 30, 2009 United States Agency for International Development/Sudan Algeraif West (1/H) Menshia Alhara Aloola (1/H) Plot No. 43/3 Khartoum, Sudan
American Consulate General USAID/Sudan Compound Juba, Sudan
Prepared by Management Sciences for Health 784 Memorial Drive, Cambridge, MA 02139
Contents
ACRONYMS AND ABBREVIATIONS ...... 1
I. SHTP II EXECUTIVE SUMMARY ...... 3
II. PROGRAM PROGRESS AND KEY ACHIEVEMENTS: ...... 4
III. PROGRESS ON INDICATOR TARGETS (QUANTITATIVE IMPACT) ...... 8
IV. MONITORING ...... 23
V. LIST OF NEXT QUARTER’S WORK PLAN ...... 23
VI. PROJECT ADMINISTRATION ...... 25
VII. CONSTRAINTS AND CRITICAL ISSUES ...... 26
VIII. FINANCIAL STATUS REPORT ...... 28
ANNEX ONE: LIST OF DELIVERABLE PRODUCTS ...... 29
ANNEX TWO: ASSESSMENT REPORTS ...... 41
ACRONYMS AND ABBREVIATIONS
AAH Action Africa Help AIDS Acquired Immune Deficiency Syndrome ANC Antenatal Care AWD Acute Watery Diarrhea BCC Behavior Change Communication CBHW Community-Based Health Worker CBOs Community-Based Organizations CHMT County Health Management Team CHMC Community Health Management Committees CHD County Health Department CHW Community Health Worker COP Chief of Party CTO Cognizant Technical Officer DPT Diphtheria, Pertussis, Tetanus DQA Data Quality Assessment EPI Expanded Program on Immunization FFSDP Fully Functional Service Delivery Point FY Fiscal Year FP Family Planning GoSS Government of Southern Sudan GoSSHA -2 Government of Southern Sudan Health Assembly - 2 HIV Human Immunodeficiency Virus HMIS Health Management Information System IMC International Medical Corps INGO International Nongovernmental Organization (NGO) IPT Intermittent Presumptive Treatment IRC International Rescue Committee JSI JSI Research & Training Institute, Inc. LLITN Long Lasting Insecticide Treated Nets LMIS Logistic Management Information System LNGO Local Non-Governmental Organization MCH Maternal and Child Health MCHW Maternal and Child Health Worker M&E Monitoring and Evaluation MoH Ministry of Health MSH Management Sciences for Health NID National Immunization Day NR No Report OJT On the Job Training ORS Oral Rehydration Salts PBC Performance-Based Contracting PBF Performance-Based Financing PHCC Primary Health Care Center PHCU Primary Health Care Unit PSI Population Services International
Page 1 RTC Regional Health Training Center SCP Subcontracting Partner SHTP Sudan Health Transformation Project STI Sexually Transmitted Infection STTA Short Term Technical Assistance TBA Traditional Birth Attendants ToT Training of Trainers TT Tetanus Toxoid USAID United States Agency for International Development USD United States Dollar WHO World Health Organization VCT Voluntary Counseling and Testing VHC Village Health Committees
Page 2 I. SHTP II EXECUTIVE SUMMARY
This report covers the period July 1 through September 30, 2009 of the Sudan Health Transformation Project Phase two (SHTP II). During the quarter, MSH continued to work with the implementing partners of SHTP I to provide health care services at the over 160 health facilities in its twelve focus counties.
Although reports from the field suffer incompleteness, and other data quality issues, nevertheless available data indicates that the project made some progress. Over 9,709 LLINs were distributed; 4,605 children less than 12 months of age received DPT3 and 5,942 received Vitamin A; 2,699 deliveries were performed by trained health workers; and 35,011 mothers received iron folate during Ante-natal visits. ACT supply to SDP were coordinated with MoH for all the partners in SHTP II focus counties
SHTP II developed a comprehensive Performance Based Contracting (PBC) Request for Proposals (RFP) and posted it on July 27 via MSH website, the Sudan NGO forum and regional publications. An evaluation committee was formed and evaluation criteria designed. In addition, a questions and answers session was performed and subsequently twenty proposals were submitted by Offerors in time covering all focus counties except for Aweil South. On September 17, Letters of Best and Final Offer (BAFO) were sent to the potential winners to clarify technical and costs queries.
Hiring of Sudanese with appropriate skills was very challenging as the protracted 22 years war devastated the populace. The few skilled Sudanese in country are currently employed by INGOs, UN or GOSS. In addition many Sudanese remain outside of Sudan. Nevertheless some key positions such as Technical Director was filled.
An elaborate and robust consultation was done between MSH and USAID team in Juba on Water and Sanitation and an RFP was finally developed and posted.
MSH technical team conducted county assessments in nine SHTP focus areas, in some of which the assessments were jointly carried out by MOH, USAID and MSH staff and recommendations were made for all the project sites visited. The assessments also provided important baseline information into the capacity of the CHD staff as well as supportive supervision to the PHC facilities and community-based health workers in their respective Counties
In compliance with USAID regulations, MSH submitted its plan for safe disposal of medical wastes and mitigation and management plan to USAID and a partial approval have been obtained waiting for final approval by USAID/Environmental Officer. Due to delay in development of the Family Planning Policy document, its analysis and dissemination to our focus counties was not done. However, SHTP II health facilities continue to provide family planning and reproductive health services and information on a limited scale.
Overall, most of the challenges from the previous quarter still exist and lessons learned indicates that capacity building in performance based contracting is a process that is to continue throughout most length of the project period.
Page 3
II. PROGRAM PROGRESS AND KEY ACHIEVEMENTS:
Quantitative and Qualitative Impact:
Quarterly Report - Key Achievements
1.1 All the SHTP II implementing agencies in the twelve focus counties continued to provide primary health care services in their respective health facilities (see Annex II)
1.2 PBC RFP Issuance
SHTP II developed a comprehensive PBC RFP and disseminated it on July 27 via our website, the Sudan NGO forum and regional publications. SHTP II formed an evaluation committee (see structure below) and designed an evaluation criteria. In addition, SHTP II performed a questions and answers session from August 10 - 17. Twenty proposals were submitted by August 31 covering every county, except for Aweil South. The figure below shows number of bidders per county.
1.3 RFP review and selection procedure, contract negotiation and award
On September 3, an evaluation committee was formed consisting of the following:
Uche Azie, SHTP II COP
John Rumunu, SHTP II Technical Director
Page 4 Felix Lado, SHTP II PHC Advisor
Michael Andreini, USAID Health Officer
Dr. Lueth Garang, MoH DG-PHC
Alternates: State DGs-PHC for their respective county
In addition, we had two observers, Kamau Lizwelicha, Director of Finance & Contracts and Judy Webb, MSH/Ethiopia Contracts Manager, to ensure the PBC was transparent in accordance to MSH and USAID procurement procedures. These observers also served as the cost proposal committee.
The evaluation committee reviewed and ranked the proposals from September 3 -16. Potential winners for each county, except for Aweil South, were selected. On September 17, Letters of Best and Final Offer (BAFO) were sent to the potential winners to clarify questions from the technical evaluation and costs committees. By the time of writing of this report MSH is still reviewing responses from some of the bidders who received the BAFO letter.
1.4 PBC RFP Issuance for Water/Sanitation
SHTP II technical team worked jointly with USAID WASH Advisor to develop the scope of work for the RFP that was reviewed and approved by USAID. The RFP will be released in October.
2.1 Facility Supervision & Assessment
MSH conducted County assessments in nine SHTP Counties, Mundri (East and West), Mvolo/Wulu, Twic East, Kapoeata North, Terekeka, Juba, Wau, Malakal, and Tonj South, in some of the counties the assessment were jointly conducted with MOH and USAID staff. Recommendations were made for all the project sites visited (see reports in Annex II).
Page 5 2.2 Disburse Micro-grants to CSO
SHTP II has developed a drafted adminstrative procedures manual with necessary forms and review procedures for micro-grants. It is expected that the implementation process of the micro-grants to CSO will begin next quarter.
Cross Cutting Issues
Capacity Building: During the reporting quarter, MSH and MOH and sometimes with USAID staff conducted County assessments in nine SHTP sites. Methods used included interviewing of the County Health Department staff. These assessments provided important baseline information into the capacity of the CHD to as well as provide joint supportive supervision to the PHC facilities and community-based health workers in their respective counties. The technical support provided to the CHDs, Health Facilities and SCPs contribute towards MSH‘s strategy of strengthening public sector leadership and management capacity which on the long run will lead to transition from relief to development, strong decentralization and increasing the number of females in the health workforce. In Kapoeta North alone, the ratio of female to males of health personnel trained with USG support is one to three. Linkages to other sectors are also being realized as many Offerors responding to the RFP have included development of basic health messages to be used at the community level and in primary schools.
Environmental Compliance
In compliance with USAID regulations, MSH submitted its plan for safe disposal of medical wastes and mitigation and management plan to USAID and a partial approval have been obtained awaiting final approval. The plan proposes a package of mitigation measures for disposal of solid, sanitary, and medical waste which include the following:
Disposal of Solid Waste (including used dressings and items contaminated with blood and organic materials; Disposal of Sharp Objects (needles, razors and scalpel blades)Disposal of Liquid Contaminated Waste (blood, feces, urine and other body fluids)
Disposal of Used Chemical Containers
Building a Simple Drum Incinerator for Waste Disposal
Making a Burial Site for Waste Disposal‘
Construction of Latrines
Lessons Learned
Lessons Learned – Start-Up
Logistics: Clearing goods from Sudan custom office still remains a problem though we have learned to plan ahead and process the documents with the Ministry of Health and Finance weeks in advance.
Page 6 Proactive recruitment and approvals: Given the low skill sets of local staff, MSH will start advertising for local positions much earlier. Due to long time taken by USAID to approve nomination letters, MSH learned to communicate to the CTO early on the coming of requests for approvals.
Lessons Learned – Contracting
The experience with contracting process in this project has yielded some important lessons. In addition to the lessons learned share in the last quarter report, which were mainly on partners information gap regarding preparation of information necessary to appropriate subcontracts, organizations transitioning from grants and having significant capacity issues in providing all the information necessary to contract management, have continued to be a challenge for the projects, and requires constant capacity building and vigilance throughout the project period.
The collection of costing information to verify costs in the proposals for performance-based subcontractors has not reached fruition. Nevertheless information on costs were obtained directly from current knowledge of what partners pay especially regarding remunerations linking it to the number of staffing prescribed in the Basic Package for Health Services.
Projected time for contracting process was underestimated thus the process was not completed in time leading to extension of the bridging period.
Involvement of Ministry of Health staff in proposal review process added a lot of value in linking between what the offerors propose to what is known on ground. Hence appropriate comments were made in the first Best and Final Offer letters (BAFO) to the Offerors.
Lessons Learned - M&E
During the quarter, the same challenges that were encountered last quarter continued to persist. First, there is very limited capacity for conducting M&E throughout the system including at the level of the sub-contracting partners. Secondly, very few of the SCPs have staff or resources that are dedicated to M&E thus data quality remains a challenge as verification of reports received by the SCPs from staff providing services within the facilities gets minimal verification. Thirdly, despite the issuance of specific guidance to all of the SCPs on reporting requirements during the bridging period, completeness and timeliness remained a problem which led to difficulties in the compilation of this quarterly report.
Due to the high level of incomplete reports received from the subcontracting partners, we suggest that the attached indicator reports be considered as preliminary data and an updated report will be submitted once all the reports are received.
Page 7 III. PROGRESS ON INDICATOR TARGETS (Quantitative Impact)
Quarterly Quarterly Quarterly Quarterly Achievement Achievement Achievement Achievement Indicator Annual Target Q1 Q2 Q3 Q4 Annual Achievement
Number of children less than 12 months of age who received DPT3 in areas currently assisted with USAID funds. NA NA 2899 4605 Percentage of children less than 12 months of age who received DPT3 in areas currently assisted with USAID funds NA NA 10.2 71.13 Number of health personnel trained in immunization, diarrhea management and ARI management with USG support NA NA 154 16 Number of children under 5 years of age who received vitamin A in areas currently assisted with USAID funds NA NA 7801 5942
Percentage of children under 5 years of age who received vitamin A in the last six months in areas currently assisted with USAID funds NA NA 7.0 12.10 Number of ITNs distributed to USG-supported counties NA NA 38,808 9709 Number of people trained in malaria treatment or prevention with USG funds NA NA 19 136 Number of deliveries with a trained TBA or MCH workers in USG assisted programs. NA NA 2466 2699 Percentage of assisted deliveries by trained health service providers or TBA in USG supported counties NA NA 40.9 47.19 Number of women with a skilled attendant at birth 520 698 Percent of women with a skilled attendant at birth NA NA 33.2 10.78 Number of mothers receiving iron folate NA NA 3559 35011 Number of health personnel trained with USG support NA NA 398 161 Number of people covered by USG-supported health financing arrangements NA NA 1,257,912 1,257,912 Number of SDP providing the BPHS with USG support NA NA 144 95
Page 8 INDICATOR TITLE: Number of children less than 12 months of age who received DPT3 in areas currently assisted with USAID funds. UNIT: DISAGGREGATE BY: Location, event, date and gender Geographic Location Event/Output Date W M Sub-total State: Upper Nile Malakal County; All Payams 20/10/09 155 138 293 State: Jonglei State Twic East County; All Payams 20/10/09 305 343 648 State: Unity Panyijar County; 3 payams 20/10/09 296 312 608 State: Warrap Tonj South County; All Payams 20/10/09 163 156 319 State: Northern Bahr El Ghazel Aweil South County; All payams 20/10/09 377 377 State: Western Bahr El Ghazel Wau County; 2 payams 20/10/09 0 State: Western Equatoria Tambura county; all payams 20/10/09 81 71 152 State: Western Equatoria Mvolo & Wulu County; all payams 20/10/09 214 238 452 State: Western Equatoria 1519 1519 Mundri East & West; all payams 20/10/09 State: Central Equatoria 0 Terekeka County; 7 payams 20/10/09 State: Central Equatoria 707 707 Juba county; 10 payams 20/10/09 State: Eastern Equatoria 146 190 336 Kapoeta North county; all payams 20/10/09 Totals 5411 Results: Cumulative for Fiscal Reporting Period This Reporting Reporting Period Reporting Period FY 2009 FY 2010 End of Project Baseline Year 31/Dec/08 Period 31/Mar/09 30/Jun/09 30/Sep/09 Target Target Target
Additional Criteria If other criteria are important, add Achieved Achieved Achieved Achieved Achieved Target Target Target lines for setting targets and tracking W M W M W M W M W M W M W M W M W M
0 0 n/a n/a n/a n/a Gender: Women (W), Men (M)
Page 9 INDICATOR TITLE: Percentage of children less than 12 months of age who received DPT3 in areas currently assisted with USAID funds UNIT: DISAGGREGATE BY: Location, event, date and gender Geographic Location Event/Output Date W M Sub-total State: Upper Nile Malakal County; All Payams 293 28.84 State: Jonglei State Twic East County; All Payams 648 117.82 State: Unity 159.58 Panyijar County; 3 payams 608 State: Warrap 41.75 Tonj South County; All Payams 319 State: Northern Bahr El Ghazel 54.17 Aweil South County; All payams 377 State: Western Bahr El Ghazel Wau County; 2 payams1 State: Western Equatoria 40 Tambura county; all payams 152 State: Western Equatoria 76.61 Mvolo and Wulu County; all payams 452 State: Western Equatoria 1519 224.04 Mundri East & West; all payams State: Central Equatoria Terekeka County; 7 payams State: Central Equatoria 707 27.06 Juba county; 10 payams State: Eastern Equatoria 336 58.03 Kapoeta North county; all payams Totals 5411 65.62 Results: Cumulative for Fiscal Reporting Period This Reporting Reporting Period Reporting Period FY 2009 FY 2010 End of Project Baseline Year 31/Dec/08 Period 31/Mar/09 30/Jun/09 30/Sep/09 Target Target Target
Additional Criteria If other criteria are important, add Achieved Achieved Achieved Achieved Achieved Target Target Target lines for setting targets and tracking W M W M W M W M W M W M W M W M W M
0 0 n/a n/a n/a n/a Gender: Women (W), Men (M)
1 Wau and Terekeka are excluded in the calculations.
Page 10 INDICATOR TITLE: Number of health personnel trained in immunization, diarrhea management and ARI management with USG support UNIT: DISAGGREGATE BY: Location, event, date and gender Geographic Location Event/Output Date W M Sub-total State: Upper Nile Malakal County; All Payams 0 0 State: Jonglei State Twic East County; All Payams 0 0 State: Unity Panyijar County; 3 payams 0 0 State: Warrap Tonj South County; All Payams State: Northern Bahr El Ghazel Aweil South County; All payams 7 State: Western Bahr El Ghazel Wau County; 2 payams State: Western Equatoria Tambura county; all payams 0 0 State: Western Equatoria Mvolo and Wulu County; all payams 0 0 State: Western Equatoria 0 0 Mundri East & West; all payams State: Central Equatoria Terekeka County; 7 payams State: Central Equatoria 9 Juba county; 10 payams State: Eastern Equatoria 0 0 Kapoeta North county; all payams Totals Results: Cumulative for Fiscal Reporting Period This Reporting Reporting Period Reporting Period FY 2009 FY 2010 End of Project Baseline Year 31/Dec/08 Period 31/Mar/09 30/Jun/09 30/Sep/09 Target Target Target
Additional Criteria If other criteria are important, add Achieved Achieved Achieved Achieved Achieved Target Target Target lines for setting targets and tracking W M W M W M W M W M W M W M W M W M
0 0 n/a n/a n/a n/a Gender: Women (W), Men (M)
Page 11 INDICATOR TITLE: Number of children under 5 years of age who received vitamin A in areas currently assisted with USAID funds UNIT: DISAGGREGATE BY: Location, event, date and gender Geographic Location Event/Output Date W M Sub-total State: Upper Nile Malakal County; All Payams 973 State: Jonglei State Twic East County; All Payams 1133 State: Unity Panyijar County; 3 payams 1307 State: Warrap Tonj South County; All Payams 665 State: Northern Bahr El Ghazel Aweil South County; All payams 0 State: Western Bahr El Ghazel Wau County; 2 payams State: Western Equatoria Tambura county; all payams 80 State: Western Equatoria Mvolo & Wulu County; all payams 1078 State: Western Equatoria 0 Mundri East & West; all payams State: Central Equatoria Terekeka County; 7 payams State: Central Equatoria 284 Juba county; 10 payams State: Eastern Equatoria 422 Kapoeta North county; all payams Totals 5942 Results: Cumulative for Fiscal Reporting Period This Reporting Reporting Period Reporting Period FY 2009 FY 2010 End of Project Baseline Year 31/Dec/08 Period 31/Mar/09 30/Jun/09 30/Sep/09 Target Target Target
Additional Criteria If other criteria are important, add Achieved Achieved Achieved Achieved Achieved Target Target Target lines for setting targets and tracking W M W M W M W M W M W M W M W M W M
0 0 n/a n/a n/a n/a Gender: Women (W), Men (M)
Page 12 INDICATOR TITLE: Percentage of children under 5 years of age who received vitamin A in the last six months in areas currently assisted with USAID funds UNIT: DISAGGREGATE BY: Location, event, date and gender Geographic Location Event/Output Date W M Sub-total State: Upper Nile Malakal County; All Payams 15.46 State: Jonglei State Twic East County; All Payams 28.09 State: Unity Panyijar County; 3 payams 124.48 State: Warrap Tonj South County; All Payams 14.30 State: Northern Bahr El Ghazel Aweil South County; All payams 0 State: Western Bahr El Ghazel Wau County; 2 payams 0 State: Western Equatoria Tambura county; all payams 3.56 State: Western Equatoria Mvolo & Wulu County; all payams 27.54 State: Western Equatoria 0 Mundri East & West; all payams State: Central Equatoria 0 Terekeka County; 7 payams State: Central Equatoria 1.91 Juba county; 10 payams State: Eastern Equatoria 11.00 Kapoeta North county; all payams
Totals 12.10 Results: Cumulative for Fiscal Reporting Period This Reporting Reporting Period Reporting Period FY 2009 FY 2010 End of Project Baseline Year 31/Dec/08 Period 31/Mar/09 30/Jun/09 30/Sep/09 Target Target Target
Additional Criteria If other criteria are important, add Achieved Achieved Achieved Achieved Achieved Target Target Target lines for setting targets and tracking W M W M W M W M W M W M W M W M W M
0 0 n/a n/a n/a n/a Gender: Women (W), Men (M)
Page 13 INDICATOR TITLE: Number of ITNs distributed to USG-supported counties UNIT: DISAGGREGATE BY: Location, event, date and gender Geographic Location Event/Output Date W M Sub-total State: Upper Nile Malakal County; All Payams 0 State: Jonglei State Twic East County; All Payams 5250 State: Unity Panyijar County; 3 payams 175 State: Warrap Tonj South County; All Payams 0 State: Northern Bahr El Ghazel Aweil South County; All payams 0 State: Western Bahr El Ghazel Wau County; 2 payams 0 State: Western Equatoria Tambura county; all payams 0 State: Western Equatoria Mvolo & Wulu County; all payams 559 State: Western Equatoria 3161 Mundri East & West; all payams State: Central Equatoria 0 Terekeka County; 7 payams State: Central Equatoria 0 Juba county; 10 payams State: Eastern Equatoria 564 Kapoeta North county; all payams Totals 9709 Results: Cumulative for Fiscal Reporting Period This Reporting Reporting Period Reporting Period FY 2009 FY 2010 End of Project Baseline Year 31/Dec/08 Period 31/Mar/09 30/Jun/09 30/Sep/09 Target Target Target
Additional Criteria If other criteria are important, add Achieved Achieved Achieved Achieved Achieved Target Target Target lines for setting targets and tracking W M W M W M W M W M W M W M W M W M
0 0 n/a n/a n/a n/a Gender: Women (W), Men (M)
Page 14 INDICATOR TITLE: Number of people trained in malaria treatment or prevention with USG funds UNIT: DISAGGREGATE BY: Location, event, date and gender Geographic Location Event/Output Date W M Sub-total State: Upper Nile Malakal County; All Payams State: Jonglei State Twic East County; All Payams 0 0 State: Unity Panyijar County; 3 payams 0 0 State: Warrap Tonj South County; All Payams State: Northern Bahr El Ghazel Aweil South County; All payams 7 7 State: Western Bahr El Ghazel Wau County; 2 payams State: Western Equatoria Tambura county; all payams State: Western Equatoria Mvolo & Wulu County; all payams 21/10/09 78 42 120 State: Western Equatoria 0 0 Mundri East & West; all payams State: Central Equatoria Terekeka County; 7 payams State: Central Equatoria 9 9 Juba county; 10 payams State: Eastern Equatoria 0 0 Kapoeta North county; all payams Totals Results: Cumulative for Fiscal Reporting Period This Reporting Reporting Period Reporting Period FY 2009 FY 2010 End of Project Baseline Year 31/Dec/08 Period 31/Mar/09 30/Jun/09 30/Sep/09 Target Target Target
Additional Criteria If other criteria are important, add Achieved Achieved Achieved Achieved Achieved Target Target Target lines for setting targets and tracking W M W M W M W M W M W M W M W M W M
0 0 n/a n/a n/a n/a Gender: Women (W), Men (M)
Page 15 INDICATOR TITLE: Number of deliveries with a trained TBA or MCHW workers in USG assisted programs. UNIT: DISAGGREGATE BY: Location, event, date and gender Geographic Location Event/Output Date W M Sub-total State: Upper Nile Malakal County; All Payams 80 State: Jonglei State Twic East County; All Payams 378 State: Unity Panyijar County; 3 payams 244 State: Warrap Tonj South County; All Payams 885 State: Northern Bahr El Ghazel Aweil South County; All payams 213 State: Western Bahr El Ghazel Wau County; 2 payams 0 State: Western Equatoria Tambura county; all payams 378 State: Western Equatoria Mvolo & Wulu County; all payams 267 State: Western Equatoria 207 Mundri East & West; all payams State: Central Equatoria 0 Terekeka County; 7 payams State: Central Equatoria 22 Juba county; 10 payams State: Eastern Equatoria 25 Kapoeta North county; all payams Totals 2699 Results: Cumulative for Fiscal Reporting Period This Reporting Reporting Period Reporting Period FY 2009 FY 2010 End of Project Baseline Year 31/Dec/08 Period 31/Mar/09 30/Jun/09 30/Sep/09 Target Target Target
Additional Criteria If other criteria are important, add Achieved Achieved Achieved Achieved Achieved Target Target Target lines for setting targets and tracking W M W M W M W M W M W M W M W M W M
0 0 n/a n/a n/a n/a Gender: Women (W), Men (M)
Page 16
INDICATOR TITLE: Percentage of assisted deliveries by trained health service providers or TBA in USG supported counties UNIT: DISAGGREGATE BY: Location, event, date and gender
Geographic Location Event/Output Date W M Sub-total State: Upper Nile Malakal County; All Payams 15.83 State: Jonglei State Twic East County; All Payams 67.2 State: Unity Panyijar County; 3 payams 205.88 State: Warrap Tonj South County; All Payams 192.01 State: Northern Bahr El Ghazel Aweil South County; All payams 46.20 State: Western Bahr El Ghazel Wau County; 2 payams - State: Western Equatoria Tambura county; all payams 115.92 State: Western Equatoria Mvolo & Wulu County; all payams 47.90 State: Western Equatoria 47.57 Mundri East & West; all payams State: Central Equatoria - Terekeka County; 7 payams State: Central Equatoria 2.74 Juba county; 10 payams State: Eastern Equatoria 6.38 Kapoeta North county; all payams Totals 47.19 Results: Cumulative for Fiscal Reporting Period This Reporting Reporting Period Reporting Period FY 2009 FY 2010 End of Project Baseline Year 31/Dec/08 Period 31/Mar/09 30/Jun/09 30/Sep/09 Target Target Target
Additional Criteria If other criteria are important, add Achieved Achieved Achieved Achieved Achieved Target Target Target lines for setting targets and tracking W M W M W M W M W M W M W M W M W M
0 0 n/a n/a n/a n/a Gender: Women (W), Men (M)
Page 17
INDICATOR TITLE: Number of women with a skilled attendant at birth UNIT: DISAGGREGATE BY: Location, event, date and gender Geographic Location Event/Output Date W M Sub-total State: Upper Nile Malakal County; All Payams 60 State: Jonglei State Twic East County; All Payams 11 State: Unity Panyijar County; 3 payams 9 State: Warrap Tonj South County; All Payams 66 State: Northern Bahr El Ghazel Aweil South County; All payams 3 State: Western Bahr El Ghazel Wau County; 2 payams 0 State: Western Equatoria Tambura county; all payams 268 State: Western Equatoria Mvolo & Wulu County; all payams 70 State: Western Equatoria 164 Mundri East & West; all payams State: Central Equatoria 0 Terekeka County; 7 payams State: Central Equatoria 23 Juba county; 10 payams State: Eastern Equatoria 24 Kapoeta North county; all payams Totals 698 Results: Cumulative for Fiscal Reporting Period This Reporting Reporting Period Reporting Period FY 2009 FY 2010 End of Project Baseline Year 31/Dec/08 Period 31/Mar/09 30/Jun/09 30/Sep/09 Target Target Target
Additional Criteria If other criteria are important, add Achieved Achieved Achieved Achieved Achieved Target Target Target lines for setting targets and tracking W M W M W M W M W M W M W M W M W M
0 0 n/a n/a n/a n/a Gender: Women (W), Men (M)
Page 18 INDICATOR TITLE: Percent of women with a skilled attendant at birth UNIT: DISAGGREGATE BY: Location, event, date and gender Geographic Location Event/Output Date W M Sub-total State: Upper Nile Malakal County; All Payams 7.36 State: Jonglei State Twic East County; All Payams 1.94 State: Unity Panyijar County; 3 payams 7.56 State: Warrap Tonj South County; All Payams 13.52 State: Northern Bahr El Ghazel Aweil South County; All payams 0.65 State: Western Bahr El Ghazel Wau County; 2 payams 0 State: Western Equatoria Tambura county; all payams 66.67 State: Western Equatoria Mvolo & Wulu County; all payams 10.89 State: Western Equatoria 27.47 Mundri East & West; all payams State: Central Equatoria 0 Terekeka County; 7 payams State: Central Equatoria 1.40 Juba county; 10 payams State: Eastern Equatoria 3.26 Kapoeta North county; all payams Totals 10.78 Results: Cumulative for Fiscal Reporting Period This Reporting Reporting Period Reporting Period FY 2009 FY 2010 End of Project Baseline Year 31/Dec/08 Period 31/Mar/09 30/Jun/09 30/Sep/09 Target Target Target
Additional Criteria If other criteria are important, add Achieved Achieved Achieved Achieved Achieved Target Target Target lines for setting targets and tracking W M W M W M W M W M W M W M W M W M
0 0 n/a n/a n/a n/a Gender: Women (W), Men (M)
Page 19 INDICATOR TITLE: Number of mothers receiving iron folate UNIT: DISAGGREGATE BY: Location, event, date and gender Geographic Location Event/Output Date W M Sub-total State: Upper Nile Malakal County; All Payams 1034 State: Jonglei State Twic East County; All Payams 864 State: Unity Panyijar County; 3 payams 852 State: Warrap Tonj South County; All Payams 3696 State: Northern Bahr El Ghazel Aweil South County; All payams 569 State: Western Bahr El Ghazel Wau County; 2 payams State: Western Equatoria Tambura county; all payams 1545 State: Western Equatoria Mvolo & Wulu County; all payams 24495 State: Western Equatoria 316 Mundri East & West; all payams State: Central Equatoria Terekeka County; 7 payams State: Central Equatoria 718 Juba county; 10 payams State: Eastern Equatoria 922 Kapoeta North county; all payams Totals 35011 Results: Cumulative for Fiscal Reporting Period This Reporting Reporting Period Reporting Period FY 2009 FY 2010 End of Project Baseline Year 31/Dec/08 Period 31/Mar/09 30/Jun/09 30/Sep/09 Target Target Target
Additional Criteria If other criteria are important, add Achieved Achieved Achieved Achieved Achieved Target Target Target lines for setting targets and tracking W M W M W M W M W M W M W M W M W M
0 0 n/a n/a n/a n/a Gender: Women (W), Men (M)
Page 20 INDICATOR TITLE: Number of health personnel trained with USG support UNIT: DISAGGREGATE BY: Location, event, date and gender Geographic Location Event/Output Date W M Sub-total State: Upper Nile Malakal County; All Payams 17 17 State: Jonglei State Twic East County; All Payams 28 28 State: Unity Panyijar County; 3 payams 0 0 0 State: Warrap Tonj South County; All Payams State: Northern Bahr El Ghazel Aweil South County; All payams 7 7 State: Western Bahr El Ghazel Wau County; 2 payams State: Western Equatoria Tambura county; all payams 11 11 State: Western Equatoria Mvolo & Wulu County; all payams 25 25 State: Western Equatoria 0 0 0 Mundri East & West; all payams State: Central Equatoria Terekeka County; 7 payams State: Central Equatoria 53 53 Juba county; 10 payams State: Eastern Equatoria 5 15 20 Kapoeta North county; all payams Totals 161 Results: Cumulative for Fiscal Reporting Period This Reporting Reporting Period Reporting Period FY 2009 FY 2010 End of Project Baseline Year 31/Dec/08 Period 31/Mar/09 30/Jun/09 30/Sep/09 Target Target Target
Additional Criteria If other criteria are important, add Achieved Achieved Achieved Achieved Achieved Target Target Target lines for setting targets and tracking W M W M W M W M W M W M W M W M W M
0 0 n/a n/a n/a n/a Gender: Women (W), Men (M)
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INDICATOR TITLE: Number of SDP providing the BPHS with USG support UNIT: DISAGGREGATE BY: Location, event, date and gender Geographic Location Event/Output Date W M Sub-total State: Upper Nile Malakal County; All Payams 5 State: Jonglei State Twic East County; All Payams 15 State: Unity Panyijar County; 3 payams 9 State: Warrap Tonj South County; All Payams 0 State: Northern Bahr El Ghazel Aweil South County; All payams 1 State: Western Bahr El Ghazel Wau County; 2 payams 0 State: Western Equatoria Tambura county; all payams 21 State: Western Equatoria Mvolo & Wulu County; all payams 10 State: Western Equatoria 21 Mundri East & West; all payams State: Central Equatoria 0 Terekeka County; 7 payams State: Central Equatoria 7 Juba county; 10 payams State: Eastern Equatoria 6 Kapoeta North county; all payams Totals 95 Results: Cumulative for Fiscal Reporting Period This Reporting Reporting Period Reporting Period FY 2009 FY 2010 End of Project Baseline Year 31/Dec/08 Period 31/Mar/09 30/Jun/09 30/Sep/09 Target Target Target
Additional Criteria If other criteria are important, add Achieved Achieved Achieved Achieved Achieved Target Target Target lines for setting targets and tracking W M W M W M W M W M W M W M W M W M
0 0 n/a n/a n/a n/a Gender: Women (W), Men (M)
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IV. MONITORING
Achievements: The M&E Plan submitted to USAID was discussed jointly by MSH/SHTP II and USAID and recommendations were made for improvement. These recommendations were incorporated into the revised M&E Plan that is being resubmitted to USAID.. . County Assessment visits were conducted in all the counties except Panyijar and Tambura counties because of the difficult landing terrain and a summary report for the visits is included in Annex II.
A data entry package has been developed for capturing the main indicators data. This package has enabled the easy inputting of monthly data from the subcontracting partners.
Challenges for M&E
During the quarter, the same challenges that were encountered last quarter continued to persist. First, there is very limited capacity for conducting M&E throughout the system including at the level of the sub-contracting partners. Secondly, very little emphasis is being placed on data quality issues and as far as could be discerned there has recently been no serious attempt to verify the reports received by the SCPs from the staff providing services within the facilities. Thirdly, very few of the SCPs have staff or resources that are dedicated to M&E capacity. Fourthly, despite the issuance of specific guidance to all of the SCPs on reporting requirements during the bridging period, only two of them submitted reports for all three months within the quarter under review. Moreover, for those that submitted, their reports were incomplete leading to difficulties in the compilation of this quarterly report.
Based on the high level of incomplete reports, we suggest that the attached indicator reports are considered as preliminary data and an updated report will be submitted once all of the reports are received from the SCPs.
V. LIST OF NEXT QUARTER’S WORK PLAN
1. Expanded access/availability of high impact services and practices:
• Continue with selection procedures of the Sub-contracting partners (SCPs); o Select Performance Based Sub-contract partners o Receive USAID approval for subcontract awards o Award Performance Based Sub-contract to successful SCPs • Define Finance & Payment Flows (written procedures of Finance & Payment Flows); • Organize a second SCPs‘ orientation on the PBC process and financial procedures. • Develop document on Fully Functional Service Delivery Point (FFSDP) for Southern Sudan; • Conduct a workshop on FFSDP for SCPs • Conduct community-based activities that promote awareness and demand for all the elements of the seven high impact services. • Coordinate with MoH-GoSS for the supply of essential medicines and EPI supplies to the SHTP II focus counties and sites; • Issue PBC- RFP for Water and sanitation;
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• Review proposals and select a Subcontracting partner for the WASH Re-reimbursable, performance based subcontract. • Receive USAID approval for WASH subcontract award • Award WASH subcontract to the successful Offeror
2. Increased Southern Sudanese capability to deliver and manage services
Provide Capacity Building for Civil Society Organizations Collate, analyze, and disseminate information, methodologies, program and training materials to agencies working with civil society in southern Sudan With input from key stakeholders identity approach for working with CSOs (including eligablity, target geographical areas and reach, sector and ideal micro grant size); Develop CSO capacity assessment tools, building on materials already in use in southern Sudan, and field test in two counties of SHTP II implementation;
Provide Capacity Building for Village Health Committees Collate approaches and materials in use by Subcontracting Partners related to working with VHCs Conduct field assessments in three counties of implementation to verify level, issues and concerns with current VHC structure and approach seeking input from Subcontracting Partners, CHDs, and communities); Conduct meetings with MOH and Subcontracting Partners to discuss VHC priorities, approaches and methodologies; Develop VHC capacity assessment tools and conduct field test
Provide Capacity Building for County Health Departments Organize TWG of Sub-Contracting Partners on CHD capacity building; Collect and analyze materials and lessons learned from NGOs Conduct rapid assessment of CHD capacity; Standardize a basic package of materials and tools for working with CHDs (including job aids); Develop criteria for PBCs for supervision with CHD
3. Increased knowledge of and demand for services and healthy practices Work with key stakeholders (MOH, SCPs, CHDs, communities, CBOs) to identify appropriate communication channels for different behaviour results; Identify the target audience and SMART behavioural objectives to be achieved For each behavioural result determine specific approaches (BCC/community mobilization, what groups need to be involved as partners, specific training needs, materials to be developed, timeline, monitoring); Develop dissemination and scale up plan
4. Project Administration/Quality Assurance Complete recruitment procedures for the following positions: i. Two Primary Health Care Advisors ii. One Primary Health Care Associate iii. One Program Assistant iv. Two M&E Officers
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v. One Micro-grant Specialist
5. Monitoring & Evaluation
Complete M&E plan for SHTP II according to USAID recommendation Develop database within SHTP II office for collation and reporting data • Establish assessment teams for baseline survey (and for later use in PBC validation visits); • In collaboration with MoH-GoSS and the SCPs, review/update the current SHTP II data collection tools (in use) at the project sites to realign it with MOH newly produced tools including policies, guidelines and protocols; o Create list of all essential policies and protocols o Create a system to assure essential documents are distributed to the appropriate level • Train SHTP II and SCPs staff on the common tools, approaches and systems for managing and monitoring performance based sub-contracts. • Conduct joint field supportive supervision and mentoring to the SHTP II sites; • Conduct Monitoring and Evaluation training workshop for the successful SCPs; • Provide MOH and CHDs with copies of the SHTP II quarterly reports; and • Monitor and Evaluate subcontractors‘ performance against M&E indicators planned for the second quarter of FY 2010 • Develop counties and SDPs basic services profiles.
VI. PROJECT ADMINISTRATION
Post start-up
MSH has started operating a fully functional office at its base in Hai Jalaba near airport road with reliable internet services. In addition, the office is connected to the South Sudan electricity power and have installed a voltage regulator to control power surges and to automatically connect the office to generator power when the city power is down. Soon after, we received expendable inventory from JSI SHTP I project. Lastly, MSH has increased its visibility by posting several SHTP II signs near theoffice. Regarding procurements, three additional vehicles have been procured and are expected in Juba by October 28th. Additionally, MOH has offered us a rent free office within the ministry. We will move our program team to the ministry. However, MSH will complete the landscaping, plumbing and electrical repairs to make office ready for occupancy by November 30. Moving the program team to the ministry will ensure capacity building and closer collaboration with MOH.
Other
During this quarter 80% of the financial and administrative policies and procedures were completed. The remaining policies will be completed and staff trained in the next quarter.
Though we have reliable internet service, we will procure a dedicated VSAT line to improve communication between our two field offices and headquarter. However, we have been unable to achieve our radio network system. We are waiting for the UN to provide us with a ―call sign‖ from Khartoum. Apparently, the UN has depleted its supply of call signs and looking for options.
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VII. Constraints and Critical Issues
Personnel
As reported in our first quarterly report, identifying Sudanese with appropriate skill sets is still challenging. In addition, many Sudanese still remain outside Sudan living within the region, such as Kenya and Uganda. As elections next year looms and the referendum in 2011, we anticipate personnel constraints to continue. Nevertheless, we have 75% of our staff on board, and we are interviewing candidates for the remaining positions. We will be fully staffed by next quarter. In addition some of our implementing partners reported: shortage of health staff, unacceptability of non local staff, difficulty in working with MOH staff and poor living condition as finding housing for staff recruited from outside prove difficult in some project areas affecting staff retention among other reasons.
Operational Constraints:
Supplies
Delays in vaccine procurement threatened immunization coverage targets. Staff capacity to manage drug supplies Some sites such as Aweil South experienced stock out of drugs because of supply chain shortage. The lack of supply chain for spare parts resulted in the inability to repair broken hand pumps affecting linkages to improve water sources The drugs that were contributed by the State Ministry of Health got expired and most of the facilities threatened to run short of drugs in Mvolo County as half of ACT has been retrieved from facilities to be destroyed.
Inaccessibility
Inaccessibility of facility sites due to rains and lack of transport. It is also reported that rains led to crumbling of infrastructure and hence leading to functional inaccessibility.
Referral Issues
Transport challenges are inhibiting institutionalizing an effective referral system. Negative attitude of women towards delivering in health facilities affect referral of at-risk expectant women to facilities where they could receive appropriate obstetric emergency services.
Funding and disbursement
Some implementing partners reported delayed receipt of funds which affected smooth running of the program.
Security Issues Insecurity in Twic East, Jonglei State reached a peak in July when 14 community members we killed in cattle raids. Continued rains also threaten the ability of health staff to access communities
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In Tambura in the month of July insecurity led to a health unit being looted and set ablaze. Insecurity due to tribal conflict in Mvolo SHTP Catchment area prohibited access to certain roads and led to the closure of two facilities.
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ANNEX One: List of Deliverable Products
A. SEVEN HIGH IMPACT SERVICES
1. Child Health
i) DTP3 Coverage IMC in Tambura reported that, during the quarter 152 children less than 12 months received DPT3. The low DPT3 coverage was due to DPT vaccine stock out and insecurity leading to inaccessibility of the State capital where vaccines are collected from
Save the Children Kapoeata North: During this quarter, 336 children under 12 months were given DPT3. Initially, EPI activities continued to improve as the community became more aware of the recently opened health facilities; most EPI activities focused on promoting awareness and immunizations around Riwoto PHCC due to increased inaccessibility of some areas due to flooding. Later, it also increased because the turn up of mothers for immunization was for the LLITN distributions as well.
IMC in Malakal: During this quarter, 203 children less than 12 months received DPT3 compared to 306 in the last quarter.
IMC Juba: During this quarter, 707 134 children less than 12 months received DPT3. This is a significant improvement compared to 134 children last quarter. This is due to conducting an accelerated vaccination campaign in July of the same quarter and as well to the increase of vaccination days in some facilities – three times a week.
Save the Children Mvolo: During the reporting quarter, 452 children less than 12 months received DPT3 compared to 1503 in the last quarter. This relative low performance was due to the absence (with no replacement) of cold chain manager from work to sickness that lasted three weeks
CARE in Twic East reported 648 children less than 12 months received DPT3 compared to 1272 children during the previous quarter.
AAHI in Mundri: 713 children less than 12 months received DPT3. EPI services were affected by heavy rains and inaccessibility due to bad roads and damage to bridges.
IRC in Panyijar: 608 children less than 12 months received DPT3. This good performance is attributed to an increase in the number of vaccination days offered at the Primary Health Care Units which increased from two to three a week in September, as well as the outreach activities out of the PHCC in Ganyliel.
ACTION: Save the Children in Kapoeata North: to continue to educate the communities about the importance of vaccinations for both mothers and children. Save the Children in Mvolo/Wulu: to train two or more cold chain operators/managers per PHCC, so that EPI is never affected as it did during the quarter.
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Tearfund in Aweil South: Increased focus on immunization. Outreach services so as to enhance coverage of vaccination CARE in Twic East: Coordinate with UNICEF and Jonglei State MoH to improve on vaccines supply IMC in Tambura: Collect vaccines from Yambio and carry out EPI acceleration campaigns IMC Tambura: At the community level, continue to carry out community health promotion campaigns particularly so as to improve uptake of EPI, antenatal and maternity services.
2. Nutrition
Vitamin A Supplementation Save the Children in Kapoeata North reported 422 children under 5 years received Vitamin A supplementation. There is improvement in the coverage (compared to 136 last quarter) due to the increased number of mothers bringing their children to be vaccinated in conjunction with the mosquito net distribution
AAH in Mundri: during this reporting quarter, only 13 children under 5 years received vitamin A supplementation at the health facilities. This was due to vitamin A irregular and inadequate supply.
IRC in Panyijar: during this reporting quarter 1307 children under 5 years received vitamin A supplementation at the health facilities.
Save the Children in Mvolo reported 1078 children under 5 years received Vitamin A supplementation. There is relative decrease in the compared to 1881 for the quarter before; this was attributed to vitamin A stock out during July.
CARE in Twic East reported 1133 children under 5 years received Vitamin A supplements in their facilities.
In Aweil South, almost all children under five years were given vitamin A during the National Polio Immunization Days. The coverage of the NIDs is believed to have reached 90% of the children in the county. The actual coverage figures are yet to be verified by WHO.
ACTION:
AAHI in Mundri suggested the following corrective measure to increase Vitamin A coverage: to collect vitamin A regularly and in adequate amount from MOH. And as well as coordinate with the NIDs campaigns to avoid vitamin A overdoses and its toxic effects. MSH will collect the report of National Immunization Days (NIDs) that includes Vitamin A conducted in May in some of the SHTP II sites.
3. Maternal Health i) ANC Attendance Tearfund in Aweil South reported high attendance of 981 mothers at the antenatal clinics. They attributed this to mobilization and clients understanding of the importance of ANC.
CARE in Twic East reported 213 pregnant mothers attended their 3rd antenatal clinics.
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IMC Juba reported 208 for 1st ANC visit and 243 for 3rd and 4th ANC visit compared to 142 pregnant women attended the 3rd ANC. Midwives from the PHC facilities were withdrawn by the State MoH to assist in Yei hospital for a week after their staff had gone on strike .
AAHI and its Sudanese partner (MRDA) reported an increase in the first (647) and a decrease in the fourth (186) ANC visits compared to the last quarter 501 (1st ANC) and 197 (4th ANC). The wide difference between the 1st and 4th ANC was in part due to the late attendance of women for the first visit, during the last trimester of pregnancy. Inadequate number of MCHWs at the health facilities was another cause. Only 21 out of the 31 health facilities have MCHWs in place.
IMC in Malakal: reported 384 pregnant women attended 1st ANC care session and 155 4th ANC care session. Most of pregnant come late for ANC.
ACTION:
AAH in Mundri Counties suggests the following remedial action to increase the number of pregnant women attending ANC clinics: to deploy the trained and active TBAs in the health facilities as facility based TBAs and pay them, they‘ll also conduct deliveries at homes and record them; to continue advertising for the posts of CMWs; to select suitable candidates by the community and CHD for CMWs training (Long-term measure/investment); and to train one class of MCHWs to fill the current gap of the MCHWs - proposed together with training of CMWs as a long –term investment under SHTP II
ii) Assisted Delivery
Tearfund in Aweil South reported a relative increase in the number (313) of assisted deliveries conducted during the quarter compared to the number (290) during the last quarter. Long distances to the health units have been a drawback to mothers coming for delivery at the clinics. Lack of motivation to TBAs due to lack of items to support them has been a big challenge. Many of them have stopped following mothers and submitting reports
CARE - Twic East reported that, during the quarter, 378 assisted deliveries were conducted at either PHC facilities by trained health workers or by TBAs in the homes. Due to either limited or no qualified staff in the project area, most of the assisted deliveries still happen at home through the TBAs.
Save the Children in Kapoeata North- reported 25 assisted deliveries during the quarter. No single mother came back for Post natal visit. Convincing mothers to come back for post natal visit still remains a challenge as most of them are not aware about the importance of post natal care; However Save the Children is trying very hard with continuous health education at the health facilities aimed at convincing mothers about the importance of Post natal care.
Save the Children in Mvolo/Wulu- reported 267 assisted deliveries during the quarter. There is a relative decrease in the number of assisted deliveries due to the closure of 6 PHC facilities for some time during the quarter as a result of intertribal conflicts.
The majority of births in all counties are assisted by TBAs.
ACTION:
Save the Children in Kapoeata north: to roll-out postnatal care strategy, inclusive of a ToT training for key health staff and a comprehensive of health facility staff.
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4. Malaria i) Intermittent Presumptive Treatment for Pregnant Women (IPTp) CARE - Twic East reported 288 women received 2 doses of IPT. This was a decrease compared to the last quarter‘s 404 women who received 2 doses of IPT.
In Mundri Counties 299 pregnant women received 2 doses of IPT.
Tearfund reported a relative increase in the number of pregnant women (677) who received the 2nd dose of IPT compared to 521 last quarter.
ii) Long Lasting Insecticide Treated Nets (LLITN)
Tearfund in Aweil South reported no LLITNs distribution during the reporting quarter due to delayed delivery by Malaria Consortium. Last quarter Tearfund reported no availability of LLITNs in the project site. CARE – Twic East reported that with the facilitation from the County Health Department and CARE, 5,250 LLITNs were distributed by PSI carried in the County
Save the Children in Kapoeata North distributed 4459 LLITNs received from PSI during EPI and ANC sessions.
AAH in Mundri Counties reported the distribution of 3161 LLITNs to pregnant mothers and children under five years of age compared to 2,839 LLITNs distributed the quarter before iii) Commonly reported morbidities
In Aweil South, disease surveillance continued during the quarter with weekly reports submitted to MOH and partners. In Aweil South, Tearfund reports that, the quarter had a high number of malaria cases in the upward trend due to the onset of the rains. Mosquitoes have more breeding areas when there is a lot of stagnant water. Fortunately, there were no reports of acute watery diarrhea (AWD) after intensive health education and case management. CARE in Twic East reported that, the leading causes of morbidities in the area during the quarter were Malaria, respiratory infections, diarrhea diseases, skin diseases, and eye infections. The reasons could be attributed to the onset of rains in August 2009 that caused many disease cases but as the rains subsided in September 2009 the diseases reduced too. In addition to the above morbidities, trauma cases shot up in the month of August 2009 due to the casualties brought to the health facilities as a result of uncontrolled insecurity in the project area
ACTION:
Tearfund in Aweil South: Disease surveillance, will be strengthened and carried by all extension workers ,TBAs ,Boma health committee. IRC in Panyijar: to identify health staff and re-trained on appropriate responses to ensure there are enough staff available in case of excessive flooding. Already the rainy season is in full force, and the surrounding areas have experienced significant flooding, IRC has started to make contingency plans to respond to any upsurge of endemic illnesses and displacement. Essential items are now being re-stocked and include: Anti-malarial drugs, ORS, Para-checks, soap, IEC
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materials on diarrhea and malaria prevention as well as LLITNs (which are currently being distributed).
5. Family Planning (FP)
Tearfund – In Aweil South Family planning activities have still been restricted to awareness creation to address strong cultural issues regarding artificial methods of birth control. Most of these activities have been integrated in health and nutrition messages which stress the importance of birth spacing in child care. TBAs and the MCHWs have also been trained on birth control, but progress has been slow due to the need for cultural sensitivity and community empowerment. Both men and women will be targeted in the remaining project period to encourage the traditional method of child spacing which is still generally respected but not always practiced
CARE - In Twic East reported that, during the quarter family planning activities were incorporated in the ANC activities as well as part of the health education campaigns. Though with challenges, a spirit of understanding is building up among the community members who are continuously showing interest in acquiring more information on child spacing and family planning. Awareness talks on contraceptives and use of condoms are slowly picking up among most of the youth and middle aged groups especially the returnees.
Hygiene and Sanitation Practices
In Aweil South, Hygiene promotion messages have been passed with emphasis of burying stool, using safe water and washing hands. Regarding training in hygiene and sanitation practices, training at the village transformation process (VTP) was on-going including various topics on hygiene and prevention of diseases. There are 7 center-based trainings of health education volunteers in Tieraliet, Panthou and Ayai payams with an attendance of 1510 people as well as 704 youth. These have received training and are now followed up to support in motivating their neighbors to change their hygiene behaviors. In addition, 46 members of market committees are also receiving training on environmental sanitation and have come up with action plans for market cleaning schedules.
IRC in Panyijar reported that, during the quarter the water level in the lowlands of Panyijar County started to rise and flooding in most areas, and as part of IRC‘s contingency planning, together with the CHD, IRC has pre-positioned water treatment tablets in all health facilities. The health facility staff have been trained on how to instruct patients and individuals on appropriate use of the water treatment tablets and will focus health education discussions on water related diseases.
Prevention of HIV/AIDS
Tearfund in Aweil South: Awareness-raising is ongoing in villages through churches, health facilities and schools. Youth are a major target and a trained counselor is in charge of the village mobilization and training others on health education. People have been reached through community teachings and video shows. VCT/PMTCT is not yet established due to lack of facility and qualified staff. One counselor is trained and is carrying out awareness activities AAH in Mundri Counties reported that during the reporting period, VCT services were carried out in Mundri VCT Centers; in July, clients were counseled but not tested since the Test kits had expired. In August VCT services were not carried out because the Counselors had gone for a refresher course. Two other VCT center were not functional during the quarter. PMTCT services
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are only carried out in Mundri PHCC. Only two VCT counselors are trained on PMTCT according to national and international standards. During the reporting period, 8 pregnant women accessed PMTCT services, counseled, tested and given results; all were HIV negative. Some of the challenges facing the implementation of HIV/AIDS activities include in Mundri Counties include: Inadequate VCT test Kits, Lack of antiretroviral drugs (ARTs) to improve the quality of life among people living with HIV/AIDS, Inadequate number of VCT counselors, Inadequate PMTCT services, and Inadequate availability of IEC materials in the local languages.
IMC in Tambura County reported that during the reporting quarter, Antiretroviral therapy (ART) program was rolled out in July; patients started to receive antiretroviral drugs. During the last quarter (April – June), various health staff from all PHCCs were trained on the management of antiretroviral therapy (ART) in preparation for the role out of the ART program in Tambura.
Action:
IMC in Tambura: after the recent role out of ART program in Tambura County, HIV/AIDS service in Tambura will provide the community with all the essential components, a land mark achievement
A. Increase Southern Sudanese capacity, particularly women’s, to deliver and manage health services
1. Number of Sudanese health professionals recruited in counties targeted by USAID
IRC in Panyijar: recruited a new midwife who will be based at the PHCC in Ganyliel.
Tearfund in Aweil South had been able to retain almost all the staff they had sent to various training institutions. This has been badly affected by the uncertainty surrounding the funding and staff are opting to look for jobs in other counties. Those remaining have very low morale and motivation is correspondingly low.
CARE in Twic East County reported staff turnovers experienced during the quarter; some went for upgrading courses at various destinations and others moved to either the government or other organizations with better pay. A total of 14 community based staffs have been interviewed and those who qualified selected to replace the vacant positions. The areas left vacant included six vaccinators, one public health officer, one medical clerk four nurses and two community health workers.
Action:
CARE In Twic East: Fill all the vacant positions at the PHC facilities
2. Number of community-based health workers (CBHW) trained in USAID-supported programs
In Kapoeata North, Twenty (5 females and 15 males) health workers received training on rational drug use. Topics covered key causes underlying irrational use of drugs, impact of
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irrational use of drugs, roles and responsibilities of dispensers in promoting rational drug use and strategies to improve drug use.
In Twic East, a total of 32 CBHWs were trained in health facilities operation and management. 10 others attended a one day HIV/AIDS workshop held during the month of August 2009. During the two trainings, CHD team of two staffs attended the same trainings and assisted in emphasizing the need for intensive awareness programs in HIV/AIDS and other preventable diseases. The trainings were part of the planned refreshers for the purpose of updates as far as medical issues are concerned. IRC in Panyijar: to bolster clinical service provision, IRC engaged the services of a resident medical doctor, who worked closely with all the clinical staff, both at the inpatient facility, and at the outpatient section. In addition to providing clinical services, the doctor also spent a significant amount of last month training nurses and clinical officers on various aspects of quality of care services.
Action: CARE in Twic East: Complete conducting the necessary trainings planned at the beginning of the project period IRC in Panyijar: to allow all the health workers providing ANC services in IRC‘s facilities to rotate through the PHCC to work with the midwife for a two-week period. This will ensure she has one-on-one training opportunities with each of them. The training will include how to set up a proper ANC clinic and the services involved. It will also focus on nutrition best practices using the local foods available, both for the mother and the baby. All facilities will continue to supply clean delivery packs to all the women who come for antenatal care services during their 2nd trimester
3. Number of community health management committees (CHMCs) formed or trained in USAID-supported programs
In Aweil South 6 Boma Health Committees (BHCs) were formed and trained for each of the health facilities. Training has been conducted on supervision and management as well as community mobilization. However their participation on their functions remains a challenge as there is no ownership of the facilities.
The 15 CHMCs established were all trained during the month of August 2009. Each health facility was represented by a team of nine (9) members that constitutes the committee. In total 136 members were trained by dividing them into two groups. The topics covered included; village health management committee functions, creating an interest in health care, enforcement of health care rules, committee team work and other cross cutting themes like HIV/AIDS. Each committee developed a work plan meant to undertake initiatives in actively getting involved in the running of PHC facilities and health program as a whole within the county. See photo below showing the participants.
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Trainees during CMHC/VHC training, Twic East County
Save the Children in Kapoeata North: Village Health Committees were formed in all the villages where the health facilities are located.
IMC in Tambura: During the month CHMC/VHC members of 2 PHCCs (Tambura and Source Yubu ) and 6 PHCUs (Mboko, Sinakpuro, Bambu, Mabenge, Mangburu and Nzama ) attended a refresher training. The rest of the members of the remaining PHC facilities will be trained next month. A total 63 CHMC members benefited from the trainings. The CHMCs of Nagero, Kuro Diayanga, Duma, Mupoi, Marbia, Nangongo, Matotot, Akpa, Nabaria and Bakiringba were retrained and informed about their roles and responsibilities. The trainings were conducted by staff from both IMC the CHD. The CHMCs of these health units pledged to be more active in the execution of their duties in the future. A total of 75 members benefited from these trainings.
IMC in Malakal: 35 members of CHMC received training on Public health issues; topics included HIV/ AIDS, Nutrition, water and sanitation were discussed. The CHMC also discussed on how to collaborate effectively so that services improve at their sites
Actions:
Save the Children in Kapoeata North: next month to conduct trainings of VHC/BHC/CHMC on their roles and responsibilities. Ensure the CHMC members are active especially since they have just been given refresher trainings. IMC in Tambura: to complete the remaining refresher trainings for the CHMC teams of the units not yet covered and to continue to encourage CHMC and the community to be involved in the management of the health units.
4. Increased availability and improved management of supplies at health facilities
Tearfund in Aweil South reported that, during the quarter medicines were received from MoH. All the PHC facilities reported stock outs in ACT but the gap was closed by the ACT donated by USAID. Last quarter when a similar stock out of ACT occurred, an emergency stock from another Tearfund site in Aweil South temporarily saved the situation. IMC in Juba and Malakal, CARE in Twic East and AAH in Mundri Counties reported that, during the quarter stocks of drugs were maintained at an adequate level at all the facilities.
5. Provide support to existing health institutions (CHD) The CHD in Mundri Counties received stationery and logistical support, conducted a joint supportive supervision to some of the PHC facilities and participated in the development of the new SHTPII proposal
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IMC in Malakal facilitated for two CHD staff to attend a computer training; CHD received donated computers by IMC. CARE in Twic East reported that the CHD held an Annual Planning meeting facilitated by CARE SHTP II Project manager. The meeting consisted of 14 participants representing all the 15 PHC facilities and the County. The team produced a plan of activities, assessed existing gaps in health services delivery and generated recommendations that will roll out an implementation of measures that will help in filling the gaps within the system. The planning meeting was meant to introduce the CHD team to the initial stages of strategic thinking and planning and therefore empower them for effective management of health services in the county Tearfund appointed A Health Systems Officer to the Tearfund team in Aweil South; his role is to specifically focus on capacity building of the County Health Department. The Aweil South County Medical Officer of health (‗CMOH‘) was involved in a community meeting with the aim of improving community participation IMC in Juba supported the CHD in planning and supervision of acceleration vaccination campaign 7 CHD members were trained on how to use a computer and on Microsoft excel and word. It is anticipated that this will help CHD in the management of records as well as running of health activities in the County. The CHD were also trained on how to manage records. IMC Tambura reported that, during the quarter, a team from CHD were able to attend a state health coordination meeting. In addition a joint all sector coordination meeting was held for the first time in many years. This was possible as there has been an increase in the number of agencies operating in Tambura County. The issues discussed were from a broad range of areas including coordination and synchronisation of humanitarian activities, water and sanitation, health and issues related to the management of Tambura hospital. During the meeting, the CHD presented a summary of the last 6 months health data during the State health coordination meeting held in the past month In Tambura County, two CHD members attended computer training in word and excel. A monthly report was prepared by CHD and was submitted to the state MOH.
Action:
. IMC in Tambura plans to have health management training for CHD members in the next month. . IMC in Tambura to continue to provide support and on job training of the CHD team.
6. Local organization personnel capacity building: CARE in Twic East conducted a one day workshop on HIV/AIDS. It was attended by 40 participants from the Panyagor women group. The workshop was meant to impart knowledge and updates on HIV/AIDS and explore ways of utilizing the group in spreading awareness of the same. Topics discussed included: basic facts on HIV/AIDS, clinical features, disease prevention and control measures, risk factors for increased transmission in emergencies population movement and counselling and voluntary testing programs. The participants showed a lot of interest during the workshop and indicated that there are some suspected cases of HIV within the community. Below is a photo of the participants during the workshop
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Participants from a local women group in Twic East attending a workshop on HIV/AIDS conducted by CARE (Photo above)
B. Increased demand for primary health care services and practices availability and improved management of supplies at health facilities
1. Community behavior change strategies and appropriate materials used to increase demand for and access to preventative and treatment services
Tearfund in Aweil South reported that health and hygiene promotion was conducted through community groups that served as volunteer health promoters through a village transformation program. The volunteers receive TOT sessions and were expected to pass health messages and mobilize communities to improve their hygiene practices. Role plays as well as demonstrations were used in the training of the health volunteers during the village transformation program trainings/ meetings. Members of church groups, market committees, VTP members and BHCs were involved in the hygiene promotion activities. These have become resource people in the community and are carrying out disease surveillance, and health education. School children were targeted for peer influence through the child-to-child program. 27 teachers received training on health education and hygiene promotion and continue to give health messages in the schools.
Save the Children in Mvolo/Wulu conducted a workshop for 75 people (50 women and 25 men) The aim of the workshop was to increase knowledge and raise awareness about the health hazards that are being encountered by mothers during pregnancy and after delivery. The topics addressed included importance of ANC/PNC, effect of malaria on pregnant mothers and prevention, hygiene and exclusive breast feeding. The leaflets on malaria prevention were distributed to all to be taken home. The messages were given to people who attended the workshop to encourage pregnant mothers to attend the maternal health services at the facilities
CARE in Twic East reported a number of health education sessions conducted by 2 PHC facilities-based public officers and others for patients, clients or community members on preventive, promotive and curative intervention to many of the communicable diseases in the project site. IMC in Tambura: During the month a total of 1546 individuals were reached through health education sessions covering topics ranging from hygiene and sanitation to HIV/AIDS
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There were a total of 2554 health education sessions at health facilities and community settings. The majority of these sessions were in the community. Residents were educated on various topics including HIV/AIDS, how to keep the hand pump area clean, need for latrines and keeping the home environment clean and tidy. In health units members were educated on subjects like diarrhoea prevention and management, basic hygiene and use of LLITNs.
IMC in Malakal: reported that, CHMC/VHC conducted health education sessions in 4 sites. Topics covered included: Importance of EPI; Advantages of breast feeding, this was greatly encouraged as the health care workers/community prepared for world breast feed week; Hygiene: Hand washing; Promotion of ANC visits; HIV/AIDS awareness; and Advantages of using LLTN as one of the methods for malaria prevention
Action: Tearfund in Aweil South: to continue with the community health education activities in the county
Constraints and challenges encountered by the implementing partners
IMC in Tambura: Insecurity continued to be a big issue in the County; one PHCU (Ngogola) was attacked by LRA; as a result, drugs were looted and the PHCU was set ablaze. This incident led to displacement of people and affected health service delivery. IMC in Tambura: Heavy rains destroyed roads and rendered them sometimes impassible. There was an incident when Tambura was cut off from Yambio due to a truck that got stacked on Biki Bridge, blocking the supplies road. CARE in Twic East: There was insecurity that engulfed the area as a result of cattle rustling activities; it interrupted project activities with project staffs being evacuated for some time AAH in Mundri and CARE in Twic East: There was high turnover of health workers that interrupted the normal operations of health activities. AAH in Mundri and CARE in Twic East: Heavy rains rendered most of the project areas impassable. This has affected the roads movement
Save the Children in Kapoeata North: Low turn up of mothers for ANC, delivery and post natal sevices due to negative attitudes towards delivering in a health facilities, Save the Children with Continuous health education aimed at changing behavior of mothers
Save the Children in Kapoeata North: Shortage of drugs in the health facilities was a major factor affecting provision of health services to the community, this was mainly due to delay in the supply of drugs by the state (Eastern Equatoria State)
Save the Children in Mvolo/Wulu: Under staffing was a big challenge in most of the facilities.
Save the Children in Mvolo/Wulu: The drugs that were contributed by the State Ministry of Health got expired and most of the facilities will soon run short of drugs. Half of ACT has been collected back from facilities to be destroyed.
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SUCCESS STORY
Two PHC health workers /students successfully graduated and received diplomas in Public Health and Pharmcy through SHTP support
David Deng and Samuel Mathet are working in the SHTP II funded PHC facilities in Aweil South. Through SHTP funds, David got trained and obtained a diploma in Public health, from Institute of Health Management, Nairobi and Samuel Mathet got trained and obtained a pharmacy assistant diploma from the same institution.
In a community meeting where questions and concerns regarding rehabilitation, development and sustainability issues were raised, Samuel said, we requested Tearfund to sponsor us for Public Health and Pharmacy training course such that we can serve our people in a professional manner. We wanted to change the bad practice of our people buying medicines from local petty traders who totally lack knowledge on proper drug utilization and of changing the harmful health practices. Tearfund respected our request and sent us to Nairobi to attend the relevant trainings.
Now after graduation, Deng and Mathet said ―We have the capacity to handle our discipline area professionally‖. We will share our knowledge by offering skilled services to improve the health status of our community. ―No one can take away the knowledge and skills we have acquired
Though both of us are still young, but because of the knowledge we have acquired, we now among the most respected members of the community. The community members (including the chiefs and elders) in Panthou Payam, Aweil South feel comfortable to share their views with and concerns freely with us. We are very glad and don‘t have enough words to express our appreciation to Tearfund and SHTP for making us productive citizens and for opening our eyes, and indeed the eyes of our community.
Samuel Mathet and David Deng show their diplomas after successfully graduating from Pharmacy Technology and Public Health Technology. (Photo above)
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ANNEX TWO: ASSESSMENT REPORTS
I. Aweil South County
Characteristics of the county
1. Identification and background information Aweil South County is located in Northern Bahr el-Ghazal State, Southern Sudan. Malek Alel is the county administrative centre, and it is still in the process of being established. There are 2 airstrips in the county, one at Malek Alel and another at Tieraliet. Malek Alel is also linked by a recently upgraded all-season road to Aweil town, one of the major towns in Southern Sudan and the capital of Northern Bahr el-Ghazal State.
2. Administrative divisions and population Aweil South County is divided into 8 Payams, namely, Tieraliet Payam, Nyeth Payam, Ayai Payam, Wathmuok Payam, Gakrol Payam, Panthou Payam, Nyoic Awany Payam, and Tar Weng Payam. The current population of the county is not known, but based on WHO and NIDS estimates in 2002 the population of the county was 232,878 people. Payam population figures are not available; neither the County Authority nor Tear Fund could produce any estimates.
3. Health Facility Information The health care system of Aweil South County is composed of 7 functional PHC facilities: 1 PHCC and 6 PHCUs. Six (6) of these facilities are located outside Malek Alel town at unspecified distances from the town. No facility in the county is made up of all permanent buildings. The 2 facilities seen consisting of some permanent buildings (Panthou and Tieraliet) also have some semi-permanent and temporary buildings badly in need of renovation. Similarly, it was reported that all those facility structures indicated as having temporary structures are in a poor state. This statement was confirmed at two facilities (Nyeth and Malek Alel) that were visited. Sudan Church of Christ (SCC) is currently constructing a permanent facility in Malek Alel as replacement for the worn out temporary buildings and it is reported that this will form the nucleus of the future Aweil South County Hospital. All facilities assessed have no waiting area good enough to protect patients from the elements and ensure their comfort. Patients generally sit around in the open waiting for their turn to be served, and where there is a grass-thatched shelter this is often dilapidated and has no seating facilities such as mats or benches. Tear Fund maintains and repairs permanent health structures, and supports the community to maintain and repair temporary health structures.
A total of 6 facilities (1 PHCC and 5 PHCUs) are supported by Tear Fund (the lead agency in the county for Sudan Health Transformation Project—Phase I (SHTP I)), with government (GOSS/State) being responsible for supplies and the salaries of some staff. All functional facilities use a borehole as the source of safe water, and have a pit latrine. The pit latrine at Tieraliet PHCU is kept clean. However, the pit latrine at Panthou PHCC is badly kept, and at Nyeth PHCU a new one is still being constructed because the old one got filled up and was closed—perhaps an encouraging sign that people are adopting the habit of using a pit latrine.
No PHC facility in Aweil South County is currently staffed according to the BPHS recommendations. As shown in Figure 1, the majority (>60%) of the manpower engaged at health service delivery points are support staff (cold chain supervisors, EPI supervisors, vaccinators, dressers, dispensers, cleaners, and guards). Among the technical staff, the vast majority are community health workers (CHWs).
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Figure 1. Manpower categories at PHC service delivery points, Aweil South County, July 2009
25%
20%
15%
10%
5%
0%
CO AN LT CHW CCS EPIS VAC DRS DISP REG CLN GRD MCHW A/CCS A/MCHW
Key: PHC: Primary Health Care CO: Clinical Officer AN: Auxiliary Nurse CHW: Community Health Worker MCHW: Mother and Child Health Care Worker A/MCHW: Assistant Mother and Child Health Care Worker LT: Laboratory Technician CCS: Cold Chain Supervisor A/CCS: Assistant Cold Chain Supervisor EPIS: EPI Supervisor VAC: Vaccinator DRS: Dresser DISP: Dispenser REG: Registrar (clerk) CLN: Cleaner GRD: Guard
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Table 1: PHC Facilities in Aweil South County
No. Staffing Location MOH per Borehole Structure Pit latrinePit guidelines Distance from Malek Alel town Supporting Agency Name of facilityPHC
1 Panthou Panthou Permanent building housing TF NK Yes Yes No. Current staffing is 1 CO, 2 PHCC consultations, pharmacy/dispensing, SHTP II Auxiliary nurses, 6 CHWs, laboratory, ANC, and EPI; permanent MOH 2 MCHWs, 2 MCHW Assistants, 1 paediatric ward; temporary male and Registrar/dresser, 1 Dresser, 2 female wards; temporary maternity Laboratory assistants, 2 Pharmacy building assistants, 2 Cleaners, 2 Guards 2 Tieraliet Tieraliet Permanent building housing TF NK Yes Yes No. Staff include 2 CHWs, PHCU consultations, EPI, and SHTP II 1 MCHW, 1 Cold Chain Assistant, 1 pharmacy/dispensing; permanent ward MOH Dispenser, for children (nutrition); temporary 3 Vaccinators, 3 Guards, building for ANC 1 Cleaner. 3 Nyeth PHCU Nyeth Temporary buildings: consultations, TF NK Yes Yes No. Staff consist of 3 CHWs, pharmacy/dispensing, food store, and SHTP II 1 Dispenser, 2 Guards, waiting area. MOH 1 Cleaner 4 Wathmuok Wathmuok Temporary TF NK Yes Yes No. Staff include 2 CHWs, PHCU SHTP II 1 Dispenser, 1 Vaccinator, MOH 2 Guards, 1 Cleaner 5 Ayai PHCU Ayai Temporary TF NK Yes Yes No. Staff include 2 CHWs, SHTP II 1 Dispenser, 2 Guards, MOH 1 Cleaner 6 Wuncum Gakrol Permanent TF Yes Yes No. Staff are 2 CHWs, 1 Dispenser, 2 PHCU SHTP II Guards, 1 Cleaner MOH 7 Malek Alel Nyoic Temporary at present, but a permanent SCC In- Yes Yes No. Staff at present are PHCU structure (2 wards and MOH town 3 CHWs, 1 Dispenser, and pharmacy/dispensing, consultations, 2 TBAs laboratory, and dressing/injections rooms, and a waiting area) is under construction and will be gradually developed into Aweil South County
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Hospital. 8 Makuei Tar Weng Temporary MOH NK No Yes Construction of the facility has just PHCU been completed by the community, 9 Pankwat Tar Weng Temporary MOH NK Yes Yes but MOH is yet to deploy staff PHCU
Key: CHW: Community Health Worker CO: Clinical Officer MCHW: Mother and Child Health Worker MOH: Government of Southern Sudan (GOSS)/Northern Bahr el-Ghazal State Ministry of Health NK: Not known PHCC: Primary Health Care Centre PHCU: Primary Health Care Unit SCC: Sudan Church of Christ SHTP I: Sudan Health Transformation Project—Phase I TBA: Traditional Birth Attendants TF: Tear Fund
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4. CBOs and NGOs operating in the county Sudan Church of Christ is the only local organization active in the health sector is Aweil South County. It supports a PHCU in Malek Alel town. There are no community-based organizations (CBOs) in Tonj South County. A women group is said to be in the process of being formed yet. Tear Fund, the sole international NGO operating in the health sector in Aweil South County is responsible for primary health care, nutrition, and food security. World Vision International also supports food security by feeding schools.
Of UN agencies, FAO operates in food security and animal health, while IOM is engaged in school construction and social welfare.
5. General health problems and seasonality According to County Health Department (CHD) officials, the main health problems in the county are acute watery diarrhea/cholera (July-November), malaria, acute respiratory infections, intestinal parasites, and sexually transmitted infections (STIs). There has been an outbreak of acute watery diarrhea in the county recently. Of these health problems, malaria is the main one that follows a seasonal pattern, with the number of cases increasing dramatically during the rainy season (June-November).
6. Information on County Health Department Aweil South County Health Department (CHD) is very small, weak, poorly supported, and lacking in competence. Tear Fund, the leading agency in the health sector in the county, certainly regards the CHD with contempt and hold the CHD members in very low esteem. In turn, the CHD accuse Tear Fund of not adequately supporting the department and of unwillingness to make a deliberate effort to build the capacity of the department. The CHD is composed of just 2 full-time members, County Medical Officer (CMO) and Administration and Finance Officer, and 2 acting members—Disease Surveillance Officer and EPI Supervisor (a vaccinator). The CMO is a nurse by profession, while the administrator is a CHW. The CMO received training in finance and administration and human resources management under SHTP I in Juba. The CHD is housed in a recently installed small 2-room prefabricated container—too hot to work in during the hot season—and it has no storage space. The county cold chain hub is therefore located at Panthou PHCC. The CHD has no means of transport or access to a computer.
It is reported that there are limited HIV/AIDS activities in the county. These consist of only BCC activities. However, although HIV/AIDS is not yet a serious health problem in the county the risk of infection is said to be high, and the youth are considered to be at high risk of infection. The CHD believes that there is need to educate and occupy the youth, and deploy a focal person for HIV/AIDS activities in order to minimize the risk of acquiring an HIV infection.
There are limited BCC activities for malaria control in the county. According to information from the CHD, long- lasting insecticide treated nets (LLITNs) have just been distributed in the whole county. Malaria is serious problem, affecting everyone, especially children under 5 years of age and pregnant women.
It is believed that about half of pregnant women do not utilize antenatal (ANC) services in the county. Of those who utilize ANC services, most drop out after the first visit. ANC services are weak and not widely available close to where women live. It is reported that malaria, STIs, abortion, stillbirth, and anaemia are the main health problems associated with pregnancy. Most deliveries take place at home/in the village. Women practice only the natural method of birth spacing—some breastfeed for more than a year.
Infectious diseases, especially vaccine-preventable diseases of childhood, and malnutrition are the main child health problems. Low EPI coverage and insufficient number of PHC facilities (and their inappropriate staff complement) are at the root of child health problems. Tear Fund has a nutrition project targeting the nutritional needs of children and malnutrition, but the technical aspects of the management of childhood malnutrition are not rigorously implemented. Sadly, a health worker at Tieraliet PHCU simply filled in an imaginary weight on the weight monitoring chart of a malnourished child; he did not weigh the child because there were not pants to weigh the child in. At Panthou PHCC there is a separate room for child health care, where Integrated Essential Child Health Care (IECHC) activities are carried out. These activities were, however, not observed as the assessment team arrived there in the afternoon when there were no patients already.
It is reported by both the CHD and Tear Fund that most people fetch drinking water directly from a river or a pond that is also used at the same time for bathing and by cattle. Few families use the chlorine tablet (WaterGuard) for
45 making drinking water safe. Tear Fund has recently deployed a WASH Project Officer to deal with water, sanitation, and hygiene matters in the county.
Aweil South County falls in the meningitis belt and experiences outbreaks of meningococcal meningitis, in addition to diarrhoeal disease, severe floods (July-October), drought, and famine (currently already in progress). The county relies on a joint effort of the CHD and partner organizations, especially Tear Fund, to provide health care and ensure food security during disasters. There are early warning and response network (EWARN) activities in the county.
Reportedly, every PHC facility in Aweil South County is supported by a Village Health Committee (VHC), comprising at least 15 members. Some VHCs are headed by a woman, and all committees have a large women representation. VHCs mobilize their respective communities to build/maintain temporary health facility structure, disseminate health messages in community, and assist relief efforts during emergencies.
Service Provision Assessment
1. Facility Identification Panthou PHCC, Tieraliet PHCU, Nyeth PHCU and Malek Alel PHCU were visited during the assessment. The following sections are a synthesis of observations made at these PHC facilities. It is believed that the synthesis serves as a representative illustration of health services provision in the county in general.
2. Information about Services All facilities are open 5 days (Monday-Friday) a week. Some members of staff live on the premises of the facility or nearby and are available 24 hours and 7 days a week in case of emergencies. This is certainly the case at Panthou, Tieraliet, and Nyeth, where staff residences were either on the premises of the facility or just nearby. However, a duty schedule showing the organization of staff could not be observed in any facility.
Tieraliet PHCU does admit patients, especially children, for overnight observation at the nutrition ward. Panthou PHCC has a bed capacity of 30 beds and does admit in-patients for treatment as well as for overnight observation. Both facilities do admit malnourished children for treatment and rehabilitation. The admission facility at Malek Alel PHCU was dangerously filthy. Panthou PHCC runs EPI outreach/mobile clinics to 7 sites (facilities) in the county on specified days every week. Support supervision by Tear Fund staff is unsystematic; there is no supervision schedule. Although Tear Fund has developed a supervisory checklist, completed copies of the tool could not be found at the facilities. Moreover, no supervisor from outside ever came to supervise any facility in the county. A referral form is reportedly used when a patient is referred, but this was not observed. No facility has as yet a constant source of power. The cold chain centre at Panthou PHCC uses kerosene refrigerators; however, the facility has a generator waiting to be connected. Waste disposal at Panthou PHCC, Tieraliet PHCU, and Nyeth PHCU is done using a drum incinerator—fenced off only at Panthou PHCC. Generally, sharps are separated in a sharps box but the full sharps boxes are incinerated together with other health-care waste in the drum incinerator. The facilities supported by Tear Fund are generally clean. Waste disposal at Malek Alel PHCU, however, is appallingly poor. All waste, including sharps (mainly used hypodermic needles), is dumped in a very shallow open pit on the compound of the facility and infrequently burnt, thus posing great danger to the public, especially children who regularly come to pass time playing there in the evenings.
Communication is achieved by use of mobile (mounted on vehicles) and base radio system. Panthou PHCC is connected to Tear Fund base by a base radio just across the road from the centre. Communication with Aweil town and other parts of the world, however, is only possible by means of a Satellite phone. There is no active mobile telephone network in the area. Public transport is available between Aweil town and Malek Alel town. Tear Fund vehicles also double as ambulances for emergency transportation for patients within the county and to other locations, like Aweil town in the case of referrals.
2a. Vaccine Logistical System The vaccine logistical system is based at Panthou PHCC. It uses Kerosene refrigerators. Tieraliet PHCU also has a kerosene refrigerator for keeping vaccines. All refrigerators observed are protected from direct sunlight and have a cold chain temperature monitoring chart displayed, and this is completed twice daily each day of the past 30 days. In case of a breakdown of the kerosene refrigerators, fridges at Tear Fund compound could serve as back-up. Other PHC facilities have no provision for storing vaccines; vaccinators have to collect vaccines from the base in vaccine carriers and used them at these facilities (outreach clinics). Stock cards for vaccines were said to
46 be used, but these were not observed. However, the county had experienced stock-outs of various vaccines at different times. The last supply of routine vaccines was received within the previous 4 weeks. Required vaccine quantities are determined by Tear Fund staff, but sometimes the exact quantities required were not delivered. There are more than 2 vaccine carriers with more than 2 ice packs each. Single-use and auto-destruct syringes are reportedly used.
2b. Child Health Services PHC facilities in Aweil South County do provide services for children under the age of 5 years on every working day at the facility. The child health services most commonly provided are consultations for the sick child, routine immunization, and BCG immunization. Routine immunization was not in session on the day of the assessment visit, but it is reported that all vaccines are offered. According to the staff, the following items are available during child immunization sessions: sharps box, BCG syringes, 2 ml or 3 ml syringes, auto-destruct syringes, waste receptacle with lid, soap and water for washing hands provided in a bucket with tap.
The catchment population of any PHC facility in Aweil South County has not been determined. Thus, there is no estimate of the target population for child immunizations in the catchment area of any facility. Similarly, DPT dropout rate or measles vaccine coverage cannot be calculated.
There are infant scales, child scales, clinical thermometers, and timers in use at the facilities visited. These were verified at Panthou PHCC and Tieraliet PHCU, although as mentioned earlier there were no pants for the hanging child scale.
Curative child health services are probably the most widely provided of all child health care services.
3. Family Planning Services No family planning services are provided in the facilities assessed, or indeed at any other facility. It is said that these services are almost taboo in the county.
4. Antenatal and postpartum care Antenatal (ANC) services are reportedly provided at nearly all PHC facilities. Of the facilities visited, MCHWs were only available for interview at Panthou PHCC. They reported that ANC services were provided for 5 days a week at the PHCC. However, the services were not being provided during the day of the assessment. It was reported that clients (pregnant mothers) routinely are weighed, have their blood pressure taken, and receive group health education. Blood tests for anaemia and syphilis or urine test for protein are not performed at ANC due to lack of reagents. Women receive tetanus toxoid during immunization days and they are given preventive antimalarial medication. It is unlikely that counseling about family planning or HIV/AIDS is carried out at any facility. When asked if they counseled women about family planning, the MCHWs said the women would not listen. Pregnant women found to have an STI are referred to OPD for treatment. There are no proper ANC registers used, but the MCHWs at Panthou PHCC estimated that they saw over 1,000 new ANC visits and nearly the same number of deliveries in the previous 12 months. However, they did not know the number of all ANC visits in the previous 12 months. The ANC section at Panthou PHCC had all equipment including blood pressure apparatus, stethoscope, Pinard fetal stethoscope, clinical thermometer, infant scale, vaginal speculum, and adult weighing scale. There are no guidelines or protocols for ANC or syndromic management. The educational material available at the facilities was a Health and Hygiene Education Flipchart developed by Tear Fund for Southern Sudan. Two TBAs are attached to Panthou PHCC; they refer and accompany women to the facility and stay with them. Tear Fund vehicles are the main means of transport for emergency cases referred to Aweil Civil Hospital or Wau Teaching Hospital. Within the county, however, the women just walk to the facility or they are carried by their relatives.
5. Delivery and newborn care Delivery and newborn care is provided at Panthou PHCC. There are 2 beds in maternity ward and a delivery bed in the delivery room. An MCHW is available to provide delivery services 24 hours. However, no duty schedule was observed. No fees are charged for ANC services, but women are advised to bring along clothes for the baby and sanitary pads, but often present without these requirements. The official MOH registers for ANC and deliveries have not yet been introduced in the county. On the delivery tray there was soap, blade, umbilical tie, ergometrine tablets, decontaminant, IV fluid and infusion set, clean gloves, and cotton wool, but no ergometrine injection, sutures, or dissecting forceps. Rooming-in is normal practice, but vitamin A is not routinely provided to mothers before they are discharged. There is no review of maternal or newborn deaths. There is no newborn resuscitation equipment and no facility is equipped to handle assisted deliveries. Similarly, there is no vacuum
47 aspirator or dilatation and curettage (D&C) kit to assist extraction of retained products of conception. It is reported that the MCHWs are able to conduct manual removal of the placenta, but this has never been performed at the facility. The nearest facilities capable of performing a caesarian section, blood transfusion, vacuum aspiration of retained products of conception, or assisted vaginal delivery are in either Aweil or Wau. Aweil South County Health Department is incapable of providing support supervision for maternal services at the PHC facilities.
6. Sexually transmitted infections (STIs) Services for sexually transmitted infections (STIs) are offered free of charge through general out-patient services on every working day. The syndromic approach to diagnosis is used, but the PHC facility staff have never received training on the approach. It is claimed that partner notification is performed and that sometimes active follow-up is carried out, but this is probably not a routine activity. Even Panthou PHCC does not keep a register for STI consultations and no reports are submitted by the county to the AIDS Commission of Southern Sudan. No counseling is offered. No laboratory tests are performed for STI tests.
II. Tonj South County
A. Characteristics of the county
1. Identification and background information Tonj South County is located in Warrap State, Southern Sudan. Tonj is the main urban centre, serving as the county administrative headquarters. Another urban centre in the county is Thiet. There is an airstrip in Tonj town. The county is also linked to Wau and Rumbek towns and other parts of Sudan by road. Zain is the only mobile telephone network active in Tonj town.
2. Administrative divisions and population Tonj South County is divided into 5 Payams, namely, Tonj Payam, Thiet Payam, Wathalel Payam, Manyangok Payam, and Jak Payam. The population of the county is not known, and population figures for Payams were not available.
3. Health Facility Information The health system of Tonj South County consists of 11 PHC facilities: 1 PHCC and 10 PHCUs and Clinics. Nine (9) of these facilities are located outside Tonj town at a distance ranging from 8 to 64 km. Six of the facilities are permanent structures (buildings), while 5 are temporary structures of grass-thatched roof and walls of wattle and mud. Eight (8) facilities are supported by Sudan Health Transformation Project—Phase I (SHTP I) through World Vision International (WVI), with government (MOH) being responsible for medical supplies. All facilities use borehole as the source of safe water, except Safe Harbour Clinic which has a broken down borehole. Out of the 11 PHC facilities, 4 have a pit latrine, 6 (5 of them supported by WVI/SHTP I) have no pit latrine, while it is not known if Kuanja PHCU has or does not have a pit latrine. Among the facilities supported by WVI, none is staffed according to the BPHS recommendations. According to the latest version of the BPHS, all facilities are understaffed.
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Table 1: PHC Facilities in Tonj South County
No. facility Agency Staffing Location MOH per Borehole Structure Pit latrinePit Tonj town guidelines Supporting Name of PHC Distance from
1 Thiet PHCC Thiet Permanent buildings, consisting of 1 WVI 42 km Yes Yes No. Staff include 1 clinical officer, consultations room, ANC block (1 ANC SHTP I 1 nurse, 1 health visitor, 1 nurse- room, 1 labour room, and 1 delivery room), MOH midwife, 1 medical store, 1 dispensing room, EPI 3 CHWs, 1 certificated nurse, 2 hall, 1 laboratory room, and 1 ward in laboratory assistant, 1 addition to a new building that is going to dispenser/store keeper, 1 serve as a nutrition centre volunteer clerk, 4 TBAs, 5 vaccinators, 3 guards, 2 cleaners 2 Malual Muok Malual Temporary WVI 19 km Yes No No. Staff made up of PHCU Muok SHTP I 1 CHW, 1 TBA, 1 guard, and 1 MOH cleaner. 3 Mabior Yar Mabior Yar Temporary building of grass-thatched roof WVI 29 km Yes Yes No. Staff consist of 1 nurse, 1 PHCU and wattle and mud walls. SHTP I guard, 1 cleaner, MOH 3 volunteer TBAs. 4 Panak Dit Panak Dit Temporary WVI 53 km Yes No No. Staff made up of PHCU SHTP I 1 CHW, 1 TBA, 1 guard, and 1 MOH cleaner. 5 Jak PHCU Jak Permanent WVI 64 km Yes No No. Staff made up of SHTP I 1 CHW, 1 TBA, 1 guard, and 1 MOH cleaner. 6 Manyiel Manyiel Temporary WVI 38 km Yes No No. Staff made up of Thon PHCU Thon SHTP I 1 CHW, 1 TBA, 1 guard, and 1 MOH cleaner. 7 Aguko PHCU Aguko Permanent WVI 42 km Yes No No. Staff made up of SHTP I 1 CHW, 1 TBA, 1 guard, and 1 MOH cleaner. 8 Wanalel Wanalel Permanent WVI 32 km Yes Yes No. Staff made up of PHCU SHTP I 1 CHW, 1 TBA, 1 guard, and 1 MOH cleaner. 9 Don Bosco Tonj Permanent DOR In-town Yes Yes No Clinic
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10 Safe Harbour Tonj Permanent Safe In-town No No No Clinic Harbour 11 Kuanja Clinic Kuanja Temporary DOR 8km Yes NK No
Key: CHW: Community Health Worker CO: Clinical Officer DOR: Catholic Diocese of Rumbek MA: Medical Assistant MOH: Government of Southern Sudan (GOSS)/Warrap State Ministry of Health NK: Not known PHCC: Primary Health Care Centre PHCU: Primary Health Care Unit SHTP I: Sudan Health Transformation Project—Phase I TBA: Traditional Birth Attendants WVI: World Vision International
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4. CBOs and NGOs operating in the county The Catholic Diocese of Rumbek (DOR) and Arkangelo Ali Association (AAA) are the only local organizations active in the health sector is Tonj South County. The former supports Don Bosco Clinic, while the latter is responsible for TB and leprosy control in the county (based at Don Bosco Clinic). It was reported that there are no community-based organizations (CBOs) in Tonj South County.
World Food Programme (WFP) is engaged in food security in the ccunty; it channels supplies through WVI. Of international non-governmental organizations (NGOs), only WVI and Safe Harbour operate in the county.
5. General health problems and seasonality The top 8 causes of morbidity in the county are malaria, trauma (from inter-ethnic clashes), acute respiratory tract infections (ARI), urinary tract infections (UTI), diarrhoeal disease, TB and leprosy. Malaria follows a seasonal pattern, with the number of cases increasing during the rainy season. It is worth mentioning that trauma has assumed significance in recent times as a result of inter-ethic violence and cattle rustling in the area.
6. Information on County Health Department Tonj South County Health Department (CHD) is very small and extremely weak. It is composed of just the County Medical Officer (CMO) and a volunteer EPI supervisor. The CMO is a Medical Assistant by profession. He received training in finance and administration and human resources management under SHTP I. The current WVI SHTP Officer (he has been in the post for only one month) is keen to work with the CHD. The CHD has no office space, storage space (warehouse), means of transport or a computer. WVI is currently constructing premises for the CHD. Meanwhile, the CMO works at Tonj South County Hospital, which is currently undergoing extensive renovation or he works from his home. The county cold chain hub is located in Thiet town.
There are no HIV/AIDS activities in the county. The CMO has no clear idea about the HIV/AIDS problem. There are limited BCC activities for malaria and long-lasting insecticide treated nets have been distributed. Malaria is a serious problem, affecting everyone, especially children under 5 years of age and pregnant women.
It is reported that the majority of women do not utilize antenatal (ANC) services. Of those who utilize ANC services, most drop out after the first visit. ANC services are weak and poorly organized. Consequently, most deliveries take place at home/in the village. Women practice only the natural method of birth spacing— breastfeeding for more that a year.
Infectious diseases and malnutrition are the main child health problems. EPI has been poorly delivered in the county. However, WVI has a child health project that targets the nutritional needs of children and malnutrition. Neither Integrated Management of Childhood Illnesses (IMCI) nor Integrated Essential Child Health Care (IECHC) activities are consistently anywhere in Tonj South County.
According to WVI officials, most people fetch drinking water directly from the river (believed to be the reason for cholera outbreak in 2008). No means of making drinking water safe is practiced in the county on a significant scale. The chlorine tablet (WaterGuard) is not used widely. Health educators are reportedly trained and deployed at PHC facilities to promote hygiene. However, public hygiene campaigns have not been organized since 2008 (WVI no longer has funds for hygiene promotion activities).
Tonj South County is prone to outbreaks of meningococcal meningitis, cholera, floods, famine, forcible displacement, and drought. The county has also suffered from repeated bouts of inter-ethnic violence. Famine is currently in progress as a result of poor rains. The county relies on the services of NGOs, especially WVI, to provide health care during disasters. There are no early warning and response network (EWARN) activities in the county. A meeting to discuss EWARN was only held recently.
The communities in Tonj South County are responsible for the construction and maintenance of temporary health facility structures, with WVI support. WVI is responsible for the construction, maintenance and repair of permanent health structures. In terms of health services management, the participation of the communities is limited. It is reported that only 2 PHCUs (Panak Dit and Aguko) have village health committees (VHC). Women are virtually not involved in the management of health services.
B. Service Provision Assessment
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1. Facility Identification Thiet PHCC and Mabior Yar PHCU were visited during the assessment. A synthesis of the health service provision at these facilities is provided in the subsequent sections as an illustration of health services provision in the county in general.
2. Information about Services Thiet PHCC and Mabior Yar PHCU are open 5 days (Monday-Friday) a week. Some member of staff lives on the premises of the facility or nearby and is available 24 hours in case of emergencies. One of the CHWs at Thiet PHCC lives close to the facility and is available to provide services outside working hours and days. However, there is no duty schedule.
The catchment population of any PHC facility in Tonj South County has not been determined.
Thiet PHCC has a bed capacity of 11 beds and does admit in-patients for treatment or overnight observation. There is only one ward and all kinds of illness, women and men, and children are all admitted there. The ward is not organized and the linen is not kept clean. The facility runs EPI outreach/mobile clinics to 15 sites. No supervisor from outside ever came to visit the facility. No official referral form is used. Patients are referred with their medical records/notes. No facility has a source of power, but the cold chain centre in Thiet is equipped with a generator. Waste disposal at Thiet PHCC is poor. A fenced-off incinerator is full to overflowing with unburned waste, including sharps, soiled gauze, etc. Although the incinerator can be tidied up and made useful again, this did not appear to be an option under consideration. Instead a shallow pit has been dug next to the incinerator and is currently being used for disposing (burning) all sorts of waste. An improvised drum incinerator is used at Mabior Yar PHCU. Generally, sharps other than vaccination needles are not segregated from the rest of health-care waste. Apart from the poor management of waste, the facility premises are generally clean.
A long verandah at Thiet PHCC serves as a waiting area for patients. At Mabior Yar PHCU, there is no waiting space. There is no means of communication used by any PHC facility in the county. Similarly, apart from WVI vehicles, there is no ambulance or vehicle for emergency transportation. Patients are never picked from home/village in the case of an emergency. Often relatives of the patient make their own transport arrangements in the event of a referral. Tonj town is linked to Rumbek and Wau towns by public transport.
2a. Vaccine Logistical System The vaccine logistical system for Tonj South County is based in Thiet town in a building separate from the PHCC premises. Vaccines are collected from this base in vaccine carriers and used at the PHCC or at outreach sites. No PHC facility has a provision for storing vaccines. Child vaccination resumed in the county in September 2008; the service had been interrupted for 19 months. Vaccination activity has since been on and off depending on availability of vaccines. It was not possible to inspect the vaccines centre during the assessment; the person with the keys was not immediately available. Stock-outs of tetanus toxoid and DPT were reported. The vaccine quantities required are not determined by any facility, so sometimes the amount of vaccines needed was never received. There are more than 2 vaccine carriers, with 2 or more ice packs. Single-use and auto-destruct syringes are reportedly used during immunization sessions at the facilities and at outreach sites. The last routine supply of vaccines was 4 weeks prior to the assessment.
2b. Child Health Services Thiet PHCC and Mabior Yar PHCU do provide services for children under the age of 5 years. These are provided on every working day. The child health services provided are consultations for the sick child, routine immunization (offered on Wednesdays and Thursdays at Thiet PHCC and during outreach at Mabior Yar PHCU), and BCG immunization. Routine immunization was not in session during the assessment visit. All vaccines are offered during sessions and outreach. The following items for child immunization are available at Thiet PHCC: sharps box, BCG syringes, auto-destruct syringes, waste receptacle without lid, and reportedly water for washing hands provided in a bucket or basin on immunization days. There is no estimate of the target population for child immunizations in any facility catchment area. There is no estimate for DPT dropout rate or measles vaccine coverage. The only piece of equipment appropriate for child health care present in the consultations room in Thiet PHCC was a clinical thermometer. There was no infant scale, child scale or timer. These items were also not available at Mabior Yar PHCU. Curative child health services were available at Thiet PHCC during the day of assessment.
3. Family Planning Services
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No family planning services are provided in the facilities assessed, or indeed at any other facility.
4. Antenatal and postpartum care Reportedly, antenatal (ANC) services are provided at nearly all PHC facilities. At Thiet PHCC, ANC services are provided for 5 days a week and the services were being provided during the day of the assessment. However, the services are not optimal. Clients were not weighed and they did not have their blood pressure taken. It was claimed that group health education was carried out but this was not observed during the assessment. No laboratory tests are performed at ANC due to lack of reagents. Tetanus toxoid is administered during immunization days. Pregnant women receive intermittent preventive treatment (IPT) for malaria. Counseling about HIV/AIDS is not carried out. Women with STIs are referred to OPD for treatment. The staff did not know the number of new ANC visits or all ANC visits in the previous 12 months because the health visitor and the midwife have been recently deployed to Thiet PHCC and record keeping has just been started. The only pieces of equipment at the ANC room were Pinard fetal stethoscopes, clinical thermometers, and a blood pressure apparatus but there was no stethoscope. No any appropriate guidelines or educational materials were available at either Thiet PHCC or Mabior Yar PHCU. Four and 3 TBAs are attached to Thiet PHCC and Mabior Yar PHCU respectively. They refer and accompany women to the facilities. The most common means of transport for referrals outside Tonj are private vehicles procured by relatives. WVI vehicles sometimes transport emergency cases to Wau Teaching Hospital. Within the county, the women just walk to the facility or they are carried by their relatives using improvised stretchers.
5. Delivery and newborn care The staff interviewed at Thiet PHCC reported providing delivery and newborn care at either facility. However, on inspection there were no any delivery or newborn care facilities. At Thiet PHCC, there was a labour room and a delivery room, but there were no beds or delivery couch. Many members of staff live within reach of the PHCC and could provide delivery services 24 hours. However, there was no evidence of any formal arrangement to provide the service around the clock. No fees are charged for any services, but women are advised to bring along clothes for the baby. However, most women need assistance even for this basic requirement. Vitamin A is not provided for mothers who have delivered. Thiet PHCC now uses official MOH registers for ANC and deliveries. On the day of assessment, only clean gloves were available on the delivery tray. There is no newborn resuscitation equipment in the county and the capacity to handle assisted deliveries does not exist. It is doubtful if the capacity exists to manually extract retained products of conception. There is no manual vacuum extractor or dilatation and curettage (D&C) kit. There is no review of maternal or newborn deaths. The nearest facilities capable of performing a caesarian section or blood transfusion are in Wau and Rumbek.
6. Sexually transmitted infections (STIs) Services for sexually transmitted infections (STIs) are offered every working day through general out-patient services. The services are offered free of charge. Reportedly, the syndromic approach to diagnosis is used, but no PHC facility staff have ever received training on the approach. It is claimed that partner notification is performed and that sometimes active follow-up is carried out. There is no register for STI consultations and no reports are submitted to the AIDS Commission of Southern Sudan. No counseling is offered. Condoms are available, but it is said that they are only used by individuals who have lived in refuge and by foreigners. No laboratory tests are performed for STI tests. There are no appropriate educational materials at the facilities visit
III. Wau County
Characteristics of the County
1. Identification and background information Wau County is located in the Western Bahr el-Ghazal State (WBEGS) of Southern Sudan. Wau town is the main urban centre in the State, and serves both as the county administrative headquarters and the capital of Western Bahr el-Ghazal State. Wau town has an airport and is also linked to other parts of Sudan by a network of roads. The town is also the southernmost terminal of Sudan railways, but the terminal is now defunct. Wau is also connected with the rest of the world by mobile phone services, namely, Sudani, MTN, Gemtel, Zain, and Vivacel.
2. Administrative divisions and population
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Wau County has a population of 151,420 people (Census 2008). The county is divided up into five Payams. Table 1 below shows the distribution of the population of the county by Payam:
Table 1: Payams and population of Wau County
No. Payam Population 1 Wau North (Northern part of the town) 47,198 2 Wau South (Southern part of the town) 65,073 3 Besselia 12,304 4 Baggari 23,901 5 Bazia (Kpaile) 2,944 Total 151,420
Wau County is playing host to a transiting population or internally displaced persons (IDPs). Their exact numbers are not specified but it was reported that an estimated 5,000 IDPs from neighbouring Tonj South County may be living in Wau County.
3. Health Facilities in Wau County Wau County has a total of about 33 PHC facilities: 16 PHCCs and 17 PHCUs. It is reported that the Western Bahr el-Ghazal State Minister of Health has recently designated new PHC facilities in Wau County, but these facilities are not covered by this report. Table 2 shows 17 PHC facilities—9 PHCCs and 8 PHCUs—which are included in the assessment. Table 3 shows 16 PHC functional facilities which are not included in this assessment.
Of the facilities assessed, 7 are located in the two Payams of Wau town (Wau North and Wau South), while the remaining facilities are in rural areas. Six (6) facilities are made up of permanent buildings in good condition, 2 are permanent buildings but now in dire need of renovation, 6 are semi-permanent buildings (including prefabricated buildings), while 3 are shacks and need replacement with more durable structures.
Eight (8) of the PHC facilities assessed are supported by GOSS and Western Bahr el-Ghazal State Ministry of Health (MOH) alone, 4 were supported by Sudan Health Transformation Project—Phase I (SHTP I) and by MOH, 3 are supported by Sudanese Red Crescent Society (SRCS)/Danish Red Cross (DRC) and MOH, while 2 are Catholic Church PHC facilities supported by SHTP I, MOH and a number of undisclosed Church donors.
Fifteen (15) PHC facilities have an accessible borehole as a source of water; 2 facilities have no source of safe water on the premises or nearby. Eleven (11) facilities have a pit latrine, while 6 facilities have none.
No PHC facility assessed has the appropriate staff complement recommended by the BPHS for its level. While Erneo wien Dut PHCC seems to be overstaffed, the main problem is understaffing.
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Table 2: PHC Facilities in Wau County
No. ency Name Staffing Location MOH per Borehole Structure Pit latrinePit Wau townWau guidelines SupportingAg Distance from 1 Mukta‘a Hai Zande Permanent building, complete with required rooms MOH In-town Yes Yes No. PHCC and components: 2 consultations rooms, 1 nurses room, 1 store, 1 dispensing room, 2 wards, 1 labour room, 1 delivery room, 1 laboratory, 1 EPI room, etc, and perimeter fence 2 Hai Dinka Hai Dinka 2 Semi-permanent buildings: 1 used as SHTP I In-town No Yes No. It has 1 medical PHCC consultations and dispensing room, the other MOH assistant, 4 midwives, 4 used as ANC and store building. A makeshift certificated nurses, 1 shelter serves as a registration, waiting and EPI vaccinator, 2 cleaners, 1 area. The buildings were residential houses, now guard. used to accommodate the PHCC temporarily. The PHCC is enclosed by a temporary perimeter fence 3 Erneo wien Daraja A PHCC made up of permanent and prefabricated Church In-town Yes Yes No. Staff include 2 part-time Dut PHCC buildings. It consists of rooms for consultations, SHTP I doctors, 2 medical ANC, Child health care, laboratory, medical store MOH assistants, 4 midwives, 6 and dispensary, EPI, and TB treatment, but no certificated nurses, 1 wards and delivery room. laboratory assistants, 2 pharmacy assistants, 3 vaccinators, 1 registrar, and 1 guard. 4 Bazia Jadid Hai Bazia 1 semi-permanent (prefabricated) building, SHTP I In-town No Yes No. Staff consist of 1 PHCC Jedid containing an ANC room, 1 consultations room, 1 MOH medical assistant, 7 dispensing room, 1 store, and 1 delivery/maternity midwives, 4 certificated room (ward). A separate room serves as nurses, 1 laboratory laboratory. An external makeshift shelter serves assistant, 2 vaccinators, 3 as registration, waiting, EPI area. There is a cleaners, and 2 guards. perimeter fence. 5 Jebel Jebel Kheir Semi-permanent buildings in poor state of repair. Church In-town Yes Yes No. Staff consist of 1 Kheir PHCC Consists of 1 consultations room, 1 SHTP I medical assistant, 4 store/dispensing room, 1 laboratory room, and an MOH midwives, 4 certificated area for EPI. A temporary house, now disused, nurses, 1 laboratory serves as the ANC centre. No perimeter fence. assistant, 1 vaccinator, 1 cleaner, and 1 guard. 6 Lokoloko Lokoloko Semi-permanent building in a very bad state of SHTP I In-town Yes Yes No. Staff made up of 2
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PHCC repair, rented from a community member. It MOH medical assistants (1 retired consists of 1 consultations/store/dispensing room, but still serving), 7 1 laboratory room, and 1 laboratory room (unused midwives, 2 certificated because there is no laboratory assistant). No nurses, 1 vaccinator, 2 perimeter fence. cleaners, and 2 guards. 7 Besselia Besselia Permanent buildings. Main building consists of 1 SRCS 37 km Yes Yes No. Staff made up of 1 PHCC consultations/dispensing room, 1 store, and 1 DRC medical assistant, 2 ward. A separate building will serve as laboratory. MOH midwives, 1 certificated Another building serves as maternity centre, with nurse, 1 nurse-under- ANC hall, labour room, and office space. There is training, 1 cleaner, and 1 a perimeter fence. guard. 8 Ngodakala Baggari Permanent buildings. Main building consists of 1 SRCS 26 km Yes Yes No. Staff is made up of 1 PHCC consultations/dispensing room, 1 store, and 1 DRC certificated nurse, 1 nurse- ward. A separate building will serve as laboratory. MOH midwife, 2 CHWs, 1 cleaner, Another building serves as maternity centre, with and 1 guard. ANC hall, labour room, and office space. There is a perimeter fence 9 Farajala Baggari A very old semi-permanent building in a poor MOH 29 km Yes No No. There is only 1 PHCC state. The building consists of 2 room and a certificated nurse serving verandah, but only 1 room is used for there. registration/consultations/storage/dispensing, while the verandah serves as waiting area. No perimeter fence. 10 Hai Bafra Hai Bafra Semi-permanent (unbaked bricks and metal SHTP I In-town Yes Yes No. Staff consist of 2 (Kalvario) sheet) building constructed by the community. It MOH certificated nurses and 1 PHCU consists of 1 consultations room, 1 ANC room, cleaner. and 1 store. A temporary shelter serves as EPI, registration, and waiting area. It is enclosed in a temporary perimeter fence. 11 Abu Shaka Besselia Permanent building with the roof blown off by MOH 20 km Yes Yes No. Staff consist of 1 PHCU storm more than a year ago and having no doors certificated nurse and 2 and windows. PHCU now operates in a single- midwives. room permanent building which serves as registration/consultations/medical store/school food store/dispensing room. No fence. 12 Kabi PHCU Besselia An old temporary building in a very poor state. It MOH 29 km No No No. Staff consist of 1 consists of 2 rooms, one serving as certificated nurse and 1 registration/consultations/store/dispensing hroom, TBA. while the other is the examination room. 13 Ngomkpa Besselia Temporary building, with the roof blown off by MOH 37 km Yes No No. Staff made up of 1 PHCU wind. PHCU now operates in a shack made of certificated nurse, 1 wood, grass and pieces of cardboard. No midwife, 1 cleaner, 1 guard, perimeter fence. and 1 volunteer (yet to be
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trained as CHW). 14 Ngisa PHCU Baggari A permanent, in poor state and needing MOH 27 km Yes No No. Staff made up of only 1 renovation. Consists of 2 rooms, one used as certificated nurse. registration/consultation/store/dispensing room, while the other is disused with no door and windows. 15 Mboro PHCU Mboro Permanent building in good condition, consisting MOH 45 km Yes No No. Staff consist of 1 of a verandah used a registration/waiting area, a certificated nurse, 4 large room serving as midwives, 1 cleaner, and 1 consultations/store/dispensing/ANC room, and a guard. small room intended to be a store room but currently not used appropriately. 16 Ndaku Mboro A single-room temporary house, serving as a MOH 27 km Yes No No. Staff made up only 1 PHCU store room. Registration, waiting, consultations, CHW. dispensing, etc. all happen under an adjacent mango tree. 17 Bringi PHCU Bringi Permanent building, consisting of 1 SRCS 10 km Yes Yes No. Staff made up of 1 consultations/dispensing room, 1 store, 1 EPI DRC certificated nurse, 1 CHW, 1 room, a verandah serving as a registration and MOH MCHW, 1 guard, and 1 waiting area . Another permanent building serves cleaner. as maternity centre, with ANC room, labour room, and office space.
Table 3. PHC Facilities in Wau County not included in the assessment
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No. from Name gency Staffing Location Distance MOH per Borehole Structure Pit latrinePit Wau townWau guidelines SupportingA
1 Baggari PHCC Baggari Temporary MOH 19 km Yes ------2 Grindi PHCU Grindi Permanent SPLA, MOH In-town Yes Yes No 3 Police PHCC Islag Permanent POLICE, MOH In-town ------4 Hai Jaw PHCC ---- Permanent MOH In-town ------5 Agok PHCC Agok Permanent MOH 8 km Yes ------6 Bussere PHCC Bussere Semi-permanent MOH 14 km Yes ------7 Bazia PHCC Bazia Permanent SRCS/DRC, MOH 77 km ------8 Canning Factory PHCU Semi-permanent MOH In-town ------9 Wau Prison PHCU Prison Permanent PRISON, MOH In-town Yes Yes No 10 Momoi PHCU Temporary MOH 10 km No No No 11 Rihan Fai PHCU Temporary MOH ------12 Khorgana PHCU Permanent, 1 room and MOH 86 km ------verandah 13 Taban PHCU Permanent MOH ------14 Gitan PHCU Permanent MOH ------15 Maju PHCU Temporary MOH ------16 Ngaku PHCU Semi-permanent MOH 10 km ------
Key (Table 2 and 3): DRC: Danish Red Cross MOH: Government of Southern Sudan (GOSS)/Western Bahr el-Ghazal State Ministry of Health. SHTP I: Sudan Health Transformation Project – Phase I SPLA: Sudan People‘s Liberation Army SRCS: Sudanese Red Crescent Society
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4. Community-based organizations (CBOs) and non-governmental organizations (NGOs) A number of local and community-based organizations (CBOs) and local organizations operate in Wau County. These are:
Catholic Diocese of Wau: Supports 2 PHCCs in Wau Town, supplementary feeding for children and pregnant women, and TB treatment.
Da’awa Islamia: Operates a PHCC in Wau town.
Women Training and Promotion (WTAP): Women health awareness in all Payams.
Women Development Group (WDG): Women and health, and GBV in all Payams.
Unity and Culture Development Centre (UCDC): HIV/AIDS awareness in all Payams.
The UN agencies supporting health activities in Wau County are UNICEF (EPI), WHO (polio), And WFP (Food Security). UNICEF also funds the Rural Water Corporation in Wau County to provide water and sanitation services. Of international NGOs, the following are active in Wau County:
Population Services International (PSI): Malaria control (social marketing of insecticide treated nets), water purification (social marketing of WaterGuard) in Wau town, and social marketing of condom.
ACTED: Provides Water, Sanitation, and Hygiene (WASH) services in all Payams.
Sudanese Red Crescent Society (SRCS)/Danish Red Cross (DRC): Support 3 PHCCs and 1 PHCU in three Payams in Wau County.
5. General Health Problems and their Seasonality The top 8 causes of morbidity in Wau County in 2008 were reportedly: malaria, diarrhoeal diseases, injuries, sexually transmitted infections, onchocerciasis, tuberculosis, guinea worm, and leprosy. Of these, malaria shows the most seasonal variation, increasing with the beginning of rains in April and reaching a peak during July-September before dropping off again.
6. Wau County Health Department The County Health Department was formed in November 2008. It is composed of 7 full-time members and one co-opted member. See Table 3 below for the composition of Wau County Health Department. However, the composition of the CHD does not correspond to the recommendations of the BPHS, except for the post of County Medical Officer and Pharmacy technician/assistant. The final draft of the BPHS proposes 8 members for the County Health Department, namely, 1 County Medical Officer, 1 Disease Surveillance Officer, 1 M&E Officer, 1 County Nursing Officer, 1 Nutrition Officer, 1 Pharmacy Technician/Assistant, and 2 Support Staff.
Table 3: Composition of Wau County Health Department
No. Name Post Cadre Training 1 Peter County Medical Officer Clinical Officer Administration and Finance, Nicola HR Management, MOH Registers, Pharmaceutical Management 2 Zachariah Assistant County Nurse Administration and Finance, Alexander Medical Officer of Health HR Management, MOH
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Registers, Pharmaceutical Management 3 Philip Administration and Accountant Administration and Finance, Juma Finance Officer HR Management, MOH Registers, Pharmaceutical Management 4 Joseph Pharmaceutical Assistant Administration and Finance, Nasir Services Officer Pharmacist HR Management, MOH Registers, Pharmaceutical Management 5 Catherine Environmental Public Health Administration and Finance, Peter Health Officer Technician HR Management, MOH Registers, Pharmaceutical Management 6 Regina Reproductive Health Visitor Administration and Finance, Pasquale Health Officer (Nurse/midwife) HR Management, MOH Registers, Pharmaceutical Management 7 Severino EPI Officer Nurse None Gaetano 8 Lydia Co-opted Assistant Assistant HR Management, MOH Natale Pharmaceutical Pharmacist, Registers, Pharmaceutical Services Officer Nurse Management
The County Health Department is located within the PHC buildings, adjacent to Wau Teaching Hospital. It occupies 2 fully furnished office spaces (rooms) in good general condition. There is no storage room for use by the CHD. A PHC meeting hall currently serves as the store for the CHD. The CHD has 2 motor bikes, manufactured in the year 2007, both in good condition. The office is equipped with 2 desktop computers and a printer, all in good working condition.
There is no Cold Chain hub for Wau County per se, but the Cold Chain hub for Western Bahr el- Ghazal State is located in Wau town. Vaccinators attached to the various PHC facilities in Wau town collect vaccines daily from the hub. PHC facilities outside the town are served by outreach missions from the hub. A medical warehouse for Greater Bahr el-Ghazal (Western Bahr el-Ghazal, Northern Bahr el-Ghazal, and Warrap States) is in the process of being constructed just outside Wau town.
HIV/AIDS control activities in Wau County consist of awareness campaigns and a VCT centre and ARV programme located at Wau Teaching Hospital. The HIV/AIDS problem in Wau County is described as very serious and affects mostly those under the age of 40 years. To address the problem, State officials believe that more VCT centres (at PHCC level) and intensive awareness campaigns are needed.
There is a department for malaria control under the State PHC directorate. Half-hearted malaria control campaigns (BCC) are carried out sometimes. Other malaria control measures applied in the county include LLITN distribution, and case management. The malaria problem is very serious, albeit seasonal. Malaria affects mainly children under the age of 5 years and pregnant mothers. To control malaria, continued BCC is needed as are distribution of LLITN especially just before the rains. Stocking of antimalarial drugs to cope with the inevitable increase in malaria caseload during the rainy season is absolutely important.
Antenatal care (ANC) services are weak across Wau County. Most pregnant women do not attend ANC because the service simply does not exist in the majority of PHC facilities close to where the women live. According to county officials many pregnancies are associated with anaemia, bleeding, malaria and nutrition problems. Nevertheless, the majority of pregnant women deliver at home in the village. Bazia Jedid PHCC is the only PHC facility in Wau town that provides delivery services. Wau Teaching Hospital provides delivery services on a larger scale, but it is not accessible to most pregnant women. Of the facilities visited in the rural areas, Besselia and Ngodakala PHCCs provide delivery services, but the midwives there report low utilization. Furthermore, the only modern method of family planning available in the county is the condom. However, it is not yet widely used. Lack of awareness may be one reason why most couples do not adopt any modern family planning method. It
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is worth mentioning though that many mothers practice natural birth spacing by breastfeeding for over a year.
Similarly, there are many problems related to child health in Wau County. Infectious diseases (including vaccine-preventable diseases) and malnutrition are the main causes of morbidity among children. There are no organized child health care services. EPI coverage is believed to be low. Child feeding practices are poorly understood. Only health workers from 6 PHC facilities in Wau town have received training on the Integrated Management of Childhood Illnesses (IMCI), but its application is still weak. Integrated Essential Child Health Care (IECH) is not implemented in Wau County.
The main source of water for the majority of people in Wau County is still river water. Most families do not use any means of rendering drinking water safe. The chlorine tablet (WaterGuard) is not popular. When offered the tablet, it is reported that some people dismiss it as a waste of time and decline to take it. There is no evidence of hygiene promotion activities either among the general public or at health facilities. Hand-washing facilities are never available close to pit latrines or in the consultations rooms at the PHC facilities that were visited.
Wau County is prone to outbreaks of meningococcal meningitis. WHO is responsible for coordination of the control of an outbreak in the State. There is an active surveillance network and an early warning system in operation.
There are no village health committees (VHCs) in Wau County. The communities are not involved in health services management in a systematic manner, although they are often mobilized by their leaders to construct and maintain temporary PHC facilities.
Service Provision Assessment
1. Facility Identification This report is a synthesis of information obtained from 9 PHCCs and 8 PHCUs in Wau County, Western Bahr el-Ghazal State. No PHC facility in Wau has a Waypoint name as facility mapping was not attempted during this or previous assessments in Wau County
2. Information about Services All facilities are open 5 days (Monday-Friday) a week for general outpatient services. PHC facilities in Wau town have no arrangements to cater for emergencies at all times (24 hours); no one is on call. All emergencies are expected to present to Wau Teaching Hospital. The rural PHC facilities have limited capacity to deal with medical emergencies. The staffing of each facility assessed is shown in Table 2 above.
There is no information about the catchment population of each PHC facility.
Bazia Jedid PHCC, Erneo wien Dut PHCC, Besselia PHCC, Ngodakala PHCC, and Mukta‘a PHCC do admit patients for overnight observation. Besselia PHCC does admit inpatiens for treatment. The number of beds per facility range from 1 bed to 10 beds. No facility in Wau County carries out any outreach/mobile clinics/services.
Supervision capacity is still weak in the county. As a result, no facility receives any support supervision either from the County Health Department (CHD) or the State MOH. The CHD members have not received any training on supervision.
There is no official referral form in use in the county. Referred patients are sent with their medical records. Hai Dinka PHCC sometimes uses a referral form it inherited from the International Committee of the Red Cross (ICRC) which used to run the facility.
Mukhta‘a and Erneo wien Dut PHCCs are connected to Wau town electricity grid. Mboro PHCU and facilities supported by SRCS/DRC are equipped with solar panels in working condition. In Mboro, however, the solar batteries have been dead for 2 years.
Only Erneo wien Dut PHCC has an incinerator for disposing health care waste. All other facilities burn their waste in a pit. Sharps are disposed in a similar manner, by burning.
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Erneo wien Dut, Hai Dinka, and Bazia Jedid PHCCs have a waiting area for patients, albeit temporary at the latter 2 PHCCs. At Mboro PHCU, Besselia PHCC, Ngodakala PHCC, and Bringi PHCU patients wait in the verandah. There is no waiting space at the other facilities.
Perhaps facilities belonging to the Church or those supported by SRCS/DRC have a programme for routine maintenance and repair of the infrastructure, and they (Church and NGOs) are responsible for maintenance and repair. However, all other permanent health facilities have no such plans and it is not clear who is responsible for maintenance and repair. The State MOH does not have the resources to undertake routine maintenance and repair work. Temporary health structures are built, maintained and repaired by the community.
There is no official means of communication used by any PHC facility in Wau County. No PHC facility has an ambulance or vehicle for emergency transportation for clients. No arrangements exist either for financing emergency referrals—the relatives of the referred patient largely make their own transport arrangements. Patients are never picked from their homes or villages during an emergency.
2a. Vaccine Logistical System Only Erneo wien Dut PHCC stores vaccines using a cold box. Vaccinators from other facilities in the town daily collect their vaccines in vaccine carriers directly from the Cold Chain hub in the town. All rural PHC facilities rely on outreach services from the hub for routine vaccinations. Although all vaccines are always available at the hub, many facilities have been unable to deliver routine immunization on a daily basis. All solar refrigerators at Bringi PHCU, Mboro PHCU, Besselia PHCC, and Ngodakala PHCC are dysfunctional either because the solar batteries are dead or the refrigerator itself is faulty. There is no solar fridge technician in Wau County or anywhere in the State.
2b. Child Health Services All facilities provide some services for children below 5 years of age during all working days. The commonest child health service provided across the county is consultation for a sick child. Systematic growth monitoring for all children under the age of 5 years is virtually non-existent. Routine immunization is erratic at the rural facilities. Only PHCCs in the town provide routine immunization daily. Where routine immunization is delivered, the following items are available: sharps box, BCG syringes, 2 ml or 3 ml syringes, auto-destruct syringes, waste receptacle, soap and water for hand washing. Water is often provided in a bucket with a tap. No facility has an estimate for the target population for childhood immunization, DPT or pentavalent dropout rate, or measles coverage. In terms of equipment, only 1 PHCC has an infant scale, 5 facilities have a child scale, all PHCCs have a clinical thermometer, no facility has a timer and few health workers have a watch with a second hand. PHCUs virtually lack any equipment for child care.
3. Family Planning Services Family planning services are hardly provided in any facility. The only modern method of contraception is the condom. However, the condom is not widely used, and hardly used by couples for contraception. No visual aids for teaching family planning, model for demonstrating the use of condom, posters, or registers were seen during the assessment. There is no full-time family health provider at any PHC facility in Wau County.
4. Antenatal and postpartum care ANC services are generally available 1-2 days a week at those facilities where these services are provided. Routine services provided reportedly include weighing, taking blood pressure, and group health education. Reagents for blood (Hb), blood (syphilis), and urine tests are not available across the county. Tetanus toxoid is only provided on immunization days, intermittent presumptive treatment (IPT) for malaria is provided on every ANC day, as is counseling about family planning and about HIV/AIDS. STIs are referred to out-patient services. ANC records covering the previous 12 months are not available. All facilities are inconsistently equipped for effective ANC, with different facilities having different combinations of the following items: blood pressure apparatus, stethoscope, fetal stethoscope, clinical thermometer, infant scale, and adult weighing scale. No facility has any vaginal speculum. Similarly, there are no any ANC guidelines, teaching aids or educational materials. None of the facilities admitted to a formal relationship with traditional birth attendants (TBAs). Most pregnant women just walk to the facility or they are carried by their relatives during an emergency.
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5. Delivery and newborn care Delivery and limited newborn care are provided at Besselia, Bazia Jedid, and Ngodakala PHCCs only. The number of maternity beds at these PHCCs range from 1 to 5. However, delivery coverage is not provided 24 hours; no one is on call 24 hours. Delivery is provided free of charge, but women are expected to bring clothes for the baby. Bazia Jedid and Besselia PHCCs now use GOSS/MOH registers for attended births. The following items were observed in the delivery tray: soap, scissors/blade, umbilical tie, oral ergometrine, decontaminant, i.v. fluids, gloves, and cotton wool. Newborn resuscitation equipment is generally absent in the county. There are no guidelines for delivery and emergency obstetric care, wall charts on resuscitation of newborn, or partographs. Rooming-in is normal practice, but vitamin A is not provided to mothers before discharge. There are no reviews of maternal or newborn deaths. All PHC facilities are incapable of handling assisted deliveries, and rarely is there anyone able to extract retained products of conception. There is no vacuum extractor or dilatation and curettage (D&C) kit. No PHC facility is capable of conducting blood transfusion. There is no blood bank, even at Wau Teaching Hospital. Only administration of parenteral antibiotics was ever performed by any PHC facility in the last 3 months. The County Reproductive Health Officer visits the PHC facilities in the town at least once a month.
6. Sexually transmitted infections (STIs) Some services for STI clients are reportedly offered by all PHC facilities through general out-patient on every working day free of charge. Diagnosis of STIs is by syndromic approach. All PHCC in- charges received training on the syndromic management of STIs in April 2009. However, STI services are generally not organized. Appropriate registers are not used, no reports are submitted to the AIDS Commission, there is no privacy for STI clients, and laboratory tests are never performed for STIs in any PHC facility due to lack of reagents. Voluntary Counseling and Testing (VCT) for HIV is non- existent at PHC facilities.
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