2012 Esri International User Conference - Paper for Presentation UC641 Improving Food Security and Empowerment with SSHiNE GIS Seth Wiafe1*, Diane Garcia-Gonzales1, Stephen Amoako2 , Sonya Funna2 , Idrissa Kamara2 , Karla Barrow-Harding1 , Molly Krans1 1 Loma Linda University School of Public Health 2 Adventist Relief and Development Agency (ADRA) International *Corresponding Author Correspondence: Seth A Wiafe, Loma Linda University School of Public Health 24951 North Circle Drive, Nichol Hall 1206, Loma Linda, California 92350, Tel: (909) 558-7596 , Fax. (909) 558 –0493, Email: [email protected] 1 Abstract The South Sudan Health, Nutrition, and Empowerment Geographic Information Systems (SSHiNE GIS) was developed as an online mapping application that integrates information about health facilities, food distribution, infrastructure, and socioeconomic data. The goal of this system is to improve the health and nutrition of women and children under five years of age within the states of Northern Bahr-el-Ghazal and Warrap in South Sudan. As part of the multidisciplinary approach to develop SSHiNE GIS, a comprehensive health facility assessment (HFA) was conducted combining survey data with latitude and longitude coordinates for each identified health facility. Data was analyzed for spatial patterns and results revealed an uneven distribution of health facilities across the region. Majority of health facilities reported high volumes of children diagnosed with malaria, however, less than 40% reported the distribution of insecticide treated bed nets. This paper will describe the methodology and challenges in developing SSHiNE GIS web services and discuss the outcome of the project. Key Words: South Sudan Health, Nutrition, and Empowerment (SSHiNE) Geographic Information Systems (GIS), Health Facility Assessment 2 Introduction Decades of unstable government rule and internal conflict have prevented the establishment of basic resources including an effective health care system in South Sudan. As a result, the South Sudanese people have experienced some of the worst health outcomes in the world (Country Cooperation Strategy for WHO and Sudan, 2009). In addition, many unstable areas lack sustainable food and water resources thus increasing vulnerability to malnutrition. In 2006, a Sudan Household Health Survey conducted by the Ministry of Health (MoH) and the Central Bureau of Statistics (CBS) found a neonatal mortality rate of 52.4 per 1,000 live births, an infant mortality rate of 102.4 per 1,000 live infants, and an under-five mortality rate of 135.3 per 1,000 children; rates approximately 20% higher than northern Sudan statistics (Sudan Household Health Survey, 2006). Furthermore, northern and southern Sudan, as a whole, suffers from a maternal mortality rate of 1,107 deaths per 100,000 live births. However, rates in several South Sudan states (i.e. Northern Bahr-el-Ghazal and Warrap) are over twice this rate with more than 2,000 maternal deaths per 100,000 live births (Sudan Household Health Survey, 2006). A 2004 UNICEF report stated that a girl born in Southern Sudan has a better chance of dying in pregnancy or childbirth than completing primary school (Kimanzi, 2004). In 2006, a MoH report (as cited in United States Agency for International Development [USAID], 2007, p. 32) identified 691 health care facilities throughout Southern Sudan. A 2008 report from United States Agency for International Development (USAID) estimated 750 – 800 functional health facilities within the same area (USAID, 2008). Although the actual number of health facilities may vary by source, there is a general consensus that most facilities are usually inadequately staffed, lack proper supplies, and depend highly on the assistance of non-government organizations (NGOs) to function. Furthermore, according to USAID, only 25 – 30% of the Southern Sudanese population has even minimal access to available healthcare services (USAID, 2008). Inadequate and unequally 3 distributed health care facilities contribute to the continuing cycle of high morbidity and mortality among the population. Unfortunately, efforts to provide underrepresented areas with basic health services have been thwarted by continuing tribal violence and northern hostility. For example, a 2011 attack by the Murle against the Lou Nuer tribe in Uror County (northern Jonglei state) resulted in at least 640 deaths, 861 injured, and 208 missing or kidnapped (“Hundreds Killed in South Sudan’s Jonglei State,” 2011). In addition, an estimated 3,421 houses and one international humanitarian medical hospital were burnt during the conflict. Such attacks escalate the public health crisis in this resource-poor region and require increased humanitarian aid, government intervention, and security for future resource development. The Southern Sudan Health, Nutrition, and Empowerment (SSHiNE) project is a two-year collaborative maternal and child health program led by the Adventist Development and Relief Agency (ADRA). The program’s goal is to improve the health and nutrition of vulnerable women and children less than five years of age in the Southern Sudan states of Northern Bahr-el-Ghazal and Warrap. The SSHiNE project aims to improve the health and nutrition of this population by accomplishing three strategic objectives: 1) reduce malnutrition in children less than five years of age, 2) decrease prevalence of illness (especially childhood diseases), and 3) enhance women’s household economic empowerment and their leadership role within the community. As a subset of the SSHiNE program, the South Sudan Health, Nutrition, and Empowerment Geographic Information System (SSHiNE GIS) project was established to help guide SSHiNE’s multidisciplinary approach to its three program objectives. Specifically, SSHiNE GIS was designed to assist with the field assessment process by conducting a health facility assessment (HFA) survey and creating a system to analyze, store, and share the resulting data with program partners to support the decision making process. 4 The SSHiNE GIS project uses geospatial technologies to integrate several forms of data (i.e. local healthcare and community based facilities, training and distribution sites, infrastructure, and socioeconomic data) to create a web-based GIS application for the SSHiNE program that provides a virtual platform to share decisive data and geographical maps with partners and stakeholders. This paper will discuss the SSHiNE GIS project as a two-part approach, which includes the health facility assessment process followed by the creation of the web-based GIS application with the ultimate goal of improving health, nutrition, and empowerment for women and children in South Sudan. Methodology As part of the multidisciplinary approach to improve health, nutrition, and empowerment for women and children in South Sudan, a HFA was conducted in the two states of Warrap and Northern Bahr-el-Ghazal (Figure 1) to evaluate the capacity of the functioning health facilities. Within these two states, the SSHiNE program focused on ten payams in Northern Bahr-el-Ghazal: Ariath, Ayat East, Bar Mayen, Gomjure Center, Malual East, Malual North, Mariem West, Myocawany, Panthou, and Wathmuok; and nine payams in Warrap: Alek South, Aweeng, Gogrial, Kuac North, Nyang, Toch East, Toch North, Turalei, and Wunrok. All other payams in the two states were eliminated due to security concerns. 5 Figure 1: Map of project and assessment areas Health Facility Assessment Survey The HFA survey was created by the partnering team at Johns Hopkins University. This survey was later modified to its final version by the South Sudan field data collection team. The final HFA survey include the following sections: general facility information, staffing information, services, infrastructure, equipment functionality, drug and supply availability, and protocol and documentation review. This paper will only report on results for the services, drug and availability supplies, and protocol and documentation review sections. Enumerator training. Training on the use of field data collection technologies was conducted in August 2011. The training occurred at the South Sudan Hotel compound in Aweil, Northern Bahr-el-Ghazal on August 14 and 15. A total of 12 local MoH workers, or data enumerators, were trained on the principles and practices of conducting HFA surveys using a combination of both electronic and manual methodologies. Each participant was trained on how to use the Trimble Juno (www.trimble.com) field data logger with integrated Global Positioning 6 Systems (GPS), digital camera, and ArcPad 10 (www.esri.com/software/arcgis/arcpad) as the mobile mapping software. A customized ArcPad 10 form was created to collect a selected number of attributes from the HFA survey (date, time, facility identification number, payam name, and county) in addition to the latitude and longitude coordinates, a field for a photo of the facility, the name of the data enumerator, and the date of entry. After this information had been captured, the enumerators were instructed to manually complete the paper-based HFA survey by interviewing the appropriate health facility personnel. It was important for the enumerators to include the health facility identification number on the paper-based surveys so that the data saved on the Trimble Juno units could be linked with the appropriate survey and the data could be digitally merged at a later date. Enumerators were naturally familiar with the local geography and were able to identify the number