South Sudan Phase 2 - Strengthening of Western Lakes State Health System through the Support to Rumbek State Hospital for Improved Access to and Utilization of Quality Primary and Secondary Care and Effective Referral System

Project location: South Sudan, Rumbek
Project start date: September 2019 - Project end date: August 2022
Project number: 2019-022
Beneficiary: CUAMM Medici con l'Africa

Former Lakes State has been divided in three new States; Western Lakes State is one of them, counting 594.000 inhabitants (52% of the total population) distributed over four Counties. Former Rumbek Centre County, where Rumbek State Hospital is located, is the main of these latter, with 253.528 people (43%). Health Services in this area are mainly funded by Health Pooled Fund, which Implementing Partner is CUAMM.
CUAMM is operating in Western Lakes State since 2014, when it launched its intervention in Rumbek North. In Rumbek Centre, CUAMM arrived in 2015. The field presence and the role of State (and County) leading agency for health and nutrition put CUAMM in the best position to have constantly updated context information and to develop a good conflict sensitiveness, based on deep knowledge of local setting and continuous interaction with local authorities and communities, facilitated by the long-term presence on ground and colocation in each of the targeted Counties. The following paragraphs have been informed by all the elements CUAMM field team are collecting on and by the data reported in the District Health Information System in the last six years.

This area is known for its internal instability, consisting in continuous violent inter clan clashes. Internal insecurity, coupled with the proximity to the areas where fighting are still ongoing, imply a consistent displaced people influx passing through this territory, besides the disruption of subsistence activities. Displaced people are being accommodated within host communities, forced to overstretch further the scarce resources, while the demand on the limited services increase above the level they can afford. Since 2015, Former Lakes State food security situation has worsen, by July 2019 65% of its population is expected to be in a crises/emergency/catastrophe situation. The acute malnutrition rate is above the emergency threshold. In Western Lakes State, there are 53 Primary Health Care Facilitiess and 1 Hospital belonging to the Government and currently supported by CUAMM. In addition, 4 private Facilities and a National Referral Hospital in Rumbek Town, which regular activities are suspended because of budget constraints. Out of the 444 staff working in the Primary Health Care facilities, only 7% is on Ministry of Health payroll, all the others have had a contract with the State Ministry of Health, paid by CUAMM. Facilities are provided with drugs kit by international donors through the Ministry of Health; for those in Rumbek Centre, it took a while to be included in Ministry of Health drugs distribution list, but the careful application of pull system principles enabled the County Health Department to cope with this situation. Although Utilization Rate (1.3) is not bad for the South Sudanese context, the number of HFs results lower than what due as per national Guidelines, especially for what concerns those providing Emergency Obstetric and Neonatal Care (EmONC); in 2018, the reported Major Direct Obstetric Complications treated in the State have been only the 6% of those expected. Further, not all Primary Health Care Facilities are offering the due services and the majority of them are concentrated within the same zones, leaving unserved the most remote ones. Integrated Community Case Management program has never been implemented in consistent way, nor integrated within County health plan. Primary Health Care Facilities are offering the key preventive and curative services (Immunization, Ante Natal Care, Uncomplicated deliveries attendance, Outpatient consultation). In terms of number of patients, there have been good improvements, since 2013: +243% outpatient consultations for children under 5 years of age, +246% first antenatal care visits and +332% fourth antenatal care visits, +665% institutional deliveries, +223% complete immunization cycles. However, many facilities are hosted in tukuls or operating in dismissed buildings, originally aimed for other purposes. This raise some questions on the quality of care, also considering they are run by Community Health Workers and Traditional Birth Attendants. Qualified personnel is concentrated in the 11 Primary Health Care Centers, expected to offer higher level services, but their presence has not been sufficient, up to now, for their upgrade to Basic Emergency Obstetric and Neonatal Care (BEmONC) level, confirmed in only 6 of them. 2018 Skilled Birth Attended (SBA) deliveries coverage was 9%; a good improvement compared to 2013 (2%), but still incredibly low. Obstetric Emergencies referral is facilitated by 24/7 free of charge ambulance service, available in all Counties, activated by Primary Health Care Facilities staff or patients with a call to the dedicated number.

However, logistic and security impairments limit ambulance responsiveness and force people to use private and alternative transport means. Reproductive Health services comprehensiveness is affected by the strong (cultural) resistance towards health system. Although Family Planning supplies being available in all facilities, health staff and women are reluctant to offer and ask for them, fearing community/family reaction. Procreation is wealth/power ground, therefore high number of early marriages (also because daughters’ dowry is the only confirmed income for several families) and teenage pregnancies (representing almost 50%).  Pregnancy and Delivery are natural events women have to handle on their own, without addressing the health system nor prioritizing related care over their domestic chores. Antenatal care utilization is poor (28% coverage for the fourth antenatal care visits, with 61% drop) and institutional delivery coverage low (24%). Cold chain has not reached all facilities yet, with only 37 with a functioning fridge and the others using 7 days cool boxes. Each facility has a motorbike for vaccines internal redistribution and vaccinations outreaches (657 sites reached on monthly bases). Coverage remains unsatisfactory; only 48% of children under 1 year of age are completing the immunization cycle, with 36% drop. There have been measles outbreaks in Rumbek Centre and Rumbek East. The most common diseases are malaria, diarrhea and respiratory tract infections. Diagnosis is based on clinical signs as few facilities (4) have a working Lab and the use of rapid diagnostic test is limited. This, merged with staff low qualification, explain drugs’ irrational use. The limited coverage of dedicated services makes hard to estimate HIV prevalence. Nutrition services have been gradually integrated, but there is a turn over in supporting partners, with CUAMM asked to handover the nutrition program, at least for what concerns Outpatient Treatment Program_OTP (activated in almost all Primary Health Care Facilities) and Targeted Supplementary Feeding Program_TSFP (in about half of them) to other organizations. 
The above described situation demonstrates that, in spite of the several steps moved forward since the launch (in 2013) of the current funding system supporting South Sudan Health Services, more efforts and investment are needed to achieve acceptable coverage and to guarantee certain quality standards. Further, keeping prioritizing Primary Health Care level risks to leave important gaps in terms of services availability and responsiveness. 

Hospitals are usually neglected by the main funding mechanisms, especially in the Humanitarian settings, where short term interventions are preferred compared to the more structured ones, needed to sustain complex systems, as Hospitals. This is in in spite of their relevance. Besides being crucial to respond to clinical emergencies (obstetric, surgical, nutritional), Hospitals are considerably contributing to overall care provision, compensating the weaknesses of a still limited Primary Health Care network. For instance, in Former Lakes State, in 2018, Hospitals accounted for almost 50% of institutional deliveries and first antenatal visits and for 35% of outpatients consultations for children under 5 years of age.  Further, Hospitals constitutes the core of County and State health system, a referee and model for protocols implementation and adaptation, a site for health staff training and practicing, a sentinel for epidemiological trend observation and monitoring. The impact of inadequate Hospital funding and support on overall population health will be therefore extremely high.

In Western Lakes State, Rumbek Hospital is the only one providing Comprehensive Emergency Obstetric and Neonatal Care and surgical care, but it is also the only site working as Stabilization Centre, offering HIV/AIDS related services (Volunteering Counselling and Testing/Anti Retroviral Treatment and the complete package of Prevention Mother To Child Transmission)... In spite of this, the support received by CUAMM is extremely limited, as institutional donors focus and available resources are such to allow sustaining only wards and departments related to mothers and children care. This, coupled with the fact the Ministry of Health is not in conditions to sustain the remaining department and wards, has resulted in an unbalanced development of Hospital offer, in terms of both availability and quality of services. This has consequences not only for patients, but for health staff and authorities as well. Differences in remuneration and working conditions are affecting personnel commitment and retention and creating internal tensions, difficult to handle for the State Ministry of Health, which efforts in terms of County/State wide promotion of health services access and utilization are being hampered by the poorly performing Hospital services. An idea of the precarious situation is given by the patients, whose satisfaction degree is being measured through a specific questionnaire introduced in the main Primary Health Care Facilities and Hospitals CUAMM is supporting. During the first Quarter 2019, all sites reported a percentage of satisfied patients above 50%, with the exception of Rumbek State Hospital and this is may  be due exactly to the fact Hospital is being supported in selected wards and departments only. Although questionnaire is administered to patients accessing these wards/departments, it cannot be excluded the same people (or their relatives) have accessed other services as well and their judgment reflect their perception of Hospital as a whole, which is likely to be under expectations because of the limited support given to other areas. Actually, limited support means also that part of the staff is receiving only Ministry of Health salary, without any allowance given by CUAMM and this affect their motivation and behavior and can incentivize coping strategy as request of hidden payment to patients; low score has been reported for attending staff behavior and free health care. Further, Rumbek State Hospital is the referral center for the most populated State of Former Lakes State area, often very crowded; in the absence of adequate investment on staffing and on Hospital compound maintenance, this affect the waiting time and the overall hygiene (especially that of the common spaces), the aspects reporting the lowest score.

The effects of this situation are amplified by the challenging transition to the third phase of Health Pooled Fund program. The gap between Health Pooled Fund 3rd phase contents and conditions and the local expectations (especially health staff ones) has created protracted tensions and services provision interruption. The main matters of discussion are personnel remuneration level and facilities selection for funding. Ministry of Health taking over of staff contracting process and incentives harmonization are expected to limit NGOs exposure to personnel blame for better conditions (as experienced in the past) and, in general, to promote fair and equal treatment for all health personnel within the Country. However, the health workers do not trust the Ministry of Health as they are aware of its limited possibilities of assuming the cost of their salaries; they know their only income will be the incentive paid by the NGOs and they push for these incentives to be much higher than what planned. The incentive scale penalized the unqualified staff, who represent the majority of the existing workforce, especially in the most remote and challenging locations, and who are therefore in conditions to deeply affect service provision and public order if they decide to go on strike or to protest. Additionally, Health Pooled Fund decision of funding a smaller number of facilities, to be staffed as per national policies requirements, and consequently of excluding part of the existing staff from the list of those entitled to receive incentives, is exacerbating even further the tension on ground. Similarly, the renewed attention on the Primary Health Care, with the consequent stricter limits imposed on Hospital support has disappointed local claims on Rumbek State Hospital development. 
As seen in the past, the rules of the game should have been clearer since the very beginning, starting from the highest level and equally shared with those expected to implement them deeply in the field. Misunderstanding and miscommunication amongst Donors, NGOs, Ministry of Health, State Ministry of Health…are still too much frequent and the main consequence is the impossibility of reaching a common agreement on new rules and conditions.
The misinterpretation between authorities and donors on the level of funding and on the eligible expenditure have been quite frequent and this resulted in contradictory orientations for organizations as CUAMM, which proposals are being judged as not aligned to Ministry of Health requirements and which are still under the pressure of continuous budget adjustment requests. In Rumbek Centre this is particularly evident, especially for what concerns Rumbek State Hospital.
The Nando and Elsa Peretti Foundation has awarded a grant for this project to complement the funding envelope sustaining CUAMM intervention on Western Lakes State Health System. While the traditional funding mechanism will cover the costs related to the Primary Health Care components, as per institutional donors’ agenda, Nando and Elsa Peretti Foundation will focus on Hospital, intended as emergency and specialized care provision and the top of the referral system, the lifesaving level. This will contribute to a comprehensive improvement of State health system, being targeted as a whole. The current project will focus on Hospital running costs, guaranteeing permanent and free of charge provision of Hospital care. In case of additional fund would be raised in the meanwhile, the intervention scope will be widen to embrace capital costs as those related to infrastructures and major equipment, which current status is quite poor. 

The Nando and Elsa Peretti Foundation is one of CUAMM donors sustaining its intervention in South Sudan. In particular, the Nando and Elsa Peretti Foundation has contributed to the intervention in the area surrounding the Port of Nyal (Panyijar County, Former Unity State). This project was effective in expanding the first line health services network and creating the conditions for obstetric complications and surgical cases treatment, narrowing a concerning gap in health care provision in that area. It was intended as focused on emergency response, with a short/medium term perspective and expected to be handed over to local counterparts and their partners. In the coming months, CUAMM aims to activate the Operation Theatre it built and equipped and to run it for some months, building local staff capacities to manage such service up to the level required for them to take over. Funds for this short term plan are being raised, mobilizing other donors previously involved on Nyal project and which priority is exclusively on humanitarian proposals.
CUAMM intervention in Nyal does not meet the criteria consultants suggested to Nando and Elsa Peretti Foundation for the selection of the next proposal. Consultants advised to prioritize projects integrated into wider programs, having regional scope and targeting all health system levels, from Community to Hospital, already well rooted in the local health system and implemented in close cooperation with local authorities, contributing to build their management capacities. 
CUAMM is not the health leading agency in Panyijar County, although highly appreciated by local authorities it has a second line role. To scale up its engagement in Panyijar County and impact on routine primary and secondary care County wide provision, running long term interventions in deep coordination with the agency in charge and with the local authorities, CUAMM should develop a stronger organizational and institutional structure, which would need a high amount of additional resources and a larger presence on ground. Indeed, consultants pointed out a strategic choice would be to prioritize projects to be implemented where the proposing NGO is well set up (and since long). At present, CUAMM is not in conditions to make such big step. 
All this considered, CUAMM decided to propose Nando and Elsa Peretti Foundation to contribute to its intervention in support to Western Lakes State health system, which CUAMM is main partner since 2014. 

The present proposal targeted site is Rumbek State Hospital (RSH), located in former Rumbek Centre County (RC), the main of the four constituting the recently established Western Lakes State (WLS), with 253.528 inhabitants (43% over State total population). Rumbek State Hospital is the referral Hospital of Western Lakes State. In Rumbek Centre, CUAMM started working in March 2015, taking over the role of County leading agency for health as Health Pooled Fund Implementing Partner. Health Pooled Fund is the main funding mechanism sustaining health services in this area. The application of CUAMM model, based on Continuum of Care principles, produced good results since the very beginning and the positive trend was confirmed in the following years. The sustain given to all existing Primary Health Care facilities, the creation of conditions for uncomplicated deliveries attendance in Primary Health Care Units and the weekly  outreaches for vaccination contributed to the improvements seen in various sectors. Comparing 2014 and 2015 Rumbek Centre data, outpatients consultations for children under 5 years of age increased by 40%, institutional deliveries by 195% and complete immunization cycle by 191%. CUAMM contributed to County Health Department establishment, which set up and operations were hampered by the lack of any asset and material resources and the poor competencies of the appointed people. CUAMM built a store, installed internet, provided transport means. Its technical team was co-located at County Health Department, focusing on local authorities’ capacity building on all dimensions of health system management. Supervision and coordination mechanisms wereenhanced, with a prominent role given to the communities, through the creation and involvement of Village Health Committees. CUAMM run nutrition program up to 2018, handing it over to PLAN International in 2019, with the exception of the Stabilization Centre at Rumbek State Hospital. In 2017, CUAMM took over Rumbek State Hospital intervention, focusing on mothers and children services. Few months after, CUAMM had to reactivate the Comprehensive Emergency Obstetric and Neonatal Care (CEmONC) package, which had been previously relocated to the Kiir Mayardit Women Hospital, a National Referral Centre built in Rumbek Town and run by the central Ministry of Health but forced to suspend activities because of lack of resources. The consequences was that, from August to December 2017, the average monthly number of attended deliveries (all by skilled staff) reached 136, against 65 reported in the previous 7 months (+109%).  

When looking at Rumbek Centre 2018 data and comparing them with those of 2017, all key indicators confirm a positive trend, improvements are reported for both access and utilization of services: +5% outpatients consultations for children under 5 years of age, +4% and +12% first and fourth antenatal care visits, +14% institutional deliveries (+36% SBA), +20% and +6% first and third dose of pentavalent vaccine. Progresses are even more impressive when looking back at 2013:+211% first antenatal care visits, +1787 institutional deliveries, +15% full immunization cycle, +361% outpatient consultations for children under 5 years of age. 
This picture confirms the relevance of working on all health system’s levels, adopting a systemic and programmatic approach rather than being guided by small and short term projects’ objectives, which results are unlikely to be sustainable over the time. This is the perspective which informed the choice of going beyond the Primary Health Care and community based intervention and including the Hospital, replicating what was being done in other Counties as well. However, differently than in Cuibet, Yirol and Lui, Rumbek State Hospital is being supported by CUAMM only for what concerns mothers and children health, because of donors’ requirements and funds constraints. Although its support is limited to certain services only, CUAMM has tried to enhance Hospital overall quality by providing technical assistance to its management bodies and to the State Ministry Of Health and by improving transversal services as Lab and Drugs Store. In spite of the positive impact these actions had, the need of a more comprehensive intervention is still evident, as raised often by local authorities and communities.

Direct beneficiaries of the project will be all people accessing Rumbek State Hospital, estimated to be at least 55.000 (out of which 18.000 Children Under 5 years of age). Rumbek State Hospital patients will benefit of a comprehensive package of preventive and curative quality health and nutrition services, including emergencies attendance. The above described activities will ensure Hospital staff regular payment and all needed materials and equipment constant availability; besides guaranteeing the respect of quality care standards, this will minimize the risk of people to be asked to contribute to personnel remuneration or to the procurement of what required for their treatment, overcoming the most common economic barriers to services access. Geographic barriers will be faced sustaining the free of charge County/State wide ambulance service, to be activated by Primary Health Care Facilities or patients relatives as well.
Indirect beneficiaries of the project will be Western Lakes State (and Rumbek Centre County in particular) inhabitants, estimated to be 594.243 (out of which  253.528 in Rumbek Centre County). They will benefit of an enhanced State (and County) health system, including a fully functional referral Hospital, which services will be particularly relevant for the most vulnerable groups, as pregnant women (13.672 in Rumbek Centre and 32.085 in Western Lakes State) and children under 5 years of age (57975 in Rumbek Centre and 136.052 in Western Lakes State), more exposed to health and nutrition status complications.

the expected results of the project are mainly two:
1. Rumbek State Hospital is permanently working and offering the main preventive and curative services, including emergencies management, being run by adequate (in number and capacities) workforce
2.     Western Lakes State referral system is permanently functioning and ensuring free of charge and timely transfer of patients from Primary Health Care facilities to Rumbek State Hospital (with priority given to obstetric cases)

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