Review of NCA's Health Programme in Eastern Equatoria and Warrap States, Republic of South Sudan

Background:
The NCA’s health programme is part of a larger multi-sector programme implemented in collaboration with several church-faith partners and local organisations. The programme under review was specifically developed to improve access to and quality of care for poor and marginalised communities and quality of life for people living with or affected to HIV and AIDS. The 3-year programme works in Eastern Equatoria and Warrap states and 3 counties.
The key results established for the programme were to support 31 health facilities through drug supply and training; increase HIV/AIDS awareness-raising with a specific focus on primary schools and; support church and faith-based actors in increasing their capacity to deliver basic health services.  The programme has been allocated a total of SSP SSP 4 825 640. The Norwegian Ministry of Foreign Affairs, bilateral cooperation between NCA South Sudan and the FCA, and the Common Humanitarian Fund have been the main sources of funding.

Purpose/objective:
By May 2012 the programme was more than half-way through its implementation period. NCA decided that a review was advisable in order to assess achievements and recommend future programme direction.

Methodology:
This review was conducted as a joint learning exercise. The consultant reviewed relevant documents pertaining to the design and implementation of the programme. Interviews and qualitative assessments were undertaken through field visits to 9 of the 31 health facilities in which support is being provided.

Key findings:
- The NCA supported programme has been critical in providing basic health services to marginalized communities and supporting a new Ministry of Health in a country emerging from 21 years of war.
- Maintaining an appropriate balance between service delivery (“peace dividend”) and building capacity and ownership has been difficult
- NCA had overestimated assumptions about capacity and partnerships with  consequence that programme design largely overlooked priority setting for activities, especially considering the geographic size and complexity of health delivery in South Sudan
- Even though the respective focus counties have varying implementing environments overall achievements within the Basic Package of Health Services have been met with limited success.
- There has been a main focus on supporting health facilities with drug supply which is not sufficient to impact positively on well being of communities, especially considering the burden of communicable diseases
- The most important preventive and cost-effective interventions appeared to be underemphasized
- The HIV and AIDS programme focused on awareness in primary schools and to support community based activities to improve knowledge and behavioral change. However at facility level there were no counseling services and no programme strategy to address the need of most at risk groups
- Despite good collaboration with Ministry of Health the programme achieved limited success in sustained changes. Primary health care system strengthening requires resources that are largely beyond the capacity of a single organization
- Creating sustainable health is a long term objective in which NCA need to play a continued and enlarged role, develop more mature relations and expectations of what partners can contribute, broaden funding base and consider Health Pooled Fund as an opportunity for future health sector funding.

Recommendations:
(i) Program design
- Increase focus, prioritize and set realistic expectations.
- Programme design needs to produce greater appreciation for the constraints that characterize post-conflict settings
- Improve the information base to support evidence based decision making. The proposal should clearly link to  the Basic Services Health Package in setting of indicators
- Conduct a rapid field assessment of infrastructure needs, WASH facilities and staffing and suggest short and long term strategies for gap reduction. Data collected should be stored in database
(ii) Thematic focus
- Stronger linkage between the WASH and health programmes
- Improving womens health and children under 5 access to basic health should be a top priority
- Give greater emphasis to high impact services that are currently seriously deficient, especially child health services including immunizations, Vitamin A and WASH
- The HIV and Aids component should not be implemented in isolation from the health system
(iii) Scope
- In order to gradually move away from direct support scale down geographic coverage and improve priority setting in Eastern Equatoria and design a capacity empowerment component for local partners
- Develop a comprehensive monitoring plan based on realistic indicators
- Improve quantitative health information data to track situation at facility level and guide further planning
(iv) Programme implementation
- Develop a culture of data and focus on results
- Training of health staff within focused priority areas of maternal health, major disease risk areas as well as hygiene and sanitation. Follow updated  protocols and guidelines provided by MoH
- Focus on health education approaches through Village Health Committees (VHCs) to effectively promote healthy practices and raise demand for services; focus on fewer messages towards the BPHS objectives
- Drug management needs to improve using tools and expertise developed by MoH
(v) Programme management
- Ensure internal NCA  technical capacity and quality assurance systems to lead implementation
- Recruit a qualified health professional with health systems development skills
- Secure backstopping support by Health advisor at NCA HQ level
- Train staff on M&E concepts and monitoring
(vi) Strategic level 
- Collaboration between MoH and faith based actors needs to be improved to clarify distribution of future roles and responsibilities.
- NCA and partners should contribute to put the issue of faithbased actors in the national health system on the MoH agenda
- NCA and partners need to consider the long term context and to secure their interventions are connected with future services and health funding strategies. The possibility for forming alliances shoud be maximized
- There is concern that the salary issue if not adressed can lead to future tensions and frustrations NCA and partners should continue to lobby with the MoH in the states on this issue
- Seek continuous  synergies between health and WASH programmes

A key learning from the review remains that the health needs in South Sudan cannot be adequately met by short term, localized, project specific and relief focused ineterventions. The widespread structural deficit can only be met by working on a systemic  and long term basis and to scale up aid interventions from local projects to national policies.