HEALTH SYSTEM ASSESSMENT REPORT

JUR RIVER COUNTY,

WESTERN BAR EL GHAZAL STATE, SOUTHERN SUDAN

BY

ISAAC MUNENE,

Public Health Technician,

HealthNet TPO.

© February 2011

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TABLE OF CONTENTS

Acronyms………………………………………………………………………………….3 Executive summary…………………………………………………………………..4 Chapter 1: Introduction

1.2: Purpose of assessment…………………………………………6 1.3: Assessment objectives…………………………………………6 1.4: Methodology……………………………………………………….7 1.5: Constraints and limitations…………………………………..9

Chapter 2: Assessment Indicators……………………………………………..10 Chapter 3: Results and Discussions…………………………………………..12 Chapter 4: Conclusion and recommendations…………………………..18

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ACRONYMS ANC: Ante Natal Care

BPHS: Basic Package of Health and Nutrition Services

CHD: County Health Department

DPT: Diptheria, Pertussis and Tetanus Vaccine

EPI: Expanded program on Immunization

GOSS: Government of Southern Sudan

ITN: Insecticide Treated Net

MoH: Ministry of Health

NGO: Non Governmental Organization

OPV: Oral Polio Vaccine

PBF: Performance Based Financing

PHCC: Primary Health Care Center

PHCU: Primary Health Care Unit

PMTCT: Prevention of Mother to Child Transmission

SPLA/M: Sudan People’s Liberation Army/Movement

STI: Sexually Transmitted Infection

TBA: Traditional Birth Attendant

TT: Tetanus Toxoid

WATSAN: Water and Sanitation

WBGS: Western Bahr El Ghazal State

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EXECUTIVE SUMMARY

Early 2005 a comprehensive peace agreement was signed between the government of Sudan and the Sudan People’s Liberation Movement (SPLM) ending the 25 year long civil war in Sudan. The long war conflict left a big deficit of social service systems, including primary health care delivery system, which has left the population vulnerable to morbidity and mortality due to common, manageable and controllable diseases. HealthNet TPO has been operating in Kuajina Payam to strengthen the health systems. In 2010 HealthNet TPO through BSF funding commenced a Health systems development project aimed at improving access to quality health service delivery through strengthening the health care system in Jur River County. The existing health care delivery system targeted for support by HealthNet TPO’s (HNTPO) health systems development project in Jur River County, was assessed through a survey labeled Health Facilities Assessment (HFA). This assessment was conducted by HNTPO in 8 health facilities targeted for intervention in Jur River County aimed at describing the availability, functioning and quality of the primary health care delivery system in Jur River County. The objectives of the assessment were to:

1. To evaluate the availability of various service packages especially as described by the South Sudan MoH basic package of health services (BPHS) 2. To assess the availability of resources that facilitates provision of the health care services to the population living in the project areas. 3. To recognize/identify gaps in the processes and quality of care related to primary health care services provided at the primary health centre and the primary health units. 4. To evaluate the involvement of the community in the management of the health facilities in Jur River county

A detailed questionnaire, with multiple modules, each module covering one aspect of evaluation, was administered at various levels of health facilities (PHCC and PHCU). Data was analyzed through SPSS. The overall bench marks established by HFA 2005 are in the form of composite indicators; each indicator signifies the overall status of a particular aspect of primary health care system. The HFA has revealed that:

Primary health care units (PHCU) are relatively well staffed in relation to Mapel health centre, the only PHCC assessed. 100% of the PHCU assessed have at least one of the key staff for a PHCU-the community health worker.

Maternal health workers found at the health facilities are actually TBAs with long years of experience.

Human waste disposal is a big problem in the health facilities with a total of 5 (62.5%) of the health facilities lacking usable pit latrines.

All the 8 health facilities are functional and provide outpatient services. Inpatient services are available in Mapel PHCC only.

The average consultation in a month in the county is 6442 and the total consultations during the twelve month period reviewed were 77,305.

Only 1 PHCU (Mbili) received a CHD official on a supervision visit in the last 3 months preceding the assessment

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Out of all primary health care service delivery protocols, the most commonly available protocol was on malaria (100%) and least commonly available was on family planning (37%).

All the health facilities assessed offer free health services. They rely solely on supplies from the MoH, GoSS. 5 (63%) of the health facilities have benefited from a Performance Based Financing (PBF) mechanism from a previous HNTPO project.

63% of the health facilities did not have most of the essential medicines including antimalarials at the time of the assessment.

Keeping in mind the findings certain interventions need to be undertaken to strengthen the primary healthcare delivery system in JUR River County. Key among the interventions proposed is:

Need to train health workers in the health facilities on the use of key primary health care protocols to the BPHS standards

The CHD requires training on standard management and supervision procedures to improve on their planning and implementation of core CHD mandate

Need to restart PBF in the 5 health facilities that participated in the pilot phase and also expand the same to the remaining 6 facilities. The CHD may also benefit from the mechanism if well designed

Health facility staff require training, mentorship and coaching on commodity management

Health facilities need to be provided with the BPHS document to help them understand their mandate

There is need to train facility management committees and mentor them on their roles

There is need for organization and training for village health committees and the home health promoters need to be involved in this.

Health facilities need to be supplied with the MoH standard recording and reporting tools and trained on their use

The CHD needs to ensure that Mapel PHCC gets the correct staff as per the BPHS standards for PHCC staffing

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CHAPTER 1.INTRODUCTION 1.1 Background Early 2005 a comprehensive peace agreement was signed between the government of Sudan and the Sudan People’s Liberation Movement (SPLM) ending the 25 year long civil war in Sudan. The long war conflict left a big deficit of social service systems, including primary health care delivery system, which has left the population vulnerable to morbidity and mortality due to common, manageable and controllable diseases. Currently, the Government of Southern Sudan (GOSS) Ministry of Health, MoH has been formed at various levels. Although MoH is functioning, it is to a limited extent especially at the lower administrative levels (County and Payam); a lot needs to be done to strengthen the health care system at these levels. After five years of the peace agreement the government still depends heavily on external support especially with regard to funding, human resource and capacity building. The situation in Jur River County (in Western Bahr El Ghazal State - WBGS) is similar to other parts of Southern Sudan. Western Bahr el Ghazal state has three (3) Counties, Wau, Raga and Jur River. Jur River County was part of what was initially known as Wau county until 2007 when it was founded as an independent county from Wau county. Though there is no officially drawn map of the county, its borders form the shape of a new-moon with Wau town at the left middle side. Jur River County is divided into six payams namely Kuajina located east of the county; Rocrocdong located in the North east; Marial Wau located in the north-west; Kangi in the north; and Marial Bai and Udici located in the north east. The County has a total of 44 health facilities with HNTPO targeting to support 11 of them.

1.2 Purpose of Assessment The purpose of the detailed assessment was to generate information for CHD and HNTPO relating to the health systems development project in Jur River County. The outcome of the survey will enable the CHD and HealthNet TPO to develop and strengthen the healthcare delivery system in the county and maximize the advantage of the opportunities offered by the project. The health facility assessment is basically an effort to establish benchmarks for devising strategies and plans to achieve project objectives.

1.3 Assessment Objectives Overall objective of the assessment was to describe the availability, functioning and quality of the primary health care delivery system in Jur River County. The specific objectives of the survey are: 1. To evaluate the availability of various service packages especially as described by the South Sudan MoH basic package of health services (BPHS) 2. To assess the availability of resources that facilitate provision of the health care services to the population living in the project areas. 3. To recognize/identify gaps in the processes and quality of care related to primary health care services provided at the primary health centre and the primary health units. 4. To evaluate the involvement of the community in the management of the health facilities in Jur River county

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5. To evaluate the availability of essential support services for optimal functioning of the health facilities 6. To establish the mechanism of health care financing at the health facilities

1.4 Methodology 1.4.1 Design The survey was based on general observation, examination of facility records, and interviews with health facility personnel. A cross sectional quantitative study was conducted and data collection was done using a structured questionnaire. 1.4.2 Assessment Coverage 1.4.2.1 Payams and Health facilities The health facility assessment exercise covered 8 primary health care facilities in Jur River County identified supported in the health systems development project. The assessment covered 2 payams as follows:

Kuajina Payam

Mapel PHCC

Kuajina PHCU

Mbili PHCU

Chono PHCU

Midel PHCU

Rocrocdong Payam

Rocrocdong PHCU

Wathalel PHCU

Achot PHCU

1.4.2.2 Areas covered within health facilities

Health facility environment; buildings, waste disposal

Human Resource for primary healthcare service delivery

Service delivery package; General primary health care services

Essential support services such as HMIS, supervision, laboratory, ambulance services, service delivery guidelines, referral system

Community involvement; Existence of facility management committee

Health care financing mechanisms

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1.4.3 Sampling Procedure All the 8 facilities agreed between the CHD and HNTPO as the target facilities were included in the assessment. These were the facilities with prior HNTPO support in a previous project.

Summary of Health Care Facilities Available in Jur river County Type of Health Facility Number in the County Number Assessed

PHCC 12

1

PHCU 32

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Total 44 8

1.4.4 Data Collection tool A total of 12 modules were developed covering various aspects of health care delivery system at facility level as described in the BPHS. The questionnaire concerning primary health care facilities was designed by using relevant modules according to the scope of health services at this level of health service delivery. The data collection instrument is available as Annexure-I; however the list of the modules is given below:

Module Title Module Title

A General information H Referral management

B Human resource and management information

I Transport and communication system

C Physical infrastructure and equipment

J Healthcare financing

D Services offered K Drug and supplies management

E Service provision data L Supervision and support

F Health management information system

G Work Coordination

1.4.5 Training and Fieldwork Strategy 1.4.5.1 Training of data collection team Training of 2 enumerators was done by the public health technician from HNTPO. They were trained for two days using combination of training methods which also included hands-on training. On the last day of training, a session was reserved to prepare plans for field work.

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1.4.5.2 Fieldwork Strategy There was wide variation in terms of distance, size and complexity of the facilities to be assessed. In order to make best use of resources, the following field work strategy was implemented. Before starting the field work, a meeting was held with CDH and SMoH for seeking support and participation .The issues relating to non-cooperation and availability of staff at the health facilities were referred to CHD for timely resolution.

Prior notice was sent to the facilities to be assessed indicating time and date for the visit by the team.

The team visited facilities on working days only and visits on off days were normally avoided.

The team worked for one day each to collect data from one health facility.

The teams were required to follow the detailed Field Work Plan at all costs. The facilities that were not covered according to the plan were postponed to the end of the assessment period ensuring that the field work plan was not disturbed due to problem at few sites.

1.4.6 Data Analysis The data was entered into computer software, SPSS-version 17.0, followed by thorough data cleaning. The data was analyzed by type of the health facilities and by Payam with focus on predefined indicators.

1.5 Constraints and limitations All efforts were made to minimize the systematic errors in planning phase, data collection and analysis but still there were certain constraints and limitations in the assessment as summarized below: • In health care delivery system diverse types of services are delivered through multiple mutually interacting and coordinating systems of auxiliary and support services. These services are managed in the same premises and under the same management resulting in complexity of need assessment in any specific area of intervention. • Scope for aggregate analysis was limited as the assessment was conducted in 8 purposely selected payams and health facilities and analysis of the results may not be taken as representative of Jur river county as a whole • Data collection in the survey was highly dependent on facility records, therefore the results should be interpreted with caution. • Service delivery data from some health facilities was mostly memory based and extrapolated as some health facilities lacked a proper system of record maintenance.

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CHAPTER 2: ASSESSMENT INDICATORS A list of indicators was compiled for the health facility assessment through discussions with the CHD officials. In this section only operational definitions of each indicator are described. The findings of each indicator are mentioned in the relevant sections of forthcoming chapters. The indicator list is as follows:

Percentage of facilities with basic staffing levels as described by the BPHS document.

Health facility deliveries as a percentage of all ANC consultations

Number of facilities with service delivery protocols and guidelines displayed.

Percentage of facilities that had a supervisory visit from MoH in last 3 months

Facilities with essential drugs / supplies during the month prior to assessment

Malaria Case fatality rates

Number/percentage of facilities sending HMIS reports during the month prior to assessment

Proportion of facilities offering routine EPI services

Facility utilization; number of OPD patients

2.1 Indicator 1: Percentage of facilities with basic staffing levels as described by the BPHS document. This indicator was used to measure the availability of key staff for delivery of primary health

care services as described in the BPHS document. Health facilities were labeled as having the

requisite staffing levels if they achieved BPHS standards

2.1.1: Staffing for PHHC

A PHCC that had the following staff at the time of the assessment was considered as having the

basic staffing levels:

2 Medical Assistant/Clinical Officers

3 Community certificated/enrolled nurses

2 Community Midwives

2 Dispensers

2 Statistical Clerks

2 Community Health Workers

2 Nutritionists

2 Laboratory Assistants

2 Pharmacy Assistants 2.1.2: Staffing for PHCU A PHCU with the following staff was considered to have basic staffing levels at the time of the

assessment: 2 Community Health Workers

2 Maternal Community Health Worker

1 Statistical Clerk

2Dispensers

2.2 Indicator 2: Health facility deliveries as a percentage of all ANC clients seen. This indicator measures the uptake of maternity services at each health facility. This represents

women who deliver at a health facility as proportion of all pregnant women seen at the

facility’s ANC clinic.

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2.3 Indicator 3: Number of facilities with service delivery protocols and guidelines displayed. The number of facilities where predetermined primary health care service delivery protocols for different processes were available/displayed constituted this indicator.

2.4 Indicator 4: Percentage of facilities that had a supervisory visit from MoH in the last 3 months prior to assessment This indicator represents the primary health care facilities that had been visited by a supervisor at least once in the last 3 months; from 1st

September 2010 to 30th November 2010.

2.5 Indicator 5: Facilities with adequate essential drugs / supplies during the month prior to assessment The MoH delivers drugs and supplies to the health facilities every six months (June and December). The following categories of key essential drugs / supplies were assessed for availability or otherwise:

Antibiotics

Analgesics

Antimalarials

Antihelmetics

Vitamins and minerals

EPI Vaccines Health facilities that did not report a stock out in any of the above categories of drugs in the month of November 2010 were considered to have adequate essential drugs supplies.

2.6 Indicator 6: Malaria Case fatality rates This indicates the proportion of deaths recorded in the health facility due to malaria related complications

2.7 Indicator 7: Number/percentage of facilities sending HMIS reports during the month prior to assessment This indicator shows percentage of health facilities that had submitted HMIS reports to the CHD for the month of November 2010 2.8 Indicator 8: Percentage of facilities offering routine EPI services This represents the proportion of health facilities in the target area that offer routine

immunization services

2.9 Indicator 9: Health facility utilization; number of OPD patients

The facility utilization was measured on the basis of OPD attendance by adult and pediatric patients.

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CHAPTER 3: RESULTS AND DISCUSSIONS The assessment was carried out in 8 (100%) health facilities (1 PHCC and 7 PHCU) targeted with intervention measures in Jur River County, Western Bar El Ghazal State in South Sudan. The results in the sections below are from all facilities visited.

3.1 Health facility environment; buildings, waste disposal Environment plays an important role in raising comfort level of the client during visit to a health facility. Summary of the findings are as follows:

3.1.1 Sign boards and accessibility In 7 (88%) of the health facilities assessed the external signboards were available and visible. 1 health unit, Wathalel PHCU, which did not have a signpost. The approach roads to most of the facilities were suitable for access during the dry season with 3 facilities reporting that they experience total inaccessibility by either cars or motorbikes during the wet season.

3.1.2 Methods of waste disposal Waste segregation was practiced in 3 (38%) facilities. Most commonly practiced method for waste disposal was burning in pits. Most of the health facilities (62.5%) did not have a functional incinerator as required by the MoH guidelines for a health facility.

Availability of Incinerators in Health facilities

Human waste disposal was seen as big problem in the health facilities with a total of 5 (62.5%) of the health facilities lacking usable pit latrines. In these facilities Health workers and patients use the bushes for human waste disposal.

Distribution of Pit latrines in the Assessed Health facilities

Condition of

Incinerator Number of health facilities Percent

Good state 1 12.5

Bad state 2 25.0

No Incinerator 5 62.5

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3.1.3 General Cleanliness of the premises General appearance of the facility was rated good or satisfactory for all facilities assessed. The cleanliness of the main building was satisfactory in majority of the assessed health facilities.

3.2 Human resource for primary healthcare service delivery The table below shows the overall distribution of staff by key cadres as described in the BPHS in all the health facilities of Jur River County.

Key Staff Availability in Assessed health facilities

CADRE PHCC PHCU Number

of PHCC Staff

Missing

Number of PHCU Staff

Missing Sanctioned

by BPHS (Total)

Filled Sanctioned by BPHS (Total)

Filled

Medical Assistant/Clinical Officers

2 0 0 0 2 0

Community certificated/enrolled nurses

3 0 0 0 3 0

Community Midwives 2 0 0 1 2 0

Dispensers 2 1 14 7 1 7

Statistical Clerks 2 1 7 0 1 7

Community Health Workers 2 2 14 10 0 4

Nutritionists 2 0 0 0 2 0

Laboratory Assistants 2 1 0 0 1 0

Pharmacy Assistants 2 1 0 0 1 0

Maternal CHW 0 3 14 11 0 3

Total 19 9 49 29 13 21

The primary health care units (PHCU) are relatively well staffed in relation to Mapel health centre, the only PHCC assessed. 100% of the PHCU assessed have at least one of the key staff for a PHCU-the community health worker. The maternal health workers found at the health facilities are actually TBAs with long years of experience. Staffing at Mapel PHCC is way below the expected BPHS standards with the most qualified service provider being a community health worker. The minimum standard for a clinical service provider qualification for a PHCC is a clinical officer or a medical assistant. The PHCC lacks 68% of expected key staff. EPI vaccinators were found at all health facilities with each health facility having at least 2 of them

3.3 Service delivery package; General primary health care services

None of the staff interviewed had ever seen or heard about the BPHS. The BPHS document as not available in any of the health facilities. None of the facilities had the essential service package displayed or known to the staff for respective types of health facilities.

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All the 8 health facilities are functional and provide outpatient services. Inpatient services are available in Mapel PHCC only. A total of 5(63%) health facilities assessed have of Maternal and Child health services. Service)

3.3.1. Out-Patient Services Data collected from all the 8 primary health care facilities for the months of December 2009 to November 2010 give an average consultation per month per health facility as 805. The average consultation in a month in the county is 6442 and the total consultations during the twelve month period were 77,305. According to the results the five commonest diseases seen at the health facilities include malaria, acute respiratory infections, dysentery, pyrexia of unknown origin and scabies as shown in the graph below:

Five most common diseases reported with age-sex disaggregation

Malaria was reported to be the most common disease affirming the information in the BPHS that malaria is a key primary health problem to be addressed by the primary health care facilities. It was also notable that all the health facilities assessed (8) had malaria treatment protocols displayed. However the respondents could not remember that the protocols complete with treatment regimens were on the walls. Scabies appears on the list of the top five common diseases raising questions about the hygiene situation of the communities served by the health facilities. The role of home health promoters is very important in combating this easy to prevent condition.

Mal

MaN=Ma

l

ARI

Dys

PUO

Scab

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3.3.2. Routine EPI Routine EPI services are provided in 5(63%) health facilities assessed and the total number of vaccines doses administered in the facilities assessed is shown in the graph below.

Routine EPI load and vaccine stock balance in the health facilities assessed

September October November

It is notable that the vaccine supply chain is quite good in the health facilities assessed. The number of children receiving measles vaccine at 9 months is more than 400 for the three months examined demonstrating that a considerable number of children are completing the immunization schedule successfully.

3.4 . Essential support such as Supervision, Service delivery guidelines and HMIS 3.4.1. Supervision Only 1 PHCU (Mbili) reported to have received a CHD official on a supervision visit in the last 3 months preceding the assessment. This is a major gap in service delivery as the health workers in these facilities require support from the health authorities in the County. 3.4.2. Service delivery guidelines Out of all primary health care service delivery protocols, the most commonly available protocol was for malaria (100%) and least commonly available was for family planning (37%). Other protocols were available in between above mentioned ranges. In most of health facilities, the protocols if available were displayed.

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3.4.3. Health Management Information System All the health facilities reported to have sent the monthly report for the month preceding the assessment to the County health department. However 12% of the facilities did not have copies of the reports. All facilities do not have a filling system for reports generated.

Facilities with copies of monthly Reports

Only 12% (1) 0f the facilities reported to ever receiving feedback on their reports from the CHD. Majority 88%of the health facilities have never received feedback from the CHD. This shows poor support supervision and technical support to the health workers at health facilities from the CHD.

Percentage of Health facilities receiving feedback from CHD

Copies Present

Copies Absent

88%

12%

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3.5 Community involvement; Existence of facility management committee The health facilities involve the community in health service delivery by having community representatives form a facility management committee. Of the 8 health facilities assessed only 2 (Mapel PHCC and Wathalel PHCU) do not have health committees. The health committees meet at least once in a month and only 1 out of the 6 existing committees keep meeting records and have an agenda when they meet. All the health facilities (11) do not have village health committees functioning in their catchment areas.

3.6 Health care financing mechanisms All the health facilities assessed offer free health services. They rely solely on supplies from the MoH, GoSS. 5 (63%) of the health facilities have benefited from a Performance Based Financing (PBF) mechanism from a previous HNTPO project. The health workers from these facilities appreciate that PBF kept their motivation high and it also helped to procure commodities such as soap and disinfectants for health facilities.PBF mechanism also employed Home Health Promoters and vaccinators in the 5 health facilities. On the other hand 37% of the health facilities assessed reported to never have heard anything about PBF.

3.7 Essential drug supplies The health facilities reported that they receive supplies twice a year from the MoH through the county health department. 63% of the health facilities did not have most of the essential medicines including antimalarials at the time of the assessment. This had been the case for the 3 months preceding the assessment. This could strongly be attributed to poor forecasting during the making of the 6 month order or an undersupply of the same. 37% of the facilities who had all the essential supplies available reported to have received supplementary supplies from HealthNet TPO.

Percentage of health facilities reporting availability of essential drugs

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CHAPTER 4: CONCLUSION AND RECCOMENDATION

4.1 Conclusion The strengths and weaknesses of the existing primary health care system in Jur River County can be concluded as under:

A. Strengths There is an established health infrastructure serving most of the population in the rural

areas

The ministry of health supplies all the medicine required in the health facilities

Health workers in the health facilities are on the government payroll and are paid regularly

The PHCU are relatively well staffed with staff able to deliver services at this level of health care

B. Weaknesses Service deliver protocols are in place but are not being used by HCW due to lack of the

necessary information on their use

Supportive supervision for the health facilities is scanty ,if any, with most of the facilities lacking regular supervision from the CHD

There is no feedback mechanism for health facilities after submitting routine reports

Health facilities do not have a filing system for reports leading to loss of data at this level

The Mapel PHCC is not able to provide all services at PHCC level due to lack of the appropriate level of staffing for a PHCC

Shortage of essential medicines and supplies for primary health care

Low levels of community engagement in health service delivery or demand creation

4.2 Recommendations

There is need to train health workers in the health facilities on the use of key primary health care protocols to the BPHS standards

The CHD requires training on standard management procedures to improve on their planning and implementation of core CHD mandate

The CHD needs to step up support supervision for health facilities in Jur River County. The CHD will require training and coaching on health facility supervision

There is a big need to restart PBF in the 5 health facilities that participated in the pilot phase and also expand the same to the remaining 6 facilities. The CHD may also benefit from the mechanism if well designed

Health facility staff require training, mentorship and coaching on commodity management

Health facilities need to be provided with the BPHS document to help them understand their mandate

There is need to train facility management committees and mentor them on their roles

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There is need for organization and training for village health committees and the home health promoters need to be involved in this.

Health facilities need to be supplied with the MoH standard recording and reporting tools and trained on their use

The CHD needs to ensure that Mapel PHCC gets the correct staff as per the BPHS standards for PHCC staffing

There is need to collaborate with other agencies implementing Watsan programs and encourage them to provide pit latrines for Health facilities in Jur River

Refresher training on malaria management and distribution of ITNs needed as malaria is reported as having the highest morbidity