Health sector recovery in early post-conflict environments: experience from southern Sudan

Health sector recovery in early post-conflict environments: experience from southern Sudan

Giorgio Cometto, Gyuri Fritsche and Egbert Sondorp1

Health sector recovery in post-conflict settings presents an opportunity for reform: analysis of policy processes can provide useful lessons.2 The case of southern Sudan is assessed through interviews, a literature review, and by drawing on the experience of former technical advisers to the Min-istry of Health. In the immediate post-conflict phase, the health system in southern Sudan was characterised by fragmentation, low coverage of health services, dismal health outcomes and limited government capacity. Health policy was extensively shaped by the interplay of context, actors and processes: the World Bank and the World Health Organization became the primary drivers of policy change. Lessons learned from the southern Sudan case include the need for: sustained investment in assessment and planning of recovery activities; building of procurement capacity early in the recovery process; support for funding instruments that can disburse resources rapidly; and streamlining the governance structures and procedures adopted by health recovery financing mechanisms and adapting them to the local context.

Keywords: contracting out, health policy, policy process, post-conflict, recovery, southern Sudan, stakeholder analysis

IntroductionFrameworks to characterise postconflict recovery processes are based on the assumption that development aid is conceptually different from humanitarian aid. While the latter aims to save lives, the former endeavours also to build states and their governance and service delivery apparatus (Macrae, 2001). Recovery has to strike the right balance between the two, trying to lay the foundations of a sustainable framework for service provision, while responding to urgent unmet needs that persist following the end of a crisis. The recovery of disrupted health sectors in postconflict states poses severe challenges. Limited government capacity, weakened management systems, deficient human resources, damaged infrastructure and the proliferation of fragmented humanitarian and recovery initiatives (Pavignani, 2005) hamper recovery. This phase, however, may also present a window of opportunity for rapid reforms and the introduction of new ideas. The start of a postconflict phase is often illdefined and may only be determined retrospectively. Sometimes a postconflict phase has a clear start, in particular when an agreement has been brokered through the international community. Ensuing reengagement with the postconflict state seeks to assist with peacebuilding and

doi:10.1111/j.03613666.2010.01174.x

Disasters, 2010, 34(4): 885−909. © 2010 The Author(s). Journal compilation © Overseas Development Institute, 2010Published by Blackwell Publishing, 9600 Garsington Road, Oxford, OX4 2DQ, UK and 350 Main Street, Malden, MA 02148, USA


legitimising a new government. Recovery and reconstruction assistance is part of this effort (Collier et al., 2003) and is usually accompanied by a flurry of activities, including ( joint) assessments of the various sectors, reconstruction frameworks and donor conferences. Progress registered in individual social sectors (such as education, health, water and sanitation) can be instrumental in contributing to broader peacebuilding objectives by demonstrating a visible peace dividend to conflictaffected populations (MacQueen and SantaBarbara, 2000). According to a 2006 review of seven case studies of postconflict recovery, ‘nationbuilding efforts cannot succeed unless adequate attention is paid to the population’s health’ ( Jones, 2006, p. xvi). Decisions taken during the early postconflict period may have longlasting effects. For the health sector, events during such ‘sudden onset’ postconflict situations have been described in Afghanistan (Bower, 2002; Strong, 2003; Strong, Wali and Sondorp, 2005), East Timor (Alonso and Brugha, 2006; Tulloch, 2003), Kosovo (Shuey et al., 2003) and Mozambique (Pavignani and Durao, 1999). Some patterns become visible and lessons are learned from these accounts. But are these applicable to situations where a peace agreement is preceded and followed by a prolonged transition characterised by myriad uncertainties, such as in Liberia (Sondorp and Msuya, 2005) and southern Sudan? Against the background of the health sector policy processes unfolding after the signing of the Comprehensive Peace Agreement in early 2005 (GoS and SPLM, 2005), this paper assesses the issues at stake and the challenges that have emerged in southern Sudan. Its intention is to contribute to a deeper understanding of postconflict reconstruction processes in the health sector.

MethodologyDetails of southern Sudan’s peace process, an analysis of its health system and an overview of the local and international actors are provided as background information. The study employs the World Health Organization (WHO)’s health system framework and focuses on the four core functions of a health system: stewardship; financing; generation of resources; and service provision (WHO, 2000). It goes on to use the policy analysis framework of Gill Walt (1994) to examine the interaction of context, actors and processes in determining policy outcomes. Information for the policy analysis was obtained in three different ways. First, we drew on two of the authors’ handson experience of the early policy process. From March 2005 until May 2006, they were both contracted as technical advisers by WHO SouthernSudan to assist the southern Sudan Secretariat of Health (SoH). Second, we held semistructured informal interviews with key actors in southern Sudan. Finally, we reviewed the relevant international literature and a range of countryspecific documents (policy papers, official reports, plans, project proposals, minutes of meetings and terms of reference for consultancies and services) to add knowledge or to triangulate our own and other stakeholders’ perspectives.

Health sector recovery in early post-conflict environments 887

A certain degree of subjectivity in the analysis and in the presentation of issues is unavoidable due to the positions that the two lead authors held at the WHO at the time.

Setting: the southern Sudan context and actorsContext

Southern Sudan’s postcolonial history is characterised by one of the longest civil conflicts in Africa (1954–73 and 1983–2002), which has claimed the lives of some two million people and displaced more than four million others (ICG, 2008). In 2002, however, peace negotiations between the Government of Sudan (GoS) and the main southern rebel group, the Sudan People’s Liberation Army/Movement (SPLA/M), gained momentum and led to the peace protocols of Machakos and Naivasha and a Comprehensive Peace Agreement (CPA), eventually signed on 9 January 2005. The CPA established a complex institutional framework for government of the country, with a semiautonomous region created in the south, to be administered by a largely independent Government of Southern Sudan (GoSS). The GoSS was endowed with significant power, including the administration of social services, its own army, and a right to 50 per cent of the revenues flowing from oilrich southern Sudan. Six months after the CPA, on 30 July 2005, the leader of the SPLA/M, John Garang, died in a helicopter crash, casting a shadow over the peace process. The GoSS was nevertheless formally established in October 2005. Two years after Garang’s death, various political uncertainties, also related to the parallel crisis in Darfur in west Sudan, unclear management of oil revenues, repeated violations of the CPA, and a slow start to recovery activities still threatened the success of the peace process (ICG, 2007). From a health status perspective, southern Sudan ranks among the most disadvantaged places in the world (Decaillet, Mullen and Guen, 2003; NSCSE and UNICEF, 2004): maternal mortality is 1,700 deaths per 100,000 live births, child mortality is 250 deaths per 1,000 live births, life expectancy is 42 years, the proportion of births attended by skilled health personnel is six per cent, measles immunisation coverage is 25 per cent, and DPT3 (third dose diphtheria, pertussis and tetanus vaccine) coverage is 13 per cent. For many years the bulk of the international assistance to the southern Sudanese health sector came through humanitarian channels, fragmented horizontally across a variety of actors (at least 76 nongovernmental organisation (NGOs) and six United Nations (UN) agencies) and vertically across multiple diseasespecific control programmes, and burdened by the bureaucratic requirements of different funding processes and reporting modalities. The humanitarian operations conducted by UN agencies and the majority of international NGOs were structured under the common umbrella of Operation Lifeline Sudan (OLS), a consortium set up initially by the United Nations Children’s


Fund (UNICEF) and the World Food Programme (WFP) and more than 35 international aid organisations to provide a common legal framework, a platform for negotiation with the GoS and the SPLA/M, and joint logistics structures. The vastness of the country and the derelict condition of infrastructure forced humanitarian operators to devote significant portions of their resources to expensive air transport of supplies and personnel. Despite an estimated annual spending figure of seven USD per capita, this fragmentation and the high operating costs resulted in a highly inefficient health sector with dismal health service coverage (Pavignani and SPLM, 2004). The main donors during the humanitarian phase were the United States Agency for International Development (USAID) (through the Office of US Foreign Disaster Assistance (OFDA)), the European Commission Humanitarian Aid Office (ECHO), the United Kingdom’s Department for International Development (DFID) and the Norwegian Agency for Development Cooperation (NORAD); other bilateral donors contributed a significant amount of resources as well. Most donors had multiple means of providing humanitarian assistance, channelling part of it to UN agencies for coordination and support services, vertical programmes and special initiatives, and part of it to NGOs for service delivery projects (mostly primary health care (PHC)). Other humanitarian operators (various faithbased organisations (FBOs), the International Committee of the Red Cross (ICRC) and Médecins Sans Frontières (MSF)) supplied limited hospitalbased services. Each donor employed separate mechanisms to provide funding to NGOs, which was typically short term (one year). Funding to UN agencies was structured according to the annual Consolidated Appeal Process (CAP), later called the United Nations and Partners: 2006 Work Plan for Sudan. During the conflict, the provision of health services by official government authorities (GoS) was for many years largely restricted to the socalled garrison towns, 11 small and mediumsized towns in southern Sudan, including Juba, the new capital, controlled by Khartoum throughout the war. The health system in these towns largely reflected that of the northern part of the country (Cometto, 2005; Richer, 2005; Fritsche, 2005a). However, it is estimated that the garrison towns account in total for little more than one million of southern Sudan’s estimated eight millionstrong population. In the part of the country under the rebels’ (SPLA/M) control, health services had been largely provided by NGOs, FBOs and UN agencies. According to one survey (Christian Health Association of Sudan, 2007), NGOs managed 86 per cent of health facilities with the remaining 14 per cent managed directly by the government. In the late 1990s, the SPLA/M set up a department responsible for relief operations (called the Sudan Relief and Rehabilitation Commission since 2004) and a Secretariat of Health was created to oversee the provision of health services. In October 2005, with the formation of the GoSS, the SoH became formally the Ministry of Health of the GoSS (MoH GoSS). Limited human and material resources, though, made it challenging for the SoH/MoH GoSS to be the primary driver of health


sector processes in southern Sudan. A range of other actors play a significant role in the southern Sudanese health sector.

Actors

In the early postconflict phase, the key actors in the southern Sudanese health sector were the GoSS, with the MoH and the Ministry of Finance and Economic Planning (MoFEP), the WHO and other members of the UN system, donor agencies, including the World Bank (WB), USAID and the Global Fund to Fight AIDS, TB and Malaria (GFATM), and numerous FBOs and NGOs. The SOH/MoH GoSS struggled with a severe lack of capacity. With staff at central level numbering between five and 20 from 2002–06, no history of utilisation of significant financial resources, inexistent management systems, and unclear decisionmaking criteria, the government authority was unable to take control of the health sector. The World Health Organization played a pivotal role in the policy development process, providing assistance to the MoH for the formulation of situation analyses (Cometto, 2005; Fritsche, 2005a, 2005b; Pavignani and SPLM, 2004; Richer, 2005), policy documents (MoH and GoSS, 2005; WB and UN, 2005a, 2005b, 2005c), thematic plans (WHO, 2006; MoH and GoSS, 2006), coordination of health activities (WHO, 2006) and resource mobilisation efforts (MoH and GoSS, 2006; UN OCHA, 2005). However, the WHO’s involvement in the southern Sudanese health sector was predominantly through a variety of disease control programmes. Other UN agencies also played an important role in the health sector. UNICEF (annual health budget of approximately 10 million USD) supported health facilities with vaccines and drugs; the United Nations Development Programme (UNDP), the Principal Recipient of GFATM grants, channelled between six and seven million USD per year to NGOs for tuberculosis and malaria control; the United Nations Population Fund (UNFPA) provided reproductive health kits; the United Nations High Commissioner for Refugees (UNHCR) supported health activities for refugees (the 2005 health budget was six million USD); the United Nations Office for the Coordination of Humanitarian Affairs (UN OCHA) supported the preparation of the UN Work Plan, the main funding mechanism for UN agencies. The efficiency of UN interventions was frequently questioned, and government ownership of the annual UN Work Plan was very limited. NGOs and FBOs numbered more than seventy. They were the main providers of health services in southern Sudan, managing nearly all health facilities and training centres in SPLA/Mcontrolled areas and supplying substantial assistance to facilities in the former garrison towns. A typical medical NGO in southern Sudan ran a onetotwo million USD per year programme (cofunded by internal sources and humanitarian donors, such as the OFDA, ECHO and DFID) supporting a hospital and/or 10–20 PHC facilities, frequently with a focus on one or more counties, but often with overlapping catchment areas, and employing between five and 10 expatriate health workers and 100–200 Sudanese staff. Severe implementation


difficulties (relating to underfunding, fragmentation and inefficiency of operations, a shortage of qualified Sudanese human resources, insecurity, a lack of access, and a forbidding operational and political environment) negatively affected both the geographic coverage and the quality of the health interventions supported. The World Bank, already involved in early assessments (Decaillet, Mullen and Guen, 2003; WB and UN, 2005a, 2005b, 2005c), was chosen as manager of the MultiDonor Trust Fund (MDTF), a recoveryoriented fundpooling mechanism set up by key donors, and in this capacity it engaged the MoH in developing a proposal for a sectorwide Health Umbrella Programme (HUP) (MoH and GoSS, 2006). The Global Fund to Fight AIDS, TB and Malaria channelled significant amounts of resources (42 million USD over five years) to NGOs in southern Sudan for tuberculosis and malaria control projects. A separate 26 million USD in the form of an HIV/AIDS grant experienced slower startup. The Principal Recipient of the grants was UNDP and the implementing agencies were NGOs and other UN entities. Similar to other basket funding mechanisms, subrecipients had a difficult relationship with the fund manager (in this case, UNDP). The GoSSled Country Coordinating Mechanism (CCM) rated the performance of UNDP as Principal Recipient as inadequate and decided to replace UNDP with Population Services International (an NGO) as Principal Recipient of the Malaria grant (Fenton, 2008). The USAIDfunded Sudan Health Transformation Project (SHTP), launched in April 2004 with the ambition of channelling 33 million USD to the health sector over five years, was the first attempt to offer assistance according to a longerterm developmental perspective. It provided financial support for MoH recurrent expenditures and it intended to deliver PHC services to 20 counties of southern Sudan (roughly corresponding to onethird of the country), but it encountered implementation difficulties and its initial ambitious scope had to be revised. By July 2008, the SHTP was supporting 25 Primary Health Care Centres and 120 Primary Health Care Units covering some 1.6 million people, or around 12 per cent of southern Sudan’s estimated population. USAID is contemplating a followup to the SHTP—SHTP2—which will inject 45 million USD between 2009 and 2011 into the health system in 12 counties, with a bearing on approximately 19 per cent of the southern Sudanese population (USAID, 2008). The Ministry of Finance and Economic Planning was involved in the development of the HUP to ensure that the budgetary implications of the programme were compatible with the requirements and the financial ceilings of the national budget. However, it did not get involved in any technical aspect of the programme. Most bilateral donors operated from Khartoum, the capital of Sudan, and were not directly involved in health sector policy development processes in southern Sudan. An important exception was USAID, which engaged the MoH mostly bilaterally and, not being part of the MDTF, did not participate in the development of the sector programme. Occasional contributions to the policy dialogue in the health sector were nevertheless made by DFID, ECHO and the Italian Development Cooperation. The relatively limited engagement of several donors in the recovery agenda


was surprising considering the primary role they had played during the humanitarian phase: virtually all of the funding for service delivery since the inception of Operation Lifeline Sudan had come from bilateral donors and had been channelled either through grants to NGOs or to UN agencies. The largest contributions to the humanitarian response in the health sector were made by USAID/OFDA, DFID, ECHO and NORAD. These same donors, joined by new ones which increased their involvement after the CPA—such as the Government of the Netherlands—remained the main financiers during the early recovery phase. The challenges to coordinating donor aid in postconflict situations are well established (Lanjouw, Macrae and Zwi, 1999). In southern Sudan, though, donor coordination did not represent a major problem. With the exception of USAID, most donors agreed to use a World Bankadministered MDTF as the main vehicle for reconstruction programmes in southern Sudan: by agreeing early on to a basket funding mechanism, they thus displayed a commitment to put into practice the aid harmonisation principles enshrined in the 2005 Paris Declaration on Aid Effectiveness.

Policy process and contentTo analyse the postconflict health reconstruction process, we employ WHO’s health system model and assess how the various building blocks of the system have been addressed. The WHO health system model (WHO, 2000) identifies stewardship, financing, generation of resources, and service provision as key functions of a health system (see Figure 1). In addition to the explicit health system objectives of reducing excess morbidity and mortality by expanding coverage of essential health services, responding to the

Figure 1 Health system functions

Source: WHO, 2000.


needs of beneficiaries and ensuring an equitable financial contribution system, another aim of the health sector reconstruction process in southern Sudan was to contribute to the broader peacebuilding efforts of the UN and its partners. The role of provision of social services in peacebuilding efforts was explicitly mentioned in the UN’s ‘Sudan Unified Mission Plan’, which stated that, in order to achieve its wider mission goals, the people of Sudan would ‘need to see a lasting peace dividend quickly, with the provision of basic social services (including water, health and education) . . .’ (UN, 2006, p. 57).

a) Stewardship

Stewardship, a quintessential function of government authorities, refers to leadership of the health system, in terms of establishing its overarching objectives, policies, strategies and regulations, as well as monitoring and evaluation (Murray and Frenk, 2000). In cases where there is no legitimate government authority, the function of stewardship can be lost or pooled among multiple stakeholders (Pavignani and Colombo, 2005a). In these settings effective coordination is essential (Buse and Walt, 1997). The MoH’s neartotal lack of capacity in the early postconflict phase translated into an absence of effective health sector leadership. The MoH was sidelined by decision processes in the health system: initiatives proliferated, often with no coordination and limited information sharing. To address this situation the coordination platform for the health sector was overhauled. For several years, threemonthly coordination meetings supported by UNICEF had focused on an agenda dominated by vertical programmes. In mid2005, a new coordination mechanism, called the Health and Nutrition Consultative Group (HNCG), was established, with clear MoH leadership, monthly meetings, participation restricted to a limited number of principal stakeholders, and an agenda oriented towards health sector recovery (WHO, 2006). This new structure became the venue for discussion of issues of sectorwide significance. However, after the departure of key individual players, coordination faltered, and the HNCG ceased to operate in early 2007; only recently have attempts been made to revitalise it. In late 2005, the MoH had ineffective management systems, an unclear internal division of responsibilities and poor communication procedures. Previous capacity-building efforts undertaken by several development partners entailed mostly the provision of training and equipment. It is well recognised, though, that in the presence of systemic deficiencies, capacitybuilding efforts should follow a hierarchy of needs (Potter and Brough, 2004) and prioritise the development of core managerial functions, without which the provision of material inputs is unlikely to be of any use. The MoH was therefore supported by the WHO in developing its organogram and decisionmaking structure; it was proposed that the Minister of Health and primary MoH officials form an Executive Board, vested with ultimate decisionmaking power. The terms of reference for the Executive Board and a MoH organogram were developed. However, the period was characterised by a severe political vacuum: the minister, nominated only in October 2005, was mostly absent; other


officials were present on a more regular basis, but in the dubious capacity of temporary caretakers. Consequently, these proposals could not be endorsed or made operational. A vital lesson from postconflict settings is the need for early development of an overarching policy framework to overcome the fragmentation and verticalisation typical of the humanitarian phase (Pavignani, 2005). Since early 2003, the WHO and the WB, filling government gaps, had assumed a lead role in formulating situation analyses and planning documents. In August 2003, the WB produced a Sudan Health Status Report (Decaillet, Mullen and Guen, 2003). The WHO assisted the SoH in developing the Health Sector Recovery Strategic Framework, released in March 2004 (Pavignani and SPLM, 2004). The WHO and the WB also collaborated on a Joint Assessment Mission ( JAM), whose report was presented to the International Donor Conference in Oslo, Norway, in April 2005 (Decaillet, Mullen and Guen, 2003; Pavignani and SPLM, 2004; WB and UN, 2005a, 2005b, 2005c). All three documents presented analogous recommendations for health sector reconstruction, identifying as cornerstones investment in management systems, human resources and infrastructure, and indicating NGOs as the main vehicle for service provision. MoH participation in these planning exercises was largely ceremonial. In September 2005, the MoH embarked on the development of a new Health Policy (MoH and GoSS, 2005), assisted in this process by DFID and the WHO. The new policy stated MoH commitment to a PHCoriented approach, equity, accountability and evidencebased decisionmaking. These new planning and policy documents, reasonably consistent with one another, sketched a vision of a health system in 2010 characterised by an effective partnership between:

• health authorities, firmly in the driving seat of the health sector in terms of policy formulation, data and needs analysis, planning, monitoring and evaluation, and not burdened by massive service delivery responsibilities;

• development partners committed to supporting consistently the recovery plan they helped shape; and

• NGOs, contracted out to deliver a basic package of health services in the context of a coherent policy framework and operating with dramatically improved efficiency standards.

With the caveat that baselines values were always the subject of much discussion due to the uncertainty surrounding the estimates, incremental targets (see Table 1) for various domains of health system performance were proposed in the framework of the Health Policy, the Health Sector Recovery Strategy, and later in the MDTF HUP (see the next section). The policy was supposed to be translated into a more operational Health Strategy, but it was overtaken by the concomitant development of the MDTF programme proposal (see the next section). The logical order of developing a Health Policy,


then a Health Strategy, and finally a programme proposal to finance it was subverted due to external deadlines: the programme proposal was developed before dialogue on the draft Health Strategy could even start. Once the MDTF programme was approved, debate on the Health Strategy became redundant.

b) Financing

Health financing refers to the mobilisation and pooling of financial resources for and their allocation to purchasers of health services and providers (Murray and Frenk, 2000). Before the CPA, in the SPLAcontrolled areas of southern Sudan, health financing mostly took the form of donor grants to NGOs and UN agencies. In 2002, the

Table 1 Quantitative targets for the southern Sudan health system in 2010

Dimension of health system performance Baseline (2004) Vision for 2010

Resource envelope (USD per capita) 7 11

Consultation per capita per year 0.1 – 0.2 0.6

Population with access to health care services 25% 50%

Skilled health workers (pre-service training of three years or more) 2,500 5,700

Hospitals 30 40

Primary Health Care Centres 100 240

Primary Health Care Units 550 800

Figure 2 Southern Sudan HUP financing structure

Source: authors.


southern Sudan budgetary allocation to the health sector was at least 55 million USD (Richer, 2002). In the early postconflict phase these mechanisms continued to exist, but in addition, the MDTF was established. Most importantly, the GoSS seemed to be in a position to share the health expenditure burden, thanks to the oil revenues (see Figure 2). The MDTF was set up after the Oslo donor conference as a developmentoriented fundpooling mechanism, stipulating that donor money should in the aggregate be matched by domestic resources with a 1:2 ratio (every dollar from donors to be matched by two dollars from government) (WB, 2008a). As of September 2006, more than 500 million USD had been pledged to the MDTF (see Figure 3). Since mid2005, the WB, as the MDTF manager, engaged the MoH in the preparation of a sectorwide Health Umbrella Programme (MoH and GoSS, 2006); the MoH requested the assistance of the WHO in its development. The final proposal, endorsed by sector stakeholders, was approved in February 2006. The HUP, acknowledging the MoH’s deeprooted lack of capacity, envisaged the contracting out of many important functions of the health sector. The programme was articulated into eight components (see Table 2): the MoH would subcontract partners for each of them, either to supply the services directly or to provide assistance to the MoH itself. Multiple contractual relationships were envisaged for each component of the programme, and detailed definition of these would occur during the implementation phase. A tension soon emerged between a longterm development perspective and the need for quick wins to demonstrate the peace dividend of the CPA. With the latter objective in mind, a component called ‘high impact health interventions’ was created, grouping mosquito nets procurement and distribution, provision of water filters, procurement of emergency drugs for the health

Source: MDTF, 2006a.

Figure 3 MDTF Sudan


facilities of garrison towns (virtually abandoned by the GoS after the CPA and therefore facing severe drug shortages in the immediate postconflict period), and other elements. Health service delivery contracts were supposed to assign, through a competitive tendering process, the delivery of a basic package of essential health services in distinct geographical areas to nonstate providers. These service delivery contracts, once operational, would become instrumental to the delivery of interventions supported by vertical programmes. Despite a sound programme design and the endorsement of the most important sector stakeholder, the MDTF HUP proved to be very slow in disbursement and ineffective in operationalising the recovery of the southern Sudanese health system. As of May 2008—more than two years after winning approval—it had spent only 20.3 million USD of 60 million USD of signed grant agreements and 135 million USD of the resources allocated for the first two years according to the initial financial plan (see Table 3) (WB, 2008b). While this is a long period of time, it is worth putting things in perspective: during the Afghanistan postconflict rehabilitation phase, for instance, which started around January 2002, the first service delivery contracts were signed towards the end of 2003, also nearly two years into the postconflict era. It is also important to note that a very significant proportion of the MDTF resources spent went on commodity procurement, such as three million USD worth of drugs, approximately one million mosquito nets, and 49 vehicles for the MoH GoSS and tertiary hospitals. Little has been spent so far on investment in the building blocks of the health system, including new health workers, rehabilitation and construction of health facilities, and building of capacity in management and information systems. Because of the shortcomings of the MDTF, the funding instruments created as part of the humanitarian response continued to play a very important role in the early

Table 2 MDTF HUP synopsis

MDTF programme component Year 1 Year 2 Year 3 Total

1. Development of public health administration 4.5 6.7 4.9 16.1

2. Infrastructure and equipment 8.9 27.5 27.8 64.2

3. Pharmaceutical capacity 5.7 1.1 1.2 8.0

4. Health human resources development 4.2 4.9 5.1 14.2

5. Expansion of health service delivery 24.8 22.7 40.5 88.0

6. High-impact health interventions 8.4 6.8 5.7 20.9

7. Monitoring and evaluation 2.5 3.3 3.4 9.2

8. Programme implementation 1.1 2.0 1.4 4.5

Total (USD) 60.0 75.0 90.0 225.0

Note: totals may not add up exactly due to rounding.Source: MoH and GoSS (2006).


recovery period. Most bilateral channels were left open and were still—three years after the CPA—the main financing modality of the health system: these included the OFDA and ECHO in the first place, followed by other bilateral donors. Among the latter, a particular case in point was the Basic Services Fund (BSF) set up by DFID in anticipation of a gap between the end of the humanitarian phase and the operationalisation of the MDTF—it was explicitly designed therefore as a bridging mechanism (Murphy, 2007). Established in early 2005 with only 17 million GBP, the BSF was not meant to be a large funding instrument, but, from the perspective of the service providers, it was one of the most effective, and the projects it supported had a tangible bearing on beneficiaries. A Common Humanitarian Fund (CHF) was set up in 2006 as part of the UN reform agenda, aimed at strengthening UN coordination at the country level: donors would provide reliable funding to support priority projects within the UN Work Plan indicated by an empowered UN Humanitarian Coordinator. The CHF received a positive review (WillittsKing, Mowjee and Barham, 2007), but, despite considerable flexibility to accommodate recovery activities, it remains a humanitarian funding instrument, and it enjoys limited government ownership and participation. Given the problematic experience with the MDTF, donors, in 2007, requested that the UN set up a Sudan Recovery Fund (SRF) with the objective of addressing immediate recovery needs more effectively through easier and faster disbursement procedures. Even though initially it was thought that the SRF would provide funding aligned to the priorities of the UN Work Plan and/or the UN Development Assistance Framework (UNDAF), recognising the potential for conflict with the MDTF, it was agreed that the SRF would instead operate under the governance arrangements of the MDTF and fund recovery activities complementary to it (Fenton, 2008). With a renewed emphasis on alignment with government priorities and planning mechanisms, it is unclear whether the SRF will prove to be less cumbersome than the MDTF. With regards to the domestic revenue base to finance the health system, the wealthsharing protocol, a cornerstone of the CPA, was expected to ensure financial sustainability of the health system through the transfer of 50 per cent of oil revenues to the GoSS. Exact figures visàvis expected financial transfers to the GoSS were unknown, but MoFEP officials hoped to receive 750 million USD per year, of which supposedly more than 100 million USD was intended for health (IRIN, 2006). Under these assumptions a 225 million USD programme was developed, with a GoSS threeyear

Table 3 MDTF HUP disbursement and expenditure vis-à-vis commitments

Commitments (grant agreements signed)

Contracts signed Disbursement Actual expenditure

MDTF GoSS Total MDTF GoSS Total MDTF GoSS Total MDTF GoSS Total

20.0 40.0 60.0 14.4 28.9 43.3 10 .0 18.0 28.0 7.3 13.0 20.3

Note: all figures in millions of USD.Source: adapted from WB (2008b).


commitment of 150 million USD. In reality, the flow of oil resources faltered, putting in jeopardy the CPA (ICG, 2007) and the financial sustainability of the health sector programme. The MDTF funding ratio of 1:2 (originally envisioned) was changed, with a revised commitment of 125 million USD from the MDTF and 100 million from the GoSS (Khama, 2008). Prior to the CPA, a previous SoH policy document (SPLM, 1998) had established a decentralised userfees system, aiming to cover 30 per cent of recurrent costs. Experience with the system was mixed, with total revenues amounting to only one per cent of recurrent expenditure (Erasmus and Nkoroi, 2002). The potential negative effect of user fees as a financial barrier contributing to poor access was not studied extensively in southern Sudan: according to the study by Erasmus and Nkoroi (2002), however, the introduction of user fees was associated with a reduction in attendance at PHC facilities of 47 per cent at three months and 41 per cent at one year; a similar decline was reported for inpatient attendance at a rural hospital. Despite the evidence gaps (this study was small scale) and the inconsistent implementation of the policy in southern Sudan, it is reasonable to assume that, as documented in other similar contexts (Poletti, 2003), user fees contributed to the low utilisation of health care services by the population (90 per cent of which, according to the New Sudan Centre for Statistics Evaluation, were living on less than one dollar per day). A prescription to adopt user fees appeared in the first draft of the new health policy, but was criticised by the WHO on equity grounds and by the WB for contradicting the Constitution’s commitment to free primary health care. Subsequent drafts of the health policy made no reference to user fees and did not prescribe their use, but their role continued to be debated.

c) Generation of resources

A health system needs a supply of human resources, infrastructure and drugs. Each area was a specific component of the MDTF programme; early technical assistance work was planningoriented, and the actual provision of inputs was to occur primarily through the MDTF programme. A detailed assessment of the human resources area was conducted in 2005–06, with the technical assistance of the WHO and the African Medical and Research Foundation (AMREF) (WHO, 2006), and revealed a mostly unskilled, unevenly distributed health workforce, fragmented across multiple management systems, with a lack of accreditation systems and an absence of uniform curricula. From a quantitative perspective, the health workforce was small in absolute terms (1.5 health workers per 1,000 populations), but relatively large (11,800) compared to the slim health care network that it was supposed to staff (around 30 hospitals and 700 PHC facilities). MoH capacity at both the central and peripheral level was limited. The survey failed to translate into an operational plan and lead to the production of standardised job descriptions or training curricula. However, one of the first MDTF programme contracts to be signed awarded AMREF (an important player in human resources development throughout the crisis) a key role in the education and training


of new cadres. AMREF subsequently supported the MoH in the preparation of a new human resources development plan (MoH and GoSS, 2007), which drastically revisited the recommendations formulated in the earlier assessment and proposed very ambitious targets for the development of new health workers, setting a goal of 23,000 health workers, a figure that seems high in relation to both the size of the health care network to staff and the capacity of southern Sudan to train new cadres. Limited progress was registered in the pharmaceutical area. The MoH developed an essential drug list and standardised primary healthcare guidelines (MoH, 2006). In the more fundamental area of a comprehensive policy and drug procurement plan, however, there was a total breakdown in consultations between the MoH and the WHO, the latter being excluded from the development of MoH pharmaceutical policy (MoH, 2005), which was produced prior to the general Health Policy with the support of a Kenyan pharmaceutical company. The MDTF programme’s pharmaceutical component was largely unrelated to the MoH’s policy and it entailed the establishment of procurement capacity in the MoH. No practical steps were taken, though, to establish this capacity before the implementation phase of the HUP. The MDTF HUP supported the procurement and distribution on an emergency basis of drugs to supply health facilities no longer supported by the GoS after the garrison towns were taken over by the GoSS, but to date, very limited investment has been made in strengthening the current procurement, storage and distribution capacity. An infrastructure assessment was performed (Christian Health Association of Sudan, 2007). A questionnairebased survey confirmed the existence of at least 754 health facilities, with one hospital bed per 1,404 inhabitants. This latter figure, not very low per se, masks however the tremendous disparities in access, with most inpatient facilities concentrated in the garrison towns and inaccessible to the majority of the population of southern Sudan. According to the JAM strategy and the MDTF programme, in the initial postconflict years only rehabilitation works would take place, with the bulk of the new infrastructure development to happen later. Therefore, detailed areabased plans, standard layouts and costing guidelines for health infrastructure expansion were not developed in the early postconflict phase. Training, infrastructure development and drug procurement continued via the usual humanitarian channels throughout the early postconflict phase without central guidance. At the time of writing (mid2008), the MoH GoSS was still in negotiation with the statelevel offices of the MoH to launch a largescale programme of health facility renovation.

d) Service deliverySimilar to other postconflict settings, southern Sudan opted to contract out the bulk of service provision to NGOs. Contracting out, although debated (Mills, 1998; Palmer, 2000; Palmer and Mills, 2004), can enhance the efficiency and equity of service provision (Loevinsohn and Harding, 2005; MoPH, JHSPH and IIHMR, 2005, 2006; Newbrander, Yoder and Bilby, 2007; Peters et al., 2007; Richards, 2007; Eichler, Axila and Pollock, 2001; Loevinsohn and Sayed, 2008).


The potentially greater efficiency of the private sector in providing services, the unanimous recommendations made by the health sector assessment studies to use NGOs for health service delivery, the virtual absence of public provision of health services outside the garrison towns, the possible focus on performancebased contracting, and a drive towards decentralisation were all arguments used by the primary drivers of the policy process (the WHO and the WB). The Afghanistan postconflict recovery experience in particular was very instrumental in the policy dialogue (Palmer et al., 2006; Strong, 2003; Strong, Wali and Sondorp, 2005). In certain postconflict settings, where dependency on nonstate providers is entrenched and government capacity extremely feeble, contracting out service delivery can represent the only feasible policy option: Afghanistan and eastern Congo have adopted the model on a large scale in recent years (Loevinsohn, 2008). Although questions have been raised about the longterm impact of this approach on health system development, the initial evidence emerging from Afghanistan seems to corroborate the thesis that contracting out health services can allow rapid and significant improvements in health services coverage and hence represents an appealing possibility in certain settings (MoPH, JHSPH and IIHMR, 2005, 2006; Peters et al., 2007; Richards, 2007; Loevinsohn and Sayed, 2008). The model to contract out provision of health services to NGOs encountered, initially, a lukewarm response in parts of the MoH, which felt largely sidelined by the decisions of NGOs and had often expressed reservations about their operations. Whereas the option to contract out health services in southern Sudan was a universal policy prescription (Pavignani and SPLM, 2004; Decaillet, Mullen and Guen, 2003), care was taken to organise frequent onetoone briefings of senior MoH decisionmakers. Eventually, the MoH selected this model as there seemed to be no feasible alternative, given that NGOs were already providing the bulk of services and the government infrastructure and administrative apparatus was not ready to take over NGOrun health facilities and programmes. The transition between the humanitarian phase and the postconflict ‘contracting phase’ would occur through a consolidation of NGO operations: contracts would be awarded on a geographical basis to agencies that would be responsible for service delivery in a given area. A Basic Package of Health Services (MoH and GoSS, 2006) was developed with the assistance of the WHO to promote uniform service provision standards and to assist in the costing of contracts. The contracting of partners for all the programme components was advertised in mid2006 (MDTF, 2006b); by August 2007, however, only a few contracts (for human resources training, infrastructure assessment, and procurement of mosquito nets and other commodities) had been signed. With regard to service delivery, of the contracts awarded to NGOs and private sector agencies, which were supposed to be the main vehicle for expanding coverage of PHC services, none was signed until earlytomid 2008. In mid2008, there was finally an acceleration of the contracting process and by the end of 2008, four service delivery contracts (covering four of the 10 states of southern Sudan) had been signed (Khama, 2008).


Humanitarian operations continue to provide services, but since humanitarian funding may soon cease, a similar transitional gap as was encountered in Liberia (Sondorp and Msuya, 2005) may emerge with a factual contraction of health services available to the population. Several actors engaged the MoH in early discussions on the development of an integrated health management information system, but progress was hard to track.

DiscussionSouthern Sudan is a paradigmatic example of how context, actors and processes interact in determining policy outcomes (Walt, 1994). A government with virtually no public sector management experience emerged from the conflict. Garang’s death worsened the political vacuum in the GoSS, which forced external actors to become primary drivers of policy change. Limited MoH capacity in this phase should not surprise: in late 2005, the GoSS had just been established after decades of conflict, had lost its leader, and was in the process of relocating from Kenya to southern Sudan. Between ‘forming’ and ‘performing’ a period of ‘storming’ and ‘norming’ should have been expected (Tuckman, 1965). Against this backdrop, various actors, with different perspectives and agendas, entered the health policy arena. The WHO and the WB played a dominant role in shaping postconflict recovery, leading a dialogue with the MoH GoSS that resulted in the development of a sectorwide health development programme centred on the strategy of contracting out many health sector functions. Interactions among key institutions played a key role in determining policy outcomes (Varvasovszky and Brugha, 2000; Brugha and Varvasovszky, 2000). The principal drivers of policy development (the WHO and the WB) adopted several actor management strategies to mobilise support for the desired—in their eyes—course of action and to minimise influential opposition. The WHO and the WB operated in synergy to mobilise backing from MoH officials, supported the involvement of NGOs through a new coordination structure and their participation in MDTF HUP development, coordinated sector stakeholders in the establishment of a shared vision, and actively countered possible opposition by some elements of the UN system by supporting the MDTF HUP in public fora and by explaining that UN agencies could participate in future MDTF tenders. The relative power of external policy actors changed rapidly in the postconflict period. As the coordination structure supported by UNICEF was abandoned, the WHO temporarily assumed a leading role in technical assistance matters; the creation of the MDTF made the WB—in theory—the principal financier of the health system, replacing USAID. A fundamental factor in understanding the reasons for the disappointing pace of the reconstruction process was that continuity and consistency of efforts was frustrated by dramatic fluctuations of capacity among key agencies. High staff turnover in the MoH and its main advisory partners meant that key individual actors changed


too, influencing the capacity of agencies to follow consistently a course of action for the health sector recovery process. The limited number of fulltime dedicated people with primary responsibility for coordinating the health sector recovery agenda (totalling three of four among the MoH GoSS, the WHO and the WB) meant that whenever one of these posts was left vacant, activities could stall for months. A variable contributing to the high staff turnover was the forbidding living conditions in Juba, the new capital of southern Sudan: the expectation that senior staff—both MoH and UN partners—would easily adapt to living in tents (from the comfortable lifestyle of Nairobi, Kenya) in an area characterised by restrictions on movement, absence of health and education services of international standards, high malaria endemicity, periodic cholera outbreaks and persisting insecurity was misplaced. Although this problem was not confined to the health sector recovery agenda, attrition among key staff members who were unwilling or unable to relocate on a permanent basis to a nonfamily duty station was an important factor in the stalling of the recovery process. Neither the UN nor the MoH foresaw this risk, so preventive measures to mitigate the problem—such as hardship allowances, flexible working and travel arrangements, and timely construction of appropriate accommodation and working facilities in Juba—were not introduced. The high attrition rate that followed the movement of the MoH and its main partners from Nairobi to Juba should not have come as a surprise. The contracting out of the majority of health system functions to entities other than the MoH occurred partly because of the potential greater efficiency and equity of private notforprofit sector providers, but also partly because of the MoH’s deepseated lack of capacity. The assumption was that, not having internal capacity to deliver services on its own, the MoH would be better advised to procure them from other agencies and organisations. It turned out, however, that the MoH did not have much procurement capacity either (IRIN, 2006).

Conclusion The early postconflict phase in southern Sudan saw the main stakeholders agreeing to a common policy framework formally owned by the GoSS. The start of recovery activities was disappointingly slow, though, with limited progress in the three years after the peace agreement (CPA). The stagnation in health service coverage has been mirrored by only marginal improvements in the governance of the health sector, as testified by the very slow pace of implementation and the low budget execution rate of the MDTF HUP. Recovery was speedier in other postconflict settings (Strong, Wali and Sondorp, 2005). Several factors may explain why the pace of recovery in southern Sudan was slower than in other countries: extremely limited MoH capacity and inconsistency in providing the sorely needed technical assistance are, in our view, the main factors. In addition, it is worthwhile pointing out that execution of the plan envisaged faltered: the MDTF apparently has not succeeded in creating efficient mechanisms


to disburse money, and it has set up tendering mechanisms that are more suitable for private contractors rather than appropriate for the southern Sudan context (where service provision was dominated by notforprofit NGOs) (Fenton, 2008). In the early recovery process, external actors drove policy change and often outpaced the capacity of government authorities. Finding the right balance between national ownership of policies and an acceptable level of effectiveness was a major challenge. The southern Sudan recovery process was similar in many ways to that in other settings, including persisting insecurity, faltering implementation of the CPA (ICG, 2007), and a lack of clarity regarding the sources of financing (transfers of oil revenues from the GoS proved very hard to track). The main differences that perhaps made the southern Sudan case particularly complex related to the very sparse population (roughly eight million people in an area larger than France) and, most importantly, almost negligible government capacity, with the MoH having never managed—as an institution—the health system, and most of its staff having health service management experience only in the context of NGO and UN humanitarian operations. Despite these differences, general patterns encountered elsewhere (Pavignani and Colombo, 2005b) broadly applied to this context and, conversely, the lessons learned in southern Sudan can be applied elsewhere.

Lessons learned

The importance of the coordination of external actors is well established (Buse and Walt, 1997). In southern Sudan, furthermore, a key factor in establishing a successful cooperative framework was the creation of a new coordination platform. This permitted the bringing to the fore of the recovery agenda while avoiding conflicting initiatives. It gave the SoH/MoH a more prominent role, involved service providers and generated consensus on the contracting out scheme. Table 4 summarises the main differences between the old and the new coordination structures. The initial relative success of the HNCG was tempered by its dependency on individuals to take it forward. When these individuals left, the activities of the HNCG stalled.

Table 4 Old and new health coordination structures in southern Sudan

Old coordination structure New coordination structure

(Health and Nutrition Consultative Group)

Frequency Quarterly Monthly

Membership All health sector partners Restricted to meaningful representative stakeholders

Leadership Unclear MoH

Agenda Updates on vertical programmes Sector-wide recovery

Meeting minutes Average 150 pages, distributed during the following meeting

Five-to-10 pages, distributed electronically a few days after each meeting


Health planning processes have been described as ‘muddling through’ (Lindblom, 1959), making reference to the incremental nature of policy change. Postconflict settings present, however, a window of opportunity to introduce bolder rationalist approaches (Banfield, 1973), giving scope for evidencebased planning. Even with the support of technical and financial external assistance, though, it is unlikely that a MoH in an early postconflict phase has sufficient capacity for all comprehensive planning processes. A ‘mixed scanning’ approach (Etzioni, 1973) should prevail: the whole health sector should be analysed, but only a few priority areas should be explored in more detail. Another positive aspect of the process was the engagement strategy with the MoH. The 2:1 funding ratio requested by the MDTF left little scope for donor conditionality and leverage based on financial power. Open and patient dialogue, the exposure to international evidence and best practices, and an indepth knowledge of the local context worked to convince the GoSS to commit significant domestic resources (150 million USD), reflecting genuine endorsement of the programme. The importance of a participatory approach cannot be overemphasised: through an inclusive consultative process and frequent oneonone meetings with key stakeholders, it was possible to garner support for the HUP and to minimise powerful opposition from influential actors. Stakeholder analysis and active actor management strategies were a fundamental part of this consensusbuilding effort. The most important failure of the recovery process pertained to its time frame. An unequivocal boost in recovery activities only occurred in mid2005, with the deployment of fulltime dedicated WHO and WB staff: much time and goodwill was consumed in the preceding years. The first two years after the CPA were spent conducting the necessary technical and administrative work that had to happen before implementation of the HUP could start, including the preparation of a detailed project plan, annexed technical documents, guidelines, thematic area situation analyses and development plans, and the establishment of the necessary administrative and fiduciary arrangements. These preparatory activities cost approximately one per cent of the total programme value. Earlier investment in such planning efforts could have led to earlier availability of necessary data and tools and swifter launching of the programme while responding to the wish of the SoH/MoH to move forward quickly and thereby fully utilise the peace dividend. The UN and the WB apparatus appeared at times excessively complex and bureaucratised to be effective in spearheading the recovery process. The WBadministered MDTF of southern Sudan was governed by a more cumbersome structure than a traditional WBfunded project (such as the one that was used as a health sector funding instrument in Afghanistan, where recovery proceeded at a relatively faster pace). A conclusion from lessons learned in the southern Sudanese health sector recovery phase is that policymakers, donors and technical agencies need to display more consistency in early assessments and planning efforts if they intend to achieve rapid improvements in the population’s living conditions. Expanding access to evidencebased health care services has a proven impact on the reduction of morbidity and


mortality, and as a part of a broader postconflict recovery agenda, it can contribute to the reinforcement of the peacebuilding process ( Jones, 2006). Donors must understand the need to support these vital preparatory activities from an early stage, which should ideally commence before the conflict formally ends. This would permit the initiation of the recovery process as soon as the political conditions allow for the scaling up of investments and a shift from the humanitarian emergency mode to the recovery and development one. Ultimately, this could result in speedier expansion of access to health services and in a reduction in excess morbidity and mortality. Specialised agencies, such as the WB and the WHO, which have the mandate and the technical capacity to support such planning activities, should demonstrate more coherence and consistency in this early reconstruction phase (Shuey et al., 2003), ensuring that quality human resources are attracted and retained to assist government authorities. In a challenging environment—as south Sudan undoubtedly is—a strategy to staff technical assistance programmes should achieve the right combination of senior staff who possess the necessary experience and diplomatic skills and early career personnel who are willing to endure more difficult living conditions. As for what concerns the main outcome of the policy process in southern Sudan, the contracting out of most MoH functions, not much can be said at this early stage. Careful followup on the implementation of this health sector programme and its impact on the health of the population of southern Sudan should occur. An early analysis of unfolding events in southern Sudan, however, points to fallacies in the traditional paradigm of outsourcing what cannot be directly managed: in the absence of meaningful procurement and contract management capacity, progress can be hard to track even with outsourcing. Support for building the procurement and financial management capacity of new (or newly legitimised) government authorities should be prioritised therefore in the early postconflict phase. The stringent procurement and tendering procedures that emerging government authorities are required to abide by, while providing reassurance on the transparency and effectiveness of use of development aid, represent a significant obstacle to rapid scalingup of services. The international institutions should strive to streamline these requirements to the extent that this is possible, and provide recipient governments with timely and consistent incountry technical assistance with procurement and programme management to minimise delays associated with administrative requirements. Multiple options exist in terms of financing the recovery of a disrupted health sector. In southern Sudan, donors seemed to prefer fundpooling arrangements. Wendy Fenton (2008) has documented in more detail the structure, objectives, successes and shortcomings of the main funding instruments operating in southern Sudan. The appropriate mixture of funding instruments in early recovery situations is likely to be contextspecific, and it is likely to depend on unforeseeable factors, including the capacity of agencies to attract and retain personnel of the necessary calibre who can guarantee sustained leadership of the recovery programmes. The structure and operational modalities adopted by the various funding instruments should be designed—or at least tailored—according to the local context, and be made responsive to the local realities facing sector stakeholders.


The applicability of the Paris harmonisation and alignment principles in the postconflict recovery process should not be taken for granted (OPM and the IDL, 2008), but evaluated from an evidencebased and pragmatic perspective. Donors should maintain flexibility in channelling their support to the financing mechanisms that are proven to provide the best tradeoff between effectiveness in expanding service coverage and in building the capacity of nascent government authorities. In southern Sudan, no funding mechanism seems to have struck the right balance so far.

AcknowledgementsWe would like to thank our former colleagues and partners in southern Sudan for patiently sharing views and insights with us that enabled the preparation of this report.

CorrespondenceGiorgio Cometto. Email: [email protected]

Endnotes1 Giorgio Cometto, MD, MSc is an independent specialist in health policy, planning and financing;

Gyuri Fritsche, MD, MSc is an independent specialist in health policy, planning and financing; and Egbert Sondorp, MD, MPH is Senior Lecturer in Public Health and Humanitarian Aid at the London School of Hygiene and Tropical Medicine, United Kingdom.

2 The contents of the paper represent exclusively the views of the authors and not those of their past or current employers.

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