july 2018 collapse - unicef...a call to action 1 executive summary if polio eradication succeeds but...

aA call to action

A call to action

JULY 2018

COLLAPSEWhat the end of polio funding could mean for South Sudan’s immunisation systems and what we can do about it

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The authors would like to thank Penelope Campbell, Kuotong Rogers and Jennifer Banda (UNICEF South Sudan); Dr Maleghemi Sylvester (WHO South Sudan); and Dennis King and Shalini Rozario (UNICEF Headquarters) for their support throughout the production of this document.

We would also like to thank the stakeholders who gave us their time to be interviewed: Dr. Samson Baba (Ministry of Health, Republic of South Sudan); The Honorable Catherine Peter Laa (National Parliament, Republic of South Sudan); Dr Mathew Tut Moses, Solomon Anguei and Dr Zecho Gatkek (Ministry of Health South Sudan); Victoria Graham and Dr Basilica Modi (USAID, South Sudan); Dan Pike, Morris Ama and Georgina Krause (DFID South Sudan); Alice Gilbert (DFID Headquarters); Grace Lee (Embassy of Canada, South Sudan); Sonja Nieuwenhuis and Dr Camene Odenyo (Health Pooled Fund, South Sudan); Takanobu Nakahara (Embassy of Japan, South Sudan); Rachel Seruyange and Anthony Laku (WHO South Sudan); Carl Hasselblad (McKing Consulting for Bill and Melinda Gates Foundation); Dr Margaret Hercules (CDC); Dr Mokaya Evans (CDC/AFENET); Peter Lado Jaden Aggrey (World Bank, South Sudan); Chali Selisho (UNDP South Sudan); Dr Lydie Maoungou Minguiel, Samuel Patti, Gopinath Durairajan, and Jean Luc Kagayo (UNICEF South Sudan); and Afework Assefa (UNICEF ESARO).

All mistakes are the responsibility of the authors.

Authors Jessica Koehs and Matthew Gibbs on behalf of DevSmart Group LLC - www.devsmartgroup.com

July 2018

Photographs: © UNICEF/Rich

Design by Inís Communication – www.iniscommunication.com

A call to action

JULY 2018

COLLAPSEWhat the end of polio funding could mean for South Sudan’s immunisation systems and what we can do about it

Contents

Acronyms and definitions i

Executive summary 1

Introduction 4

1.1 Country context 6

1.2 The ramp down of GPEI in fragile states 8

What has the Polio Programme brought to South Sudan? 9

What will the impact of the Polio Programme ramp down be? 14

Looking beyond the Polio Programme at the critical functions 17

4.1 What are the critical functions and why are they critical? 17

4.2 What are the risks if these functions do not continue? 18

4.3 What does this mean for the health system in South Sudan? 19

4.4 What does this mean for the health of the population at large? 20

Options to absorb critical functions identified by the Government of South Sudan and partners 21

Option 1: The Boma Health Initiative 21

Option 2: Integrated Disease Surveillance and Response 22

Option 3: Routine immunisation within primary healthcare 22

Option 4: Mixed distribution of assets within the entire health system with focus on the three health priority areas 22

Barriers to leveraging the resources to support these options 23

6.1 Political and economic barriers 23

6.2 Programmatic barriers 24

The last option – Preventing collapse by maintaining the bare minimum for surveillance,

routine immunisation, community mobilisation and outbreak response 25

Call to action 27

1.

2.

3.

4.

5.

6.

7.

8.

iA call to action

Acronyms and definitions

AFENET African Epidemiology Network of CDC

AFP acute flaccid paralysis

BHI Boma Health Initiative

BMGF Bill and Melinda Gates Foundation

BPHNS Basic Package for Health and Nutrition

DTP diphtheria-tetanus-pertussis vaccine

DTP3 Third dose of the diphtheria-tetanus-pertussis vaccine

CDC Centers for Disease Control and Prevention

CGPP CORE Group Polio Project

DFID United Kingdom Department for International Development

ECB EPI Capacity Building Programme

EPI Expanded Programme on Immunisation

GAVI Vaccine Alliance

GHSA Global Health Security Agenda

GPEI Global Polio Eradication Initiative

HMIS Health Management Information Systems

HPF Health Pooled Fund (for South Sudan)

HR human resources

ICCM Integrated Community Case Management

IDSR Integrated Disease Surveillance and Response

M&E monitoring and evaluation

MSF Médecins Sans Frontières

MOH Ministry of Health

NGO non-governmental organization

NPO National Programme Officer

RI routine immunisation

SIA supplementary immunisation activities

UNICEF United Nations Children’s Fund

USAID United States Agency for International Development

WASH water, sanitation and hygiene

WHO World Health Organization

DefinitionsBoma Lowest-level administrative division in South Sudan, below payams

Payam Second-lowest-administrative division in the Republic of South Sudan, below the county

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1A call to action

EXECUTIVE SUMMARY

If polio eradication succeeds but poorer countries’ public health services collapse in the initiative’s wake, it would be a major failure of global governance and stewardship. The risks to global health and to vulnerable populations are high if the polio transition process is mismanaged.

The End of the Beginning: First Report of the Transition Independent

Monitoring Board of the Polio Programme, July 2017

The Global Polio Eradication Initiative (GPEI)1 is the main health programme reaching children across South Sudan, the world’s youngest and most fragile state.2 No other initiative has so successfully accessed the most vulnerable and hardest to reach communities despite armed conflict, migrating communities and natural disasters.

Globally, GPEI has protected millions of children from polio since 1988 and the “global incidence of polio has decreased by 99.9%”.3 South Sudan has not reported a case of wild polio virus since 2009.4

1 Transition Independent Monitoring Board, The End of the Beginning: First Report of the Transition Independent Monitoring Board of the Polio Programme (Transition Independent Monitoring Board, July 2017), pg 3

2 Messner, J.J., 2017 Fragile States Index (Washington: The Fund for Peace, 2017), pg 8

3 “Our Mission”, The Global Polio Eradication Initiative, accessed June 11, 2018, http://polioeradication.org/who-we-are/our-mission/

4 “South Sudan”, The Global Polio Eradication Initiative, accessed July 5, 2018, http://polioeradication.org/where-we-work/south-sudan/

In South Sudan, GPEI has also helped to create the key structures for both polio vaccination and routine immunisation (RI) in the country. Thus, polio-funded assets ensure many other life-saving vaccines and services reach women and children and that outbreaks of diseases like cholera and meningitis are quickly addressed nationwide.5

As GPEI continues to work towards global polio eradication, GPEI funding in some countries, particularly in the non-endemic ones, will gradually ramp down over the next few years. For South Sudan, this will mean declining support to critical activities, such as a national system for disease surveillance and outbreak response, immunisation campaigns, social mobilisation networks, and a cold chain network that provides potent vaccines to the most remote and isolated portions of South Sudan. In order to ensure continuation of polio essential functions beyond GPEI funding, other resources need to be mobilized.

The end of the Polio Programme must be seen in the context of South Sudan as a fragile state. The situations in fragile states have prevented

5 Global Polio Eradication Initiative, Investment case, (Geneva: World Health Organization, March 2017), pg 21

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governments from investing time and resources into developing systems – while donors have been focusing on humanitarian response. Unlike other more stable countries, these functions will not be absorbed by a waiting health system. On the contrary, South Sudan’s fragile health system is built upon these polio structures and must find a way to maintain its key functions.

While the Government of South Sudan and partners have come up with various options for transition of the polio assets, there are significant political, economic and programmatic barriers that make uptake of the options challenging at the present time. In light of this situation, implementing partners and donors who already fund many components of the health care system recommend a contingency plan, partly because there is hesitation about investing in long-term development programmes during a protracted emergency and partly because there are insufficient funds available to cover all that the options presented need to run effectively.

Call to ActionTo avert a public health crisis, South Sudan needs to maintain, as a minimum, active surveillance, better immunisation coverage, strong resilience – through social mobilisation – and robust outbreak response capacity. Supporting fragile states through a longer transition period must be a political priority nationally, regionally and globally. We call upon high-level stakeholders to come together to acknowledge the special case of South Sudan and other fragile states in the context of the global GPEI ramp down and formulate plans to help these states fortify routine immunisation and supporting systems.

WHAT’S AT RISK?

DISEASE SURVEILLANCE

Active case-based surveillance would end and the quality of available data would dramatically decline.

OUTBREAK RESPONSE

The ability to detect outbreaks of vaccine preventable disease and to support critical frontline staff in the field will severely deteriorate.

IMMUNISATION

All immunisation figures for the population would further decline. All supplementary immunisation activities would stop (or be of poor quality), ending the most effective health interventions in the country.

COMMUNITY MOBILISATION

Social mobilisation activities promoting health-seeking behaviour would be reduced by about 50 per cent.

VACCINE INTEGRITY

The cold chain would be interrupted, severely limiting vaccines getting to end-users.

3A call to action

RECOMMENDATIONS

1. Support routine immunisation and continue campaigns Routine immunisation processes and functions must be progressively transferred to the Ministry of Health to ensure sustainability and avoid parallel structures. Strengthening the Expanded Programme on Immunisation (EPI) needs to be a key priority.

2. Maintain funding for health-based community mobilisation Ensure continuity in fostering behaviour change in terms of health-seeking behaviour, the creation of a demand-based culture and community awareness of rights. South Sudan is fragile and communities are vulnerable, so this work is critical to building resilience and ensuring rights are recognised.

3. Maintain active surveillance Nationally, South Sudan currently runs different surveillance systems in health and in other sectors. A streamlined system would reduce gaps in disease surveillance, ensure the same quality of surveillance for all risk monitoring and improve inter-sectoral collaboration. Internationally, South Sudan should collaborate with its neighbours in information sharing, surveillance and response capacity to maintain minimum standards in the detection of and response to infectious disease threats.

4. Monitor relevant initiatives The options presented by the Government of South Sudan, like the Boma Health Initiative, should be carefully monitored so that polio assets can be transferred to them when they can successfully absorb them.

5. Reorganise current funding streams to include vital parts of the polio structure While funding for 2018 is already allocated for the Health Pooled Fund, GAVI and other major donors’ portfolios in South Sudan, it would behove these donors to reconsider whether more funding to cover this transition and strengthen routine immunisation, surveillance, social mobilisation and outbreak response needs to be integrated into their portfolios.

6. Initiate a Fragile State Fund for Routine Immunisation, surveillance and social mobilisation South Sudan is not the only fragile state that could put national, regional and global health at risk if the already tenuous immunisation and surveillance systems stop working. A new pooled fund structure could allow donors to support several fragile states at the same time while preventing duplication of efforts by working bilaterally with each.

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INTRODUCTION1The GPEI is the main health programme reaching children across South Sudan, the world’s youngest and most fragile state.6 It has helped to create the key structures for both polio vaccination and routine immunisation in the country.

No other initiative has so successfully accessed the most vulnerable and hardest to reach children despite armed conflict, migrating communities and natural disasters. Currently, for the Republic of South Sudan “polio vaccination campaigns are the best planned public health arrangements in the country, covering [over] 80 per cent of the population”7 while similar programmes cover between just two to ten per cent.8

GPEI was established in 1988 and the “global incidence of polio has decreased by 99.9%” since its foundation.9 In 2018, polio remains endemic in only three countries: Afghanistan, Nigeria and Pakistan. South Sudan has not reported a case of wild polio virus since 2009.

Having nearly reached their commitment in South Sudan and other countries, GPEI partners will be ending their funding for polio eradication activities and helping countries transition “polio assets” to national health programmes. For South Sudan, this will mean declining support to critical activities, such as a national system for disease surveillance and outbreak response, immunisation campaigns, social mobilisation networks, and a cold chain network that provides potent vaccines to the most remote and isolated portions of the country.

6 Messner, J.J., 2017 Fragile States Index, pg 8

7 Transition Independent Monitoring Board, The End of the Beginning, pg 8

8 Ibid.

9 “Our Mission”, The Global Polio Eradication Initiative website, accessed June 11, 2018, http://polioeradication.org/who-we-are/our-mission/

More than 95 per cent of funding from the GPEI goes to sixteen countries to support their eradication activities. While many of these countries will have their own difficulties with polio transition, most are more likely than South Sudan to absorb essential functions that are currently funded by GPEI.

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South Sudan is one of sixteen priority GPEI countries producing a national Polio Transition Plan. GPEI’s primary goals for transition planning are “to protect a polio-free world and to ensure that the investments, made to eradicate polio, contribute to future health goals after the completion of polio eradication”.10 For South Sudan, “the key is for transition of GPEI assets to support broader health initiatives”.11

In South Sudan, investments from GPEI partners12

have totalled around USD 20 million per year for almost 20 years, including pre-independence, under the Sudan programme. These investments will continue to ramp down into 2019 and beyond until funding ceases.13

GPEI, GAVI, the Bill and Melinda Gates Foundation (BMGF), the Centres for Disease Control and Prevention (CDC) and the United States Agency for International Development (USAID) have been the major sources of guaranteed funding coming into the health system. Other resources for health are short-term due to the conflict – and thus unguaranteed for medium-term planning and programming. Without GPEI resources, South Sudan will be unable to detect outbreaks of vaccine preventable disease, to deliver vaccines, or to support critical frontline staff in the field.

10 Republic of South Sudan, Transition Plan for The Polio Eradication Initiative (Juba: Ministry of Health, June 2018), pg 19

11 Ibid.

12 USAID, WHO, UNICEF, Rotary Club International, CDC, JICA and CIDA.


South Sudan’s routine immunisation and other health programmes have benefited from GPEI partners’ investments of

USD 20 million per year for almost 20 years.

With the eventual closure of GPEI, the possibility of collapse of the Expanded Programme on Immunisation (EPI) system is imminent:

1. Vaccine security is 100 per cent dependent on GPEI funds (cold chain storage and vaccine transportation);

2. Local technical capacity is sub optimal;

3. 4. Insecurity is widespread;

5. 6. DPT3 coverage is extremely low at 59 per

cent in 2017; and

7. Measles, rubella and cholera outbreaks have occurred recently or are occurring in most states.

Sources: Presentation by Dr. Makur Kariom, Undersecretary, Ministry of Health South Sudan (May 4-5 2017): “Update on South Sudan Polio Transition Process”, for the Polio Transition Independent Monitoring Board and the South Sudan EPI Joint Reporting Form (JRF) from May 2018.

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1.1 Country contextThe primary reason South Sudan has returned to the number one spot in the Fragile States Index14 is because of conflict between supporters of President Salva Kiir and Vice President Riek Machar, reports of ethnic cleansing, and suspended elections.15 The conflict has caused the world’s worst food security crisis,16 inducing famine in some parts of the country as recently as 2017.

As with other fragile states, administrative structures in South Sudan are weak or non-existent. Exacerbating this is the new state structure the Government put in place in 2016. The old ten states have been replaced by 33 new states, most of which do not have adequate administrative structures. Some planned government health programmes, such as the Boma Health Initiative (BHI),17 aim to use the old state structure for ease of programming. In addition, the Government has not paid some staff for several months, such as teachers and health



16 “South Sudan - The Most Dangerous Country for Aid Workers”, Editorials, Voice of America, September 11, 2017, https://editorials.voa.gov/a/south-sudan-the-most-dangerous-country-for-aid-workers/4024375.html

17 See section 5 for more information on the Boma Health Initiative.

care professionals. Budget allocations for the social sector are shrinking,18 while the defence budget has increased.19

18 UNICEF, National Budget Brief Fiscal Year 2017/18, Republic of South Sudan (Juba: UNICEF South Sudan, November 2017), pg 7

19 According to the World Bank, military spending has increased from 4.1 per cent in 2010 to 12.8 per cent in 2015 (as percentage of GDP). “Military expenditures”, Stockholm International Peace Research Institution Yearbook: Armaments, Disarmament and International Security, accessed 11 June 2018, https://data.worldbank.org/indicator/MS.MIL.XPND.GD.ZS?end=2016&locations=SS&start=2010

NationalMinistryof Health

State Ministries of Health

County Health Departments(80% run by non-governmental

organizations)

650 Payams:

2532 Bomas:

80

original states

Counties:

in 10

No permanent health structures or systems yet

No permanent health structures or systems yet

South Sudan’s Health System Structure by Geographic Area

Jonglei

Mayendit

Unity

Upper Nile

Eastern Equatoria

WesternEquatoria

P

P

P

P

P

P

P

PP

Warrap

Lakes

Western Bahrel Ghazal

Northern Bahr el Ghazal

Raja

Pibor

Wau

Lafon

Ayod

Wulu

Yei

IbbaKapoeta East

Baliet

Ezo

Renk

Maban

Duk

Tambura

Akobo

Bor South

Torit

Melut

Budi

Maridi

Nagero

Nyirol

Yambio

Terekeka

Pariang

Jur River

Tonj North

Nzara

Manyo

Pochalla

Mvolo

Twic

Aweil Centre

Koch

Guit

Ulang

Magwi

Tonj South

Longochuk

Cueibet

Panyijiar

Awerial

Twic East

Aweil East

Yirol East

Ikotos

MayomAweil North

Lainya

Maiwut

Panyikang

Yirol West

Tonj East

Mundri West

Aweil West Canal/Pigi

Mundri East

Fashoda

Rubkona

Kapoeta North

Leer

Gogrial EastLuakpiny/Nasir

Kajo-keji

Rumbek North

Rumbek East

RumbekCentre

Abiemnhom

Uror

Fangak

Abyei region

Juba

Bor

Wau

Torit

Aweil

Yambio

Rumbek

Kuajok

Bentiu

Gogrial West

Morobo

Aweil South

Malakal

Kapoeta South

Malakal

CentralEquatoria

1

South Sudan map

7A call to action

South Sudan stands to benefit from “inheriting the bulk of Sudan’s oil wealth”, 20 but today the country rates 181st out of 188 countries on the UN Human Development Index21 and over 80 per cent of the population of approximately 13 million lives on less than 1 USD per day. 22 The absolute poverty rate is estimated to be 50 per cent of the total population.23

Accurate estimates on the current literacy rates or how many children are enrolled in and attend school are difficult to ascertain as diverse estimates exists. Literacy is predicted to be lower than 20 per cent and school enrolment 31 per cent. Girls have lower literacy and enrolment rates than boys.24

With regard to health financing in the country, the Government of South Sudan “spends less than one per cent of its Gross Domestic Product on health”25 and the country has some of the worst health indicators in the world. The maternal mortality ratio is the world’s fifth highest 26, at 789 per 100,000 live births and neonatal and under-five mortality rates are also extreme at 39.3 and 99.6 per 1000 live births respectively (2014).27

Complicating matters, 80 per cent of health facilities in South Sudan depend on non-governmental organizations (NGOs) to provide primary health care services at the county level, including immunisation.28 Thus, health care at the community level is underdeveloped with communities often unaware of the benefits of immunisation, or how or where to access

20 BBC South Sudan Profile, 27 April 2016 (accessed 11 July, 2018): https://www.bbc.com/news/world-africa-14019208.

21 “Human Development Index”, Human Development Reports, UNDP, accessed 11 June 2018, http://hdr.undp.org/en/countries/profiles/SSD

22 UNDP. About South Sudan (accessed July 11, 2018): http://www.ss.undp.org/content/south_sudan/en/home/countryinfo.html”

23 ibid.

24 South Sudan Poverty Profile, World Bank (2015) (accessed July 11, 2018): microdata.worldbank.org/index.php/catalog/2778/download/39504 Poverty Profile.


26 “Maternal Mortality Rate” Maternal and Newborn Health, UNICEF, accessed 11 June 2018, https://data.unicef.org/topic/maternal-health/maternal-mortality/

27 WHO, Country Cooperation Strategy at a Glance: South Sudan, (Juba: WHO, May 2018), pg 1

28 Republic of South Sudan, Transition Plan for The Polio Eradication Initiative, pg 7

services.29 Today, only about a third of health facilities have functioning immunisation services due to lack of appropriate staffing, equipment, and planning30 and many facilities were looted during periods of unrest. Cold chain equipment, necessary for protecting the integrity of vaccines, was damaged in more than 100 facilities between 2015 and 2017.31

29 UNICEF. Draft Programme Strategy Note (May 2017)

30 Ibid.

31 Ibid.

“Staff shortages at all levels have led to immunisation, and wider health care services being outsourced to NGOs, with unskilled staff only receiving training on the job, making it difficult to maintain community trust. Staff are largely paid through per diems or ‘performance based incentives’ rather than by regular salaries, resulting in poor motivation and high staff attrition, with many positions left unfilled. At national level, EPI managerial skills are weak making programme planning, coordination, monitoring, supervision and reporting difficult.”

Transition Independent Monitoring Board, The End of the Beginning: First Report of the Transition Independent Monitoring Board of the Polio Programme, July 2017

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South Sudan is experiencing low immunisation rates, at 44 per cent in 2016, and has ongoing measles and rubella outbreaks in most states.32 Compromised security and lack of access has also led to diphtheria-tetanus-pertussis (DTP) coverage falling nationally from 72 per cent in 2012 to 26 per cent in 2016.33 Frequent outbreaks of measles, cholera, whooping cough and Kalazar34 are also having a disturbing impact on public health.

Since December 2013, more than 3.4 million people have been displaced: almost 2.5 million refugees35 crossing into Uganda, Kenya, Ethiopia and Sudan and 1.9 million internally displaced persons.36 The people movement has added to tensions over land ownership and occupancy, which is becoming increasingly fragmented along ethnic lines. In addition to the significant insecurity faced by millions of people across the country, South Sudan is regarded as one of the most dangerous countries in the world for aid workers. Since the conflict began in December 2013, 101 aid workers have been killed.37 According to the United Nations, nearly 630 incidents hindering humanitarian access occurred between January and July of 2017.38

32 Transition Independent Monitoring Board, The End of the Beginning, 8; The Government of South Sudan’s Joint Reporting Form 2017

33 Ministry of Health, Health Management Information System data (2016)

34 WHO, Weekly Bulletin on Outbreaks and Other Emergencies: Week 52, 31 December 2017.

35 “South Sudan Emergency”, UNHCR, updated January 2018, http://www.unhcr.org/uk/south-sudan-emergency.html

36 UNICEF, South Sudan Mid-Year Humanitarian Situation Report (Juba: UNICEF, July 20, 2017) pg 1

37 UNOCHA, Humanitarian Bulletin, Issue 5, (Juba: UNCHA, May 23, 2018), pg 2

38 “South Sudan - The Most Dangerous Country for Aid Workers”, Editorials, Voice of America, September 11, 2017, https://editorials.voa.gov/a/south-sudan-the-most-dangerous-country-for-aid-workers/4024375.html

1.2 The ramp down of GPEI in fragile states More than 95 per cent of GPEI funding goes to sixteen countries to support their eradication activities. While many of these countries will have their own difficulties with polio transition, efforts to finance and absorb essential functions currently funded by GPEI are especially complex in some countries. Countries dealing with long running conflict that brings insecurity economic uncertainty and stunted development - like South Sudan, Somalia, Chad and the Democratic Republic of the Congo - are among those that may face more extreme challenges.39 As noted by the Transition Independent Monitoring Board, the “reason that they [these countries] have the GPEI staff and resources in the first place is because they were not considered capable of eradicating polio on their own.” 40 In this connection, these states are dealing with transition differently than other countries and the risks they face are more hazardous to health systems.


40 Ibid.

“States are fragile when state structures lack political will and/or capacity to provide the basic functions needed for poverty reduction, development and to safeguard the security and human rights of their population.”

Source: OECD DAC, 2007 (Mcloughlin, Claire, ‘Topic Guide on Fragile States’, Governance and Social Development Resource Centre, International Development Department, University of Birmingham, August 2009, page 8)

9A call to action

WHAT HAS THE POLIO PROGRAMME BROUGHT TO SOUTH SUDAN?

Over the past three decades, the GPEI has built significant infrastructure in immunisation campaigns, disease surveillance, social mobilisation, and vaccine delivery; developed in-depth knowledge and expertise; and learned valuable lessons about reaching the most vulnerable and hard-to-reach populations on earth.42

South Sudan has achieved something remarkable: it has all but eradicated polio. This is no mean feat for a country that has been involved in conflict for most of the period of the GPEI. Since 1988, GPEI has protected millions of children from polio, saving them from a debilitating illness that would affect them for their entire lives. Even though the health system has been compromised and parts of the country are frequently inaccessible, campaigns ensured that polio vaccination rates remain high. The country has not had an outbreak of wild poliovirus since 2009.

But that’s not all.41

Funding from donors like CDC, USAID, BMGF and Rotary International through GPEI is the backbone of the country’s communicable disease surveillance system; vaccine cold chain system; laboratory networks; routine and supplementary immunisation programmes; and human resource networks for health in the areas of coordination, surveillance, social mobilisation, and disease outbreak responses. Thus, polio-funded assets ensure many other life-saving vaccines and services reach women and children and that outbreaks of diseases like cholera and meningitis are quickly addressed nationwide.42


42 Global Polio Eradication Initiative, Investment case, pg 21

Surveillance: The Polio Programme, with support from GPEI and other donors and technical guidance from WHO and UNICEF, introduced an active acute flaccid paralysis (AFP) surveillance system in South Sudan. This system has helped to ensure South Sudan has remained polio-free. At both state and county levels there is active surveillance in a number of sites, including internally displaced persons’ sites. Even in Greater Unity, Upper Nile and Jonglei, partners funded by the Bill and Melinda Gates Foundation continue to conduct active surveillance, despite the ongoing conflict. In 2014, there was an outbreak of vaccine-derived poliovirus, but it was detected by the surveillance system, showing just how effective active surveillance can be in South Sudan with its limited infrastructure and health system. Another example of this was when Rift Valley fever of 2017 was detected and the initial investigation was conducted by the AFP surveillance network. Surveillance extends to other vaccine preventable diseases, which has led to many suspected outbreaks of measles being notified, investigated and responded to through the polio infrastructure, including collection of samples.

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GPEI

IMMUNISATION SYSTEM COLLAPSE

OUTBREAK RESPONSE

COLD CHAIN

CAMPA

IGNS

POLIO SURVEILLANCE

MEASLES SURVEILLANCE

MENINGITIS SURVEILLANCE

SOCIAL MOBILISATION

IMMUNISED RATE

DONOR

DONOR

SOCIAL MOBILISATION

VIT A

11A call to action

Health systems modelling: In South Sudan, the Polio Programme has demonstrated an effective systems-approach, which other priorities have been able to leverage. The polio network cuts across the county level, in which it has about 95 per cent presence.43 Other programmes, such as water, sanitation and hygiene (WASH) and nutrition also leverage across this network. In addition, with limited government capacity to support staff, a number of health workers are motivated during the polio campaigns with performance based incentives.

Improved immunity and routine immunisation: The Polio Programme has helped to strengthen RI in the country, relying heavily on supplementary immunisation activities (SIAs) to achieve a basic level of coverage in the country. Vitamin A and deworming as well as measles, meningitis, and tetanus vaccinations are administered using the structure of the Polio Programme, including microplanning, funds management, capacity building and logistics. That is, a lot of the assets currently being used for RI come from the Polio Programme. Thus, not only has stronger immunity to polio been achieved, but immunity to other diseases too – which is helping to control the rates of childhood diseases in the country.

43 WHO team, South Sudan, Interview by Matthew Gibbs, DevSmart, Juba, April 2018

Social mobilisation: A major value-added of the Polio Programme has been the proliferation of social mobilisation as a key intervention and platform for public health. Engaging the community is a central pillar in polio eradication efforts around the world and critical to the success of eradication efforts. Social mobilisation started as a health promotion strategy, sharing information to facilitate achievement of the goals of the Polio Programme and encouraging parents to immunise their children. Over time, social mobilisation has grown into a strategy that seeks to empower beneficiaries of health programmes to become active stakeholders in public health. Communities are knowledgeable about basic life-saving services and are empowered to demand services that will contribute to the health and wellbeing of their children and communities. As a strategy, it now reaches into other programmes. For example, UNICEF’s ‘Communication for Development’ was initially developed for the Polio Programme and is now utilised as a cross-sectoral strategy for health, nutrition, WASH, and education around the world. Moreover, for UNICEF in South Sudan, social mobilisation funding is already transitioning: only 50 per cent of it is reliant on funding from the GPEI.

WASH

NUTRITION

POLIO

ROUTINE IMMUNISATION MEASLES, MENINGITIS, TETANUS

Many health interventions depend on Polio Programme systems and structures

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Logistics and laboratory testing: Vaccine security is 100 per cent dependent on GPEI funding44 and the Polio Programme has shown just what can be achieved with good logistics. For example, the conflict has meant that some communities in Greater Unity, Upper Nile, and Jonglei states have been hard to access communities, but during campaigns the Polio Programme used microplanning and community social mobilisation to access and vaccinate these hard to reach populations. The Nutrition Programme uses the polio network twice a year to reach children under-five across the country to boost their immunity and growth with Vitamin A supplementation and deworming. There have also been times when the Global Fund for AIDS, Tuberculosis and Malaria has used campaigns – a critical component of the Polio Programme

44 Global Polio Eradication Initiative, Update on South Sudan Polio Transition Process, Presentation delivered by Dr. Makur Kariom Undersecretary Ministry of Health, Republic of South Sudan (London: GPEI, May 2017) slide 12

– to distribute bed nets to prevent malaria. The Polio Programme essentially established the cold chain in the country, which goes down to county level, extended to the end-user, the child, during polio National Immunisation Days. Without the Polio Programme, the Expanded Programme on Immunisation (EPI) in the country would face chronic shortfalls. Infrastructure, particularly roads and electricity, in South Sudan is very limited, so the Polio Programme brings the basics to the table – vehicles and fuel for generators, transport and chartered flights when no other access is possible. Furthermore, since South Sudan does not have a national laboratory for testing suspected cases of polio, the Polio Programme pays for the quick transfer of specimens to laboratories outside the country for examination within the Global Polio Laboratory Network.45

45 Abegunde, Dele, The Business case for integrating polio assets into priority health services in South Sudan (Juba: WHO, May 2018), pg 10

Greater UnityUpper Nile

Jonglei

GPEI

3.2 Reaching the hardest-to-reach children

13A call to action

Outbreak response: Disease outbreak response capacity in South Sudan is heavily dependent on the polio infrastructure and instructions passed from the state to lower levels. The EPI Officers at the state level and Field Assistants at the county level, including Polio Field Assistants and community informants follow these instructions when investigating community alerts, supporting sample collection and packaging and shipping specimens. These same people increase active surveillance site visits, link communities with health facilities, provide sensitisation for health facility staff, and implement recommended public health surveillance interventions in response to confirmed outbreaks.46 In addition to surveillance response, one of the major tasks the polio staff is responsible for is conducting supplemental immunisation – this includes preparation, training, implementation and monitoring each campaign’s quality. Thus, the polio structure supports the health system to respond to any outbreak with an effective and timely response mechanism.

46 Ministry of Health, Republic of South Sudan, Polio Simulation Exercise, Polio Transition Planning (Juba: Ministry of Health, 29-30 July 2017), pg 14

Training and capacity development: The Polio Programme established and equipped a team capable of detecting and eliminating poliovirus and running the country’s most successful health initiative. Today, the Polio Eradication Initiative in South Sudan is composed of a disciplined workforce that utilises performance standards and accountably structures to effectively immunise, detect, and respond. For example, the workers are expected to visit priority facilities as per surveillance priority standards. Every week, every two weeks and every month they visit high, medium and low priority sites respectively using open data kits to collect and submit information – and record geo-coordinates. For active surveillance, each officer has to be in the field for at least 14 days each a month to visit 9–15 health facilities. To reach this level of efficiency, the Polio Programme invested millions of dollars into staff training, manuals and tools, which has significantly strengthened the health system.

Each of these areas have helped to drive the process of eradicating polio, but they share something else in common: they have introduced elements to the health system that are critical to its functioning. They have helped to demonstrate that a functional immunisation system is the bedrock of a sound health system.

The funding gaps for just cold chain logistic transport and cold chain logistic fuel between 2018 and 2022 will be USD 3,000,000 and USD 4,999,038 respectively if new sources of funding are not identified.

Source: Republic of South Sudan, Transition Plan for The Polio Eradication Initiative, Juba, South Sudan, June 2018.

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WHAT WILL THE IMPACT OF THE POLIO PROGRAMME RAMP DOWN BE?

Parts of the health system will shut down due to lack of funding.

The Polio Programme support to routine immunisation will stop. Currently, RI in South Sudan is sub-optimal. A key global indicator of immunisation programme performance is third dose coverage of DTP vaccine (DTP3) by age 12 months. Global coverage in 2016 was 86 per cent47, but 26 per cent in South Sudan. This level of coverage will not result in strong herd immunity (see graphic on page 15). The elimination of polio and high levels of polio immunisation in South Sudan has been the result of campaigns – SIAs, including National Immunisation Days administering oral polio vaccines. Moreover, many of the counties in conflict affected states’ campaigns are the only chance for children to get vaccination including routine vaccination. In 2017, there were four campaigns to supplement RI; in 2018 and 2019, there will be one national and two subnational campaigns. As GPEI funding continues to ramp down in 2019, there will be less funding provided for polio functions and polio vaccination campaigns, and there is a very real concern that EPI will come close to collapse.

UNICEF has been trying to expand the existing cold chain in support of the EPI and the GPEI has already made a big contribution. The cold chain system will be at risk of breaking down when the GPEI funding expires. Maintenance is expensive, for vehicles, generators and regional cold chain stores for vaccines. Fuel is a very important element here. Currently, the EPI is trying to adjust the budget for fuel and transportation to make it cheaper and more efficient. Added to the mix is GAVI – the

47 “Overview”, Newsroom Fact Sheet on Immunization Coverage, WHO, accessed 11 June 2018. http://www.who.int/news-room/fact-sheets/detail/immunization-coverage

global Vaccine Alliance – which is providing some support to introduce solar energy into South Sudan’s cold chain at the county level. Progressive solarisation is reducing the fuel bill. However, the state and national levels still rely on fuel and GAVI (whose contribution is already quite significant) may not be able to cover all of the gap. In addition, some solar refrigerators have been stolen or misappropriated during recent conflict. Replacement of this equipment becomes complicated by the due diligence processes of donors and implementing agencies and ongoing assessment of the unpredictable situation.

Active surveillance will no longer be adequately practiced in the country. Currently, surveillance for polio, mainly run by WHO, CoreGroup and McKing Consultancy/BMGF, is almost a parallel structure to other surveillance activities conducted by the Ministry of Health. WHO is helping to strengthen the Integrated Disease Surveillance and Response (IDSR) system in South Sudan, but there is considerable work still to be done. The Polio Programme has invested a lot in surveillance – county supervisors, national officers and staff at the lowest levels of implementation have all been adequately trained to conduct surveillance activities including AFP. Other diseases interventions and surveillance activities have piggy-backed on the polio network and infrastructure, including measles, so if no support is forthcoming, surveillance activity quality across the board will be seriously affected. Data analysis will be compromised and all partners will have even less access to quality data. This data is not just important to understand immunisation rates, but to understand how effective Primary Health Care units are working.

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15A call to action

IMMUNITY

Susceptible (indirectlyprotected)

Immunised Contagious

No one is immunised

Contagious disease spreads through the population

Some of the population gets

immunised

Contagious disease spreads through some of the population

Most of the population gets immunised

Spread of contagious disease is contained

HERD

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Another issue is the surveillance infrastructure. Good surveillance is about speed. While the Ministry of Health will have the motorbikes and other vehicles to support surveillance, concerns about their maintenance following the end of GPEI funding give rise to worries about the collection of data, even if staff could be maintained to conduct active surveillance.

The ramp down of the Polio Programme will be felt at the community level. Polio funding is still financing approximately 50 per cent of the current number of social mobilisers – some 5,000, 2,397 of whom are part of the Integrated Community Mobilisation Network.48 Without them, there will be less information reaching communities, which will have a knock-on effect in terms of health-seeking behaviour. This will not just affect the immunisation work in the future, but the other interventions that now benefit from the social mobilisation strategies. The health system needs community involvement and a diminished network will have a significant impact. In a fragile country,

48 UNICEF, Polio Transition Snapshot, South Sudan (Juba: UNICEF, April 2018) pg 4

the empowerment of community members is critical to building resilience to current and future shocks.

The brain drain will begin. When the polio money goes, the personnel involved in surveillance, vaccination, and social mobilisation will suddenly not be a resource. At the implementation level, trained social mobilisers and vaccinators will no longer be financed to work. The technical experts in the immunisation sector are mostly recruited by polio, so there will be diminished capacity to plan and run immunisation programmes. The data surveillance system will suffer for lack of active surveillance people at the lower levels. International workers with expertise will move on to another country that has positions for their skills, while national workers could be recruited to other organisations, go to work abroad or simply withdraw from the public health scene in South Sudan. Capacity gains built up over time will be lost.

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LOOKING BEYOND THE POLIO PROGRAMME AT THE CRITICAL FUNCTIONS

WHO, UNICEF and the Ministry of Health in South Sudan have initiated a process reviewing the end of the GPEI funding and transitioning “assets” into other programmes. This process identified and prioritised key assets that emerged from the Polio Programme that will not be supported when funding ceases – and that the health system needs in order to function.

However, the transition instigated by the ramp down of GPEI funding is not about preserving the assets of the Polio Programme. It is about the functions carried out by these assets and how they have been used. Going further, it is about understanding which ones are critical to maintaining a bare minimum of presence and services and helping to ensure these functions continue.

The questions moving forward as polio funding ramps down are the following:

• What functions will still be required by the health system to ensure a basic level of information and services continue from the community level up?

• What is at risk if the functions are not absorbed by the health system?

• How can these functions continue?

4.1 What are the critical functions and why are they critical?The following functions are some of the most critical to maintain after polio ramp down in South Sudan:

1. Active surveillance The AFP surveillance network encompasses 1,882 surveillance sites across the country. This includes personnel at the national, county, payam and community level – including more than 3,000 community informants49 – making it the most comprehensive surveillance system in the country. In addition, the surveillance for polio is currently the only active surveillance system (case-based) in the country and most disease surveillance activities are the platform for the AFP surveillance as well as for measles, neonatal tetanus, yellow fever, meningitis and other diseases.


4

“The Polio Programme currently pays for at least 703 staff in South Sudan that would be lost without assertive planning and attention…

The impact would be felt in routine immunisation activities, vaccine cold chain, logistics, polio and other disease surveillance, training, and outbreak response.” Transition Independent Monitoring Board, The End of the Beginning: First Report of the Transition Independent Monitoring Board of the Polio Programme, July 2017 and updated numbers (703 staff) from the South Sudan Polio Transition Plan, June 2018.

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2. Social mobilisation The social mobilisation network established to support the SIAs includes eleven NGOs with 4,500 social mobilisers.50 This Integrated Community Mobilisation Network mobilises communities towards key healthy behaviours around health, education, WASH, child protection, and nutrition. This community mobilisation network operates all year round.51

3. Immunisation supply chain management While GAVI continues to generously support the cold chain, GPEI funding has been critical to its smooth running, including provision of fuel and distribution of vaccines and EPI supply, mainly done by air.

4. Outbreak response capacity As a vertical programme, the outbreak response was designed only for polio, but it has become essential: polio-funded officers have always contributed to outbreak response. This goes hand-in-hand with active surveillance and social mobilisation. The network – from the community upwards – needs to be in place to protect public health in South Sudan. Without the Polio Programme, the health system does not have an effective mechanism for outbreak response.

A note on human resources: Human resources are necessary to sustain these vital functions. While the focus of the investment case is on the functions, these functions are implemented by highly skilled personnel – on salaries or incentives – who are vital to sustaining presence and services across the country.


51 Ibid.

4.2 What are the risks if these functions do not continue?

Disease has no borders and requires no visa.

Dr. Baba Samson, Special Adviser to the Minister of Health, Republic of South Sudan

Heavily dependent on polio funding, South Sudan’s fragile health system is at risk of collapse without new funding commitments from donors to ensure the essential functions discussed above are maintained for routine immunisation, surveillance, and other basic health services. Other risks include limited technical capacity for transition, lack of awareness about the transition process and understanding of the imminent changes, and insufficient governance structures.

An estimated 70 per cent of polio funding in South Sudan is normally shared with routine immunisation activities covering staff salaries, vaccine logistics and cold chain systems.52 In 2017, while donor funding for polio was USD 25.7 million, approximately USD 18.2 million supported RI.53 Thus USD 18.2 million will be the “deficit that will confront RI in South Sudan” when GPEI phases out if new funding is not allocated to cover these core functions.54 Stakeholders are concerned that the ramp down in funding will result in increased rates of child morbidity and mortality due to the impact

52 Abegunde, Dele, The Business case for integrating polio assets into priority health services in South Sudan, pg 22

53 Ibid.

54 Ibid.

Annual cost for polio personnel:

USD 9.8 million

of immunisation staff are funded by polio resources.

70 per cent

19A call to action

on the immunization programme and broader health system.

In terms of human resources, if trained staff members are let go at the end of the transition period, it is possible they will not be available if funds come at a later date to cover the minimal immunisation and surveillance needs that every country must have to prevent and protect its population, neighbouring countries and the world from disease outbreak.

In summary, what are the risks?

• Active case-based surveillance would end and the quality of available data – monitoring the health of the population and disease outbreak – would dramatically reduce;

• All immunisation figures for the population would be expected to further decline;

• The cold chain would be interrupted, severely limiting vaccines getting to end-users;

• Social mobilisation activities promoting health-seeking behaviour would be reduced by about 50 per cent;

• Sorely needed inter-sectoral collaboration would be threatened; and

• All SIAs would stop (or be of poor quality), ending the most effective health interventions in the country.

4.3 What does this mean for the health system in South Sudan?Without sustaining the functions from the Polio Programme, the health system is in danger of collapse. GPEI, CDC, BMGF and USAID polio resources have been the only sources of guaranteed funding coming into the health system. Other resources for health are short-term due to the conflict – and thus unguaranteed for medium-term planning and programming. Thus, without these resources, there is a risk that vaccines will not be delivered and staff will lose support in the field. Outbreak response will be limited as this has been led by the polio team, which is in place at the county and payam

USD 20 million per year

The loss of polio’s

will place South Sudan’s entire health system at risk.

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levels. The cold chain will be weakened and may break. Fuel is also a huge expense (currently averaging USD 1.67 million per year), which is covered by GPEI funding. While technicians are funded by GAVI, they need GPEI-funded fuel and transportation to do their work.

The Boma Health Initiative is currently the Ministry of Health’s key strategy for building the health system in the country (see section 5) and the new state structure in the country is mostly without infrastructure. Both of these will require support. However, as they are new, there is a risk that they cannot sustain the existing system established with polio funding.

4.4 What does this mean for the health of the population at large?Lack of secure future financing for the transition process and activities required post certification has resulted in well-founded concern among partners about the risk of an outbreak in South Sudan when the Polio Programme finishes. It should be noted that this is not only related to the consequent ramp down in immunisation campaigns and the possibility of reduced immunity in the population. It is also concerned with the diminished outbreak response capacity that will transpire and the shift from active surveillance to the passive surveillance system of the Ministry of Health.

An outbreak in South Sudan could be a public health crisis for the region, given its current vulnerability, relatively porous borders and the weak state of health systems in South Sudan and neighbouring countries. Communicable disease has no borders, as the Ebola epidemic demonstrated. The epidemic in Guinea, Liberia and Sierra Leone and its introduction to seven other countries “illustrates how all countries are connected and that a threat in one country is a threat everywhere.” 55

55 Bell BP, Damon IK, Jernigan DB, et al. Overview, Control Strategies, and Lessons Learned in the CDC Response to the 2014–2016 Ebola Epidemic. MMWR Suppl 2016;65(Suppl-3):4–11. DOI: http://dx.doi.org/10.15585/mmwr.su6503a2

A review of lessons learned from the Ebola outbreak showed that weak surveillance systems and limited health infrastructure impeded detection of and response to the outbreak. Furthermore, these factors hampered control efforts, particularly in the hard-to-reach areas.56 The spread of the virus was also boosted by high mobility populations and ignorance of the virus and how to respond,57 which speaks directly to the value of the community mobilisation work, but also the high risks brought by mobile populations, in the context of the prevailing insecurity in the country.

This is a critical reminder of the obligations of global health security. Readiness to detect and respond to outbreaks of infectious disease is the goal of the Global Health Security Agenda (GHSA), an initiative supported by countries, government agencies, and international organisations to assist countries with attaining compliance with the International Health Regulations and accelerate progress toward detecting and mitigating infectious disease threats quickly and effectively.58

The structures now at risk are the very structures that should be kept alive, nourished and alert if the health system is to avoid collapse. The opportunity to maintain the polio structures that are indispensable for routine immunisation and disease surveillance while ensuring South Sudan stays polio-free is important to the health of the population not only in South Sudan but in the region.

56 Ibid.

57 Ibid.

58 Ibid.

Up to 1.5 millionchildren could go unprotected from vaccine-preventable diseases

21A call to action

OPTIONS TO ABSORB CRITICAL FUNCTIONS IDENTIFIED BY THE GOVERNMENT OF SOUTH SUDAN AND PARTNERS

GPEI wind down provides the chance to seize a unique opportunity to strengthen routine immunisation this century, yet at the same time it could equally become the biggest threat to the progress made to date.

Kerr, Laura, Results UK. “A Balancing Act: Risks and opportunities as polio and its funding disappears”. November 2017.

How can risks linked to the Polio Programme ramp down be turned into opportunities?

In the Government of the Republic of South Sudan’s Transition Plan for the Polio Eradication Initiative and the connected Business Plan, the broad areas identified as national health priorities in the context of polio transition planning are 1. the Boma Health Initiative; 2. Integrated Disease Surveillance and Response; 3. Routine immunisation within primary healthcare; and 4. Mixed distribution of assets within the entire health system.

Option 1: The Boma Health InitiativeThe BHI has been identified as a key mechanism that could benefit from the functions developed by the Polio Programme. The BHI focuses on the lower unit of the health system.59 This is where most of the polio workers are, thus the human resources could play a key role at the payam and boma level – indeed, these workers could make up the Boma Health Team, as they already have


significant background in public health at the community level.

The BHI’s main goal is to strengthen the health system to efficiently deliver components of the Basic Package for Health and Nutrition (BPHNS) at the community level, contributing to the achievement of universal coverage.60

The BHI takes health care to the lowest level of the country’s administrative structure, focusing on community action. The aim is to relieve pressure on the health system by not having to treat simple disease and ailments. This is an area in which immunisation is important. Boma Health Teams, comprised of three health workers selected by and from within the community, will be trained on health activities and promotion; Integrated Community Case Management (ICCM) for malaria, pneumonia, malnutrition; health education; vital statistics; Health Management Information Systems (HMIS); reporting; and IDSR for unusual disease events in the community. They also have capacity to make referrals.

60 Ibid.

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Option 2: Integrated Disease Surveillance and ResponseWHO supports the Ministry of Health to maintain IDSR, WHO’s global model. It is intended to be the primary surveillance mechanism in the country. Currently, polio funding supports IDSR core functions by complementing case detection, reporting and verification of IDSR priority diseases/outbreaks at community level through field assistants and community informants, investigation of community alerts, support sample collection, packaging, and shipment, implementing recommended public health surveillance interventions in response to confirmed outbreaks and linking the health facilities to the communities.61 The ramp down provides an excellent opportunity to streamline surveillance in the country. “Although IDSR’s surveillance scope is much larger than polio’s horizontally, its integrated form allows for pooling all resources including human resources, facilities, and equipment for improving public health surveillance and response.”62

Option 3: Routine immunisation within primary healthcareIntegrating polio assets into the routine immunisation system would strengthen the health system. Close to 70 per cent of resources that support RI in South Sudan were obtained with polio funding through WHO, UNICEF and the CORE Group64 and already support the routine immunisation system.65

While ramp down is being affected, introduction of new vaccines are also being planned.66 This will require capacity building and new messaging for community mobilisation – both of which could easily use the polio structure, if it is still in place. If this is unavailable, or at reduced capacity, quality will be compromised.



Option 4: Mixed distribution of assets within the entire health system with focus on the three health priority areas636465

A mixed distribution option allows for gradual uptake of assets until complete allotment within a given option, and subsequent uptake by the other options until all the transferable assets have been transferred. This integrative option, in principle, is more suitable for the transfer of the functional assets that have been established within the polio-funded programme in South Sudan.66

63 The CORE Group Polio Project is a multi-country, multi-partner initiative providing financial support and on-the-ground technical guidance and support to strengthen South Sudan efforts to eradicate polio. CORE Group members form and staff an in-country secretariat- a small team of neutral, technical advisors, independent from any one implementing partner, team facilitates communication, coordination, and transparent decision-making among all partners-unifying the community-level expertise of INGOs and local NGOs with the international knowledge and strategies of the Global Polio Eradication Initiative partners.


65 In 2019, tetanus toxoid (TT) is shifting to tetanus and diphtheria (TD); in 2020, MEN A (meningitis vaccine); in 2021 pneumococcal conjugate vaccine (PCV); in 2021 totavirus vaccine; and in 2022, yellow fever.


23A call to action

BARRIERS TO LEVERAGING THE RESOURCES TO SUPPORT THESE OPTIONS

While each of the options mentioned would be optimal ways to repurpose polio assets and functions, there are significant political, economic and programmatic barriers in South Sudan that make uptake of the options presented above challenging at the present time.

6.1 Political and economic barriersPolitical commitment: For the 2017/2018 fiscal year, the Government budget allocation for the health sector is 2.6 per cent, down from 3.1 per cent in 2015/201667, indicating a limited commitment to public health. The Ministry of Health has indicated willingness to continue the functions developed through the Polio Programme (as above), but that willingness is not accompanied by government funding. In addition to funding levels, there is concern among stakeholders that functions will not be picked up by government as their capacity is limited. For example, Médecins Sans Frontières (MSF) left knowledge-based assets and human resources when the Tuberculosis Programme closed down in 2017, and these were not absorbed by the Ministry of Health. Similarly, the Nstop programme supported by CDC was to be absorbed by the Ministry after a two-year mentoring programme but this has not yet been possible due to limited resources. Stakeholders recognise that there is limited will and capacity to continue these functions.

Economic breakdown: The economy is suffering and if the conflict continues, it will continue to decline. Insecurity and inflation is impacting the price of everything: fuel, transportation and salaries. Government staff

67 UNICEF, National Budget Brief Fiscal Year 2017/18, Republic of South Sudan, pgs 7, 9

have not been regularly paid for some time. Sustaining the functions – particularly with salaries, incentives and logistics costs – that will be unfunded by the end of the Polio Programme will become increasingly difficult.

Limited Infrastructure: Transportation of vaccines is difficult at every level due to the poor road system, and the high and rising cost of fuel and transportation that is entirely dependent on donor support.

Availability of funding: The goodwill of the post-independence years has passed following almost five years of conflict that has eroded many of the gains made since the Comprehensive Peace Agreement (with the then North Sudan in 2005). The country faces diminishing donor resources in the face of ongoing conflict. With examples of classrooms and health facilities being damaged, destroyed or taken over by military forces and cases of theft of parts of the cold chain, some donors are downsizing resources available, while others, such as GAVI, are finding ways to provide funding that avoids going through government mechanisms. In some of the social sectors like education, teachers’ salaries are paid by donors. The US Government has initiated “a comprehensive review of its assistance programs [sic] to South Sudan”68 over concerns about the peace process.

As a result of the shrinking donor pot and the lack of government funding available to line ministries, donors are under pressure to cover more programmes with fewer resources. For example, the new phase of the Health Pooled Fund (phase three) and some small allocations from GAVI are currently the only funding

68 “Statement from the Press Secretary on the Civil War in South Sudan”, White House, Government of the United States of America, issued May 8, 2018, https://www.whitehouse.gov/briefings-statements/statement-press-secretary-civil-war-south-sudan/

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available for the BHI and will be insufficient to take the scheme to scale.

Given these constraints, it is unlikely that the Government will be able to make any budget allocation to cover costs for functions coming out of the Polio Programme – functions that will be critical to maintain public health.

6.2 Programmatic barriersThe BHI is not ready: There is consensus that the BHI is a positive step for the health system in South Sudan. However, stakeholders – particularly donors – have expressed the following concerns69 over its potential to be realised in the near term:

• The BHI is mostly unfunded, with no financial commitment yet forthcoming from the Government. Transferring assets will only be meaningful if they are funded.

• As the Boma Health Teams are selected by the communities, there is no guarantee that the polio workers will be chosen.

• Even if they are selected, the financial incentives offered will be lower than the incentives received for their work on polio. There is no guarantee the same people will want to take on these roles.

• With the workload quite large already for the Boma Health Teams, it may not be possible for them to conduct active surveillance and assume outbreak response at the lower level too.

• EPI workers will not be under the BHI, nor will BHI workers take on responsibility for vaccinations (at least not yet).

• Access and security is still an issue for routine immunisation.

The chief concern is that BHI is in its infancy. The country would be going from a fully functional polio structure to a structure that currently exists only on paper. As one stakeholder said, “We can’t just say that the BHI can absorb these people if that is not yet functioning.” Indeed, that would place considerable pressure on a fledgling initiative.

69 Polio transition stakeholders WHO team, South Sudan, Interview by Matthew Gibbs, DevSmart, Juba, April 2018

What would also place pressure on the BHI would be a degradation of immunisation services in the country. When GPEI funding ends, the routine immunisation system will become the main immunisation programme in the country, and it is currently below the desired herd immunity thresholds. If vaccine-preventable diseases become a threat, the new BHI will become burdened with treating disease and dealing with outbreaks.

All of these together suggest that it is currently not realistic to plan for the BHI to absorb the relevant functions from the Polio Programme. Thus, there seems to be a gap between the GPEI transition period and BHI nationwide roll-out and functioning.

Integrated Disease Surveillance and Response needs more development: There are no IDSR personnel at the community level (payam, boma or village). Event detection takes place at the local level most often involving staff at a health facility. A team from the county and/or the state level comes for confirmation, assessment and response planning. Possible disease events are reported as part of a weekly scan and reported via counties to state, then national levels. A week or more could pass by the time a disease has been spotted, delaying testing, treatment and outbreak response. This structure is short of staff and its performance is not yet optimal. WHO and the EPI Capacity Building (ECB) Programme/African Epidemiology Network (AFENET) of CDC are both investing time and resources to move surveillance – including facility-based surveillance and community-level engagement – rooted in the Ministry of Health, forward in South Sudan. However, it is currently not sufficient to maintain active surveillance, nor is it of the same quality of the polio structure.

25A call to action

THE LAST OPTION – PREVENTING COLLAPSE BY MAINTAINING THE BARE MINIMUM FOR SURVEILLANCE, ROUTINE IMMUNISATION, COMMUNITY MOBILISATION AND OUTBREAK RESPONSE

7

Transitioning from the Polio Programme leads to an urgent need to streamline the functions it created to maintain at least the bare minimum for surveillance, routine immunisation, community mobilisation and outbreak response in South Sudan. However, as noted above, the key health priorities identified to take on the critical functions will not be ready by the end of the transition period to do so.

The protracted conflict in the country and financial situation makes it nearly impossible for the Government to immediately take over and/or fund these functions. Unlike other more stable countries, these functions will not be absorbed by a waiting health system. On the contrary, South Sudan’s fragile health system is built upon these polio structures and must find a way to maintain its key functions.

While the BHI has an excellent plan to roll out primary health care services at the boma level it does not yet have a strong enough structure to take on these functions70 nor can it pay for or

70 Transitioning polio human resources to BHI would “cost the South Sudanese Health system over USD 38 million by 2022 in aggregated salaries (31.5 million) and training cost (USD 6.7 million). CHW equipment will cost USD 11.9 million and medicines and supplies for the ICCM community level operations (excluding vaccines) will cost USD 10 million by 2022.” Abegunde, Dele, The Business case for integrating polio assets into priority health services in South Sudan, pg 19

mobilise the resources (nearly USD 105.9 million) it will need between now and 2022.71

As an estimated USD “18.2 million GPEI donor support directly supports RI and will not be available after the ramp down”,72 RI will fail without new funding.73 Social mobilisation will scale-down by 50 per cent.

With regard to polio, South Sudan’s status is “no longer poliovirus-infected, but at high risk of outbreaks” so even polio becomes a much greater risk for a country with such low immunisation rates among the general population, especially children, when funding declines. Yet, South Sudan needs to maintain polio free certification as well as oral/injectable polio vaccination coverage at over 80 per cent. For this to be achieved, continued polio investment is needed, in one form or another, given the country’s fragile state.

71 The plan has an estimated budget need of USD 105,870,289, pledged budget of USD 42,885,857 covering 40.51 per cent of the needs, and the budget gap of 59.49 per cent worth USD 62,984,431. Republic of South Sudan, Transition Plan for The Polio Eradication Initiative, pg 57



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In light of this situation, implementing partners and donors who already fund many components of the health care system recommend a contingency plan, partly because there is hesitation about investing in long-term development programmes during a protracted emergency and partly because there are insufficient funds available to cover all that the BHI needs to run effectively and take on the critical functions.

The end of the Polio Programme must be seen in the context of South Sudan as a fragile state. The situations in fragile states have prevented governments from investing time and resources into developing systems – while donors have been focusing on humanitarian response.

When GPEI bids farewell to the global health community, a new financing Initiative should be considered to support fragile states, like South Sudan, to maintain the essential functions established by GPEI of immunisation, active disease surveillance, outbreak response and social mobilisation to maintain a polio free world.

The aim is for these functions to be mainstreamed into South Sudan’s health system.74 However, it is clear that in the case of South Sudan the challenges are considerable. The health and surveillance systems in South Sudan will not be sufficiently established before the end of the transition period. These systems would simply be unable to cope with absorbing the additional human resources and response capacity before the end of the transition period. If these elements are not maintained, stakeholders agree: the health system will collapse.

In the short-term, it will be critical to continue immunisation campaigns, disease surveillance, outbreak response and social mobilisation functions during an extended transition period to shore-up these functions in the absence of government capacity.

74 Kerr, Laura, A Balancing Act: Risks and opportunities as polio and its funding disappears (London: Results UK, November 2017), pg 18

Beyond that, stakeholders will need to look simultaneously at the bigger issue of supporting disease control and prevention in the country and supporting systems strengthening over a multi-year period. Thus, the transition from GPEI funding needs to revolve around three core objectives:

• To support essential functions for disease control and prevention, including immunisation and surveillance;

• To enable longer-term transition planning for disease control and prevention functions; and

• To explore innovative solutions for surveillance of key health indicators (see below).

Finally, at the international level, donors and partners need to consider a financing programme for fragile states to ensure funding for surveillance, immunisation campaigns, community mobilisation and outbreak response for a near- to medium-term period to help transition to primary government financial ownership – up to ten years. It will be critical to use this funding – likely to be more limited than the extraordinary scale of the GPEI – to streamline systems and drive inter-sectoral collaboration to improve efficiency of available funds.

27A call to action

CALL TO ACTION

To avert a public health crisis, South Sudan needs to maintain, as a minimum, active surveillance, better immunisation coverage, strong resilience – through social mobilisation – and robust outbreak response capacity.

Supporting fragile states through a longer transition period must be a political priority nationally, regionally and globally. We call upon high-level stakeholders to come together to acknowledge the special case of South Sudan and other fragile states in the context of the global GPEI ramp down and formulate plans to help these states fortify routine immunisation and supporting systems. These include:

• Ministers of Health

• UNICEF country, regional and head offices

• WHO country, regional and head offices

• UNDP country, regional and head offices

• GAVI, the Vaccine Alliance

• The Global Fund

• Bilateral donors – country and headquarters offices – including, but not limited to, DFID (and HPF in South Sudan), USAID, ECHO, Canada, Japan, Australia, National Philanthropic Trust (NPT), Rotary International, Sweden and Italy.

• Disease control organizations like CDC

• The Bill and Melinda Gates Foundation

• The World Bank Group

• Civil Society Organisations, particularly NGOs involved in service delivery for the polio programme, including routine immunisation, surveillance and community mobilisation

Recommendations:1. Support routine immunisation and

continue campaigns

Global, regional and country level action

Routine immunisation must be broad and horizontal now as there are insufficient funds for vertical or disease-specific programmes. During a longer transition period, RI needs to be strengthened.

A key factor in the success of raising immunity to polio has been the campaigns, which mobilise whole communities and get vaccines down to the county level and the trained vaccinators. However, with the ramp down, the numbers of campaigns will go down progressively: four campaigns were carried out in 2017, targeting 3 million; in 2018 plans are in place for three campaigns countrywide, with the first and third rounds targeting 50 per cent while in 2019 it will only be 40 per cent for the first and third rounds. Currently, SIA calendars and estimated budgets for beyond 2019 are not available. The planned campaigns include polio (up until the end of the 2019) and measles – and rely on the polio structure for support.

If routine immunisation were strong enough, the ramp down would not be as concerning. Strengthening EPI needs to be a key priority. Without this, there is a high risk to the community. The RI processes and functions must be progressively transferred to the Ministry of Health to ensure sustainability and avoid parallel structures.

Sustainable and innovative solutions, like cold chain facilities that operate on solar energy, should be considered, especially in areas where insecurity is less of an issue.

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2. Maintain funding for health-based community mobilisation

Country level action

Community mobilisation has expanded and is developing messaging and capacity across sectors. This is no longer just about educating communities about polio and mobilising parents to ensure their children receive vaccinations during campaigns; this has reached other areas of public health and other sectors like education and child protection. This is about behaviour change, not just in terms of health-seeking behaviour, but creating a demand-based culture, so communities know what minimum standards they are entitled to. South Sudan is fragile and communities are vulnerable, so this work is critical to building resilience and ensuring rights are recognised.

3. Maintain active surveillance


The systems that have been built must be sustained. In the short-term, they will need funding to continue using the polio structure, pending streamlining and promoting regional systems.

a) Streamline surveillance structures

Country level action, with possible input from global for innovation

South Sudan currently runs different surveillance systems in health and in other sectors. In the context of the polio programme ramp down, diminishing donor resources and increasing demands on all sectors, more focus needs to be directed to making these systems more efficient not just maintaining them.

Stakeholders are being called to find innovative ways to bring these systems together to define a surveillance system that reports the data required by all stakeholders in a way that maximises use of available in-country capacity – including the polio structure and IDSR – and external resources. A streamlined system would reduce gaps in disease surveillance, ensure the same quality of surveillance for all risk monitoring and improve inter-sectoral collaboration.

To effect this change, stakeholders in South Sudan should take advantage of the current transition period – up to the end of 2019 – to

kick-start a process. Stakeholders need to come together to:

• review existing surveillance systems – including disease surveillance, active and passive, and nutrition surveillance;

• analyse whether the existing systems are what government and its partners need to maintain critical information on the status of public health;

• explore innovative systems that would maximise the limited resources available-Innovation Units from supporting agencies (UNICEF and WHO) and corporate partnerships might be considered relevant to feed into this exploration; and

• set a realistic implementation timeline with a clear exit strategy for the system to be supported almost entirely by government.

It should be noted that USAID intends to continue funding polio-related functions beyond the transition period, through to post-certification. In addition, CDC/AFENET with the EPI Capacity Building Programme (vaccine preventable diseases surveillance) will likely run until 2022. However, two donors cannot be expected to fund all ongoing surveillance, nor a streamlining process, so these resources should be perceived only as part of a larger picture of multi-donor support.

b) Invest in cross-border surveillance

Regional and country level action

In the same way that disease knows no borders, mitigation measures should know no borders. South Sudan should collaborate with its neighbours in information sharing, surveillance and response capacity to maintain minimum standards in the detection of and response to infectious disease threats. Steps have already been taken75 in this regard, which need to be supported by preparedness plans for international surge capacity. For South Sudan to meet the standards required for regional surveillance, the current active surveillance needs to be maintained – and innovative measures need to be taken, as above. As recommended in the

75 “South Sudan, Uganda, and Kenya strengthen implementation of cross-border disease surveillance and outbreak response in East Africa”, WHO in Reliefweb, issued April 30, 2018, https://reliefweb.int/report/south-sudan/south-sudan-uganda-and-kenya-strengthen-implementation-cross-border-disease

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wake of the Ebola crisis in West Africa, cross-border surveillance is only effective when all stakeholders invest resources in joint activities76, meaning all governments must bring resources and commitment to the table.

4. Monitor relevant initiatives


Boma Health Initiative: Given the critical importance of the BHI to the Government’s primary health care plans for the country but also the scepticism of partners who fund the majority of the health system structures in the country, monitoring BHI’s implementation will be an important part of a longer transition period. GAVI, with UNICEF and WHO, are planning an evaluation at the end of 2019. Despite political will, there is a lack for funding for rolling out the BHI. Given this, stakeholders will need to assess whether it starts working; how surveillance, vaccinations and outbreak response would fit into the structure in practice; and what its reach is – that is, can the Boma Health Teams (once they are formed) access the fragile, conflict-affected and hard-to-reach areas of the country?

Incentive schemes: With the European Community-funded and UNICEF-supported incentive programmes for teachers reaching the end of their planned periods, it is recommended that stakeholders analyse lessons learned and assess whether these models are practical for application to the critical functions in the medium-term.

5. Reorganise current funding streams to include vital parts of the polio structure


While funding for 2018 and even the next few years is already allocated for the Health Pooled Fund, GAVI and other major donors’ portfolios in South Sudan, these donors need to reconsider whether more funding to cover this transition and strengthen routine immunisation, surveillance, social mobilisation and outbreak response needs to be integrated into their portfolio. This is important both because the collapse of these

76 National Ebola Response Centre, Lessons From The Response To The Ebola Virus Disease Outbreak In Sierra Leone May 2014–November 2015 Summary Report, (Freetown: National Ebola Response Centre, 2016) pg12

functions could lead to major repercussions for the entire country, but also because a lot of the programmes and initiatives these donors plan to fund will not function as well without the structure that the Polio Programme has created.

6. Initiate a Fragile State Fund for Routine Immunisation, surveillance and social mobilisation

Global and regional action

South Sudan is not the only fragile state that could put national, regional and global health at risk if the already tenuous routine immunisation and surveillance systems stop working. A new pooled fund structure could allow donors to support several fragile states at the same time while preventing duplication of efforts by working bilaterally with each.

This pooled funding mechanism would ensure sufficient resources for surveillance, immunisation campaigns (in partnership with GAVI), community mobilisation and outbreak response. Fragile states covered could include those prioritised by GPEI – like Chad, DRC, Somalia and South Sudan – and countries that were not GPEI priority countries but have equally weak structures, such as Yemen, Syria, and Iraq.

A fund available globally would help to reduce pressure on donors in South Sudan – who are already at maximum capacity – while opening up the special situation of fragile states to international attention and scrutiny. It could enable greater support in terms of finance, problem-solving and innovation and would attract both donors that understand the importance of transitioning polio assets and new donors interested specifically in RI and surveillance in fragile states.

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july 2018 collapse - unicef...a call to action 1 executive summary if polio eradication succeeds but...

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