Nine months after the signing of a peace agreement in South Sudan, the country’s healthcare system is still in serious trouble – under strain in some areas, totally collapsed in others.
South Sudan faces a formidable array of public health challenges, from epidemic malaria to cholera, river blindness, kala-azar, malnutrition and measles, maternal mortality, a constant flow of war wounded and, inevitably, a decades-long challenge of caring for the war-disabled.
The country is under-equipped to face these challenges. It suffers long-standing shortages of qualified medical personnel and a lack of infrastructure. And a government cash crunch means that doctors and nurses go unpaid for months at a time. Inflation, meanwhile, driven by falling oil prices and the cost of war, has cut the real value of workers’ salaries to a fraction of what they were worth just two years ago.
During two years of war, investments that would have gone toward upkeep and development of the health sector have instead been diverted to emergency programs to assist refugees and displaced, war-wounded, trauma victims and the malnourished. Numerous hospitals and clinics have been attacked and looted, sometimes repeatedly, or suffered frequent shortages of drugs and other medical supplies, even as health workers in some areas have fled and not returned.
Further complicating the situation is the complexity of the healthcare system itself, which is really a network of a dizzying number of actors: scores of aid groups, UN agencies, bilateral and multilateral donors, private sector, national ministries, and a multiplying number of state and county governments, in a country in which 60-plus languages are spoken and hardly any of the roads are paved.
Foreign donors have stepped to the fore in this crisis, giving hundreds of millions of dollars each year to aid groups – often termed ‘NGOs’, or non-governmental organizations. This has placed part of the healthcare system beyond the direct control of government, and only loosely under its oversight.
Coordinating bodies such as the Health Cluster, the NGO Forum, and the UN’s Office for the Coordination of Humanitarian Affairs (OCHA) seek to bring order to this multitudinous healthcare ‘system’, encouraging collaboration, identifying gaps, and avoiding duplication of effort.
None of these coordinating bodies, however, is a real authority, and the actual accountability for most NGO health providers is in the hands of their donors, which require NGOs to report to them how they spend money and what they have achieved in doing so. If an aid group fails to do so, another one – a competitor, essentially – could be asked by the donor to take its place. In principle, this system keeps them accountable, limiting waste and discouraging poor performance.
But who keeps donors themselves accountable? What if they willfully choose to fund a poorly performing NGO, or insist on funding a conceptually flawed project? Donors have discretion to disburse funds how they wish, of course, but how do we know if they are spending them wisely?
Aid donors in South Sudan include the World Bank, the US and UK governments, the European Union, the UN and others. Their offices in Juba and elsewhere are staffed by hundreds of technocrats who disburse funds to NGOs, evaluate their performance, plan new funding schemes and in turn report their activities back to bureaucracies in the donor capitals.
Faced with the difficulty of knowing whether their interventions are effective or not, the donors have built an entire private research industry around ‘monitoring and evaluation’, they have subjected their programs to audit requirements, and they have tried to encourage good performance by awarding most grants on the basis of competitive bidding. In principle, donor governments are also accountable to congressional or parliamentary oversight in their home capitals.
In practice, however, these accountability mechanisms are sometimes subject to manipulation. Too easily, for example, an evaluator simply tells donors what he thinks they want to hear, or a report to Congress glosses over losses and waste, or a negative audit report is explained away. And donors themselves sometimes lack the expertise to interpret feedback and data. “There is very limited health expertise in the donor community in South Sudan,” reported the UK Department for International Development in a report published before the outbreak of South Sudan’s civil war.
The scope for independent criticism is also limited. Some aid sector officials who are privately critical of donor choices choose to keep silent over fears of repercussions. One international aid worker who spoke to Radio Tamazuj in the course of reporting this series, for example, complained of ‘major failings’ in project design on the part of one donor, but she declined to speak openly for fear it could affect funding for her former organization. “That’s the nature of the aid world,” said a second former NGO worker who worked at the health policy and donor coordination level for several years. Another source, a South Sudanese whistleblower who contacted us over a lack of HIV test kits and critical drugs at donor-funded health facilities, said he feared to be named because he could be removed from duty.
South Sudanese media, for their part, have played only a limited role in scrutinizing the aid sector in spite of its multi-billion dollar impact on South Sudan’s economy and society. Partly this is because specialized beats such as education, health or science, which are routine in Western newsrooms, and specializations such as data journalism and investigative reporting, do not exist in under-resourced South Sudanese newsrooms. Another factor is that national media have often struggled to connect with international NGOs – a result, in part, of different priorities, but also because of cultural and language barriers.
But perhaps most significant is that much of the South Sudanese media is itself reliant on the very same donors who fund the health sector and the rest of the aid industry. The largest radio network in the country, for example, is operated by the UN, while a second FM network is funded by USAID. (In full disclosure, Radio Tamazuj is also donor-dependent, though we have never experienced editorial interference).
Additionally, many journalists who struggled to make a livelihood in independent media have joined NGOs, UN agencies and embassies as press officers, communications staff or even as radio producers working on humanitarian ‘messaging’ projects. The brain drain is not limited to national media: as major Western newspapers have scaled back foreign bureaus and wire services have cut costs, foreign correspondents have also turned to NGOs, UN agencies and donor governments to earn income as writers of ‘success stories’, videographers, consultants and researchers. These services feed into a vast information flow on the aid industry – very little of which is independently published.
Such information is also a kind of currency in South Sudan’s aid world, tradeable in a contest among NGOs and donors for more funding – what researcher Joshua Craze has termed ‘a genteel version of a turf war’. It has value, in other words, in justifying the work of the very organizations that commission it. This is not to say, of course, that aid-funded research is always lacking in intellectual, journalistic or even scientific value – only that it is produced in an institutional context that is not necessarily optimal to ensuring constructive debate and preventing suppression of dissenting voices.
In some countries, free press is considered the ‘fourth estate’ – an institutional force independent of government that is in a position to observe and comment on both state and society, and to provide a platform for others to do the same. Media houses in South Sudan, including this one, face serious risks to their independence that could ultimately end their involvement in such a role. In the meantime, however, for as long as we are able, we will strive to provide to our readers the independent reporting and insights that are expected of a free press.
In that spirit, today we are launching a series of reports on the healthcare sector in South Sudan, with attention to the roles of government, donors and aid groups. Our series, ‘Healthcare in Crisis’, is published in the hope of adding value to the existing public discourse on healthcare. We begin with a look at why South Sudan faces a shortage of essential medicines. Next, we turn our attention to the HIV epidemic and ask what health providers are doing to try to check its spread.
In the third chapter of this series, we explain why so many rape victims in South Sudan are unable to access timely medical care. After that, we have a few articles explaining some aspects of aid culture and donor systems in the healthcare sector.
There’s even more to explore - we invite you to read at your leisure and share what interests you with friends or colleagues.
This series cannot pretend to offer a fully comprehensive or definitive look at this vast and complex sector; it is instead meant to mark the beginning and not the end of a new thread within the existing set of conversations around healthcare in South Sudan and service delivery, performance and accountability. To that end, we welcome health professionals, aid groups, journalists and the general public to also engage with us after reading these reports, and to submit your reactions or ideas to us via our contact form, via Twitter, or on Facebook.
South Sudan’s health system faces a crisis nearly a year in the making. Health centers across the country are experiencing dangerous stock outs of the medicines needed to treat the most basic health problems. Beyond leaving patients without immediate medical care, it also means parts of the country are now unequipped to stem potential disease outbreaks.
Without any clear solutions in the offing, some humanitarians are warning that drug shortages will become a systemic problem for large swathes of the country.
“There are more and more delays,” said Sarah Vuylsteke, the South Sudan humanitarian affairs officer for Médecins Sans Frontières (MSF). The emergency medical group started raising the alarm about potential stock outs last year. “You see it everywhere,” she said. “Health centers left and right are running out of medicines. If you can’t get basic, lifesaving medication into this country, you’re looking at a massive medical crisis.”
An essential medicines list is common in most developing countries. It includes hundreds of drugs and supplies required to meet the majority of the basic healthcare needs and guides a country’s procurement and distribution mechanisms.
Starting in the middle of 2013, an initiative called the Emergency Medicines Fund (EMF) took responsibility for procuring and distributing 112 of the most critical items on the list in South Sudan. The price tag for the EMF came to $55 million annually, paid for by the country’s biggest backers – the United States, the United Kingdom and Norway – but also Canada, Sweden, Australia and others.
The idea was that at the end of a year, the government would essentially take over the work the EMF was doing. But when the conflict broke out in December and expanded in early 2014, it became clear that was not going to happen. The donors re-upped, pushing back the deadline for the government to take charge by a year.
Except, by the time the EMF’s second round expired at the end of June 2015, the government still was not ready. There was no line item at all in the 2015-16 national budget for procurement and distribution of essential medicines.
“The government did not deliberately fail to procure essential drugs,” said Dr. Makur Kariom, the undersecretary at the ministry of health. “The current economic situation could not allow. It did not allow the government to include in the budget procurement and distribution of essential drugs.”
Still, the EMF was allowed to expire with no mechanism set up to replace it. The result has been widespread shortages of basic drugs and supplies throughout the country.
Dr. Mounir Lado heads IMA World Health in South Sudan, which supports distribution of essential medicines in Jonglei and Upper Nile, two of the states worst-affected by the fighting. He said by the time the last round of medicines provided by the EMF expired in October 2015, “most of the health facilities have run out of stock and some have closed.”
There is never a good time to run out of essential medicines, but health partners worry that shortages now, at the start of the country’s rainy season, are particularly dangerous. MSF and others have already warned that in some parts of the country malaria rates are already worse than last year, when South Sudan saw unprecedented outbreaks. The country has also experienced cholera outbreaks each of the last two rainy seasons. There are also concerns about the possible spread of Hepatitis E, usually transmitted in contaminated water, and measles.
In an open letter issued at the beginning of April, MSF International President Dr. Joanne Liu warned that the situation could “put the lives of thousands in jeopardy and again disproportionately impact the most vulnerable in this country, particularly women and children.”
It is impossible to get a read on just how dire the situation is, because there is no functioning system in place to track drug shortages in South Sudan. Simon Mansfield, the head of office for ECHO – the European Commission’s humanitarian aid wing – said one of the main priorities right now is simply “trying to get a better idea of what are the essential gaps and what do we need to do to address them.”
Though the EMF expired, delivery of essential medicines has not been completely neglected. The aid arms of the United Kingdom and the United States put money into a temporary procurement and delivery system run by an agency called CAIPA – a collaboration between Crown Agents and IPA, two international procurement groups. However, CAIPA is only procuring 55 of the 112 items that the EMF did.
The CAIPA team started work in November, with a goal of having a first delivery of essential medicines by January. It did not arrive until March, exacerbating further the ongoing stock outs. Representatives from CAIPA declined to be interviewed, but aid agencies blamed the delay on logistical difficulties. IMA’s Lado said they are now expecting to start receiving medicines at the beginning of this month.
“We hope CAIPA starts the distribution to cover the three-month gap and other donors accelerate the drug procurement for the next period otherwise, facilities will be closed, health workers will migrate and above all there will be an increase in morbidity and mortality,” he said.
Even now, more than a half a year after the EMF expired and with CAIPA’s six-month mandate set to come to an end, there is still no clear answer as to how essential medicines will be procured going forward.
International donors point to the Health Pooled Fund (HPF). Originally a three-and-a-half-year program operating in six states, HPF worked on a range of health issues, including strengthening primary healthcare services and improving accountability mechanisms. Funded by the British, the European Union and the Australians, among others, the first round expires this year. Now a second HPF, “HPF-2”, has been approved, expanding to eight states.
After the CAIPA arrangement ends in August, HPF-2 is scheduled to take over delivery of essential medicines in the eight states where it works, with support from USAID, the United States’ development agency. The World Bank, meanwhile, would be responsible for procurement and distribution in Jonglei and Upper Nile.
This proposal has Vuylsteke and others worried, not least because HPF-2’s goals – including health system strengthening and increased access to nutrition services – are much more diverse than the singularly focused EMF. There is concern that procurement and distribution of essential medicines may not be prioritized.
There are also worries about whether the HPF-2 mechanism will be operational in time. ECHO’s Mansfield said the initiative has been “rather slow to get going.” And Vuylsteke said she was concerned the HPF-2 and World Bank delivery mechanisms would not be operational until 2017.
The British Department for International Development, or DFID – the main donor for HPF-2 - declined to discuss these concerns on the record.
Meanwhile, there is still no timeline on when – or if – the government will finally be able to take responsibility for delivering essential medicines.
“As soon as the economic situation improves, the government will assume its normal responsibility of providing services, including healthcare services,” Kariom said. But he cautioned that an economic recovery would depend on oil production ramping back up and international crude prices increasing.
“I have severe doubts that there’s going to be a regular supply of drugs to this country,” Vuylsteke said. “And it’s vulnerable. After two years of conflict, civilians are super vulnerable.”
South Sudan’s conflict has reshaped the country’s HIV epidemic in ways that will be difficult to contain once peace returns.
In the rush to meet South Sudan’s emergency medical needs over the more than two years of fighting, deaths related to HIV and the disease that frequently accompanies it, tuberculosis, have quietly become the second-highest cause of mortality among the internally displaced, according to UNAIDS.
That reality has finally pushed the government, international donors and humanitarians into a scramble to arrest the virus’ spread and suppress its effects within infected patients. To do so, however, they must contend with a systemic lack of basic knowledge about HIV among South Sudan’s citizens and the country’s severely limited medical infrastructure, along with the consistent flare-ups in fighting that constantly disrupt their efforts.
Among the early victims of South Sudan’s war were HIV-positive patients in the areas most-affected by the fighting: Upper Nile, Unity and Jonglei states. The conflict scattered the vast majority of the approximately 400 HIV patients who were on anti-retroviral therapy (ART) in those three states and they were lost to the medical system.
If they weren’t killed in the fighting, they were still at tremendous risk. Abruptly stopping ART can crash an HIV patient’s immune system, making him susceptible to potentially deadly opportunistic infections, including TB. It can also render that cocktail of drugs ineffective if the patient is later able to re-access treatment.
At the same time, humanitarian partners found it difficult to get even standard HIV services up and running in the displacement camps that formed at the UN Mission in South Sudan (UNMISS) bases in the affected states. These services could have helped any patients already enrolled on ART maintain their treatment, while diagnosing new patients and slowing the spread of the disease within the sites. (There are virtually no HIV services – or medical services at all – for the displaced who are hiding in remote corners of South Sudan, waiting for the fighting to end.)
The International Organization for Migration (IOM) started prevention of mother to child treatment at the UNMISS camps in Malakal and Bentiu in August 2014. IOM’s Health Program Manager Kelsi Kriitmaa said the organization hopes to expand testing and treatment to other people at the site this year, in addition to introducing services in Renk. But it’s been a struggle to get the support they need for the programs.
“Many donors do not consider HIV as ‘life-saving’ and do not want to invest given the long-term nature of HIV treatment,” she said. She conceded that the concerns are valid, given the harm that can come from stopping a patient’s treatment after he has started. “However, South Sudan is in a protracted crisis, and development and humanitarian partners need to work together to ensure we are offering more than simply ‘life-saving’ emergency care. This includes access to both HIV and TB testing and treatment.”
Meanwhile, though the causes of their deaths are impossible to definitively confirm, people in the sites are continuing to die from diseases traditionally linked to AIDS.
In 2013, HIV and TB-related deaths were not even among the top 10 causes for IDP deaths. By last year, though, an estimated 8.3 percent of all deaths were linked to the diseases, according to official early warning and disease surveillance bulletins. Malaria was the leading killer, at 17.9 percent. At the same time, deaths from other diseases, including pneumonia and watery diarrhea, have declined – an indication that the response to acute illnesses among the internally displaced is improving. So why not the HIV response?
Maybe it finally is. Mumtaz Mia, the strategic interventions advisor for UNAIDS in South Sudan, said those numbers “shook partners up in the health cluster. Since then they’ve been trying to restart health services or push for treatment of opportunistic infections.”
The initial lack of funding was understandable, given the crush of medical needs that developed after the fighting started and as greater numbers of people became displaced, he said. Still, “the big picture is that we have failed people living with HIV in the three states,” Mia said. “We have seen that mortality rates are going up. Going forward, hopefully partners will do better.”
Even after a peace agreement was signed last year, clashes in Western Equatoria State picked up, displacing thousands of people and destabilizing an area that is one of the epicenters of South Sudan’s HIV epidemic. The country’s overall infection rate is an estimated 2.6 percent, but the disease is actually concentrated in specific areas, with the majority of new infections happening in the Equatorias. Those three states account for 60 percent of all new infections, according to UNAIDS.
Violence in the region means the number of HIV-positive patients fleeing alongside everyone else will be far larger than it was in the three northeastern states where earlier fighting centered. And international donors and humanitarian partners have taken that into account, Mia said, organizing a response that far outstrips the earlier efforts.
Organizations are trying to figure out how to track patients and maintain services as they flee, even across the border into the Democratic Republic of the Congo. At the same time, Mia said they are “developing some kind of continuation plan, which should also feed into new treatment sites that are coming up.” The idea is that no matter where you end up in the country, HIV services should always be available.
“Things can happen anywhere,” Mia said. “Displacements are happening all the time.” And unless the health providers are better prepared, then these movements will alter the nature of South Sudan’s epidemic – if they haven’t already.
There are two specific and interrelated concerns. The first stems from the fact that basic knowledge about HIV – how it is spread, how to prevent it and how it can be treated – is extremely low. That ignorance fuels stigma and discrimination, said Dr. Victoria Achut, the director of the HIV department in South Sudan’s ministry of health, which makes people even more afraid to learn about the disease.
“Stigma and discrimination is the biggest hindrance” in the fight against HIV, she said. “Social and cultural context doesn’t allow people to access testing services.” According to the country’s application for a grant for HIV services from the Global Fund to Fight AIDS, Tuberculosis and Malaria, only 10 percent of people who are older than 15 have comprehensive HIV prevention knowledge.
At the same time, the war forced encounters among people from different geographical and cultural backgrounds. People fleeing from Jonglei, for instance, where HIV prevalence is low, spilled into Eastern Equatoria, where it is much higher. And at UNMISS’ protection sites, people from all over have massed together. Sexual encounters between people from different areas are inevitable.
Add to that, many of the displaced have abandoned their possessions and lost their livelihoods, which increases instances of extraordinarily needy women exchanging sex for basic needs, such as food or a place to sleep.
Now consider that many of these people don’t know what steps to take to protect themselves and don’t have access to HIV testing facilities. When the conflict finally ends and people begin the slow process of returning to their homes, many will carry with them undiagnosed infections, giving the disease a foothold in areas where it had only a minor presence.
Meanwhile, people will be returning to areas where the medical infrastructure that did exist – including regional hubs, like the Malakal Teaching Hospital – has been destroyed, making services even scarcer.
Yet in Juba, one humanitarian group was able to look at a displaced camp there as an opportunity to improve knowledge about HIV. Mia said the International Medical Corps has set up a suite of services, including educating people about how to prevent the spread of the disease. This includes voluntary medical male circumcision. Research has shown that circumcision can reduce HIV transmission by 60 percent.
Now people living in the camp are starting to ask for male circumcision services, Mia said. She called it, “incredible. It’s the first time you are seeing, in an IDP situation, a demand for something that is one of the development interventions. You wouldn’t expect it in an emergency context.”
The government and its partners have also been ramping up knowledge about HIV prevention within the Sudan People’s Liberation Army and other uniformed services, Achut said. Because of their constant movement and poor understanding of HIV transmission, security forces are considered one of the groups most at risk of new infections in South Sudan.
Achut said they have increased outreach to soldiers and police officers across the country and opened new testing and treatment centers. “We can reduce the infection rate if we do prevention, provision of condoms, lessons on safe sex,” she said. “We can stop one of the biggest contributors to new infections in this country.”
There has been other good news to emerge in the past two years. In spite of the conflict, South Sudan’s public health officials have delivered some advances in the fight against HIV. In 2014, they registered 4,000 new HIV-positive patients on treatment and another 7,000 in 2015. There are now 19,000 people on treatment across the country, according to UNAIDS, among the estimated 179,000 people living with HIV in South Sudan.
A new $40 million Global Fund grant includes substantial funding to curb new HIV infections, with a goal of cutting them in half by 2017, while also dramatically increasing prevention activities – especially for groups like female sex workers and uniformed men, who are most at risk of new infections.
Achut said the ministry has even started discussions about how to meet new World Health Organization guidelines, which call for every HIV-positive patient to be started on ART as soon as she is diagnosed. Though she cautioned that the introduction of “test and start,” as the initiative is known, is still years away.
But first the public health community needs to find out just how much the fighting has changed the country’s HIV epidemic. Achut said the government, in collaboration with several international partners, is planning to roll out a $6-8 million AIDS Indicator Survey next year. A population-based survey from across the country, it will offer officials in South Sudan the clearest picture they have ever had of just how extensive the country’s HIV epidemic is – and what strategies they need to fight it.
“I believe the epidemic picture has changed, but we don’t have the evidence for that,” Mia said. “Hopefully we can get that evidence.”
In spite of hundreds of millions of dollars in foreign investment, healthcare providers in South Sudan are struggling to reach one of society’s most vulnerable groups: victims of a wartime rape epidemic and victims of sexual violence in general.
Women who are raped often go months without accessing drugs to protect them from sexually transmitted diseases, counseling and other assistance, while others receive no help whatsoever, sources said. An atmosphere of pervasive fear further hampers medical efforts, even after the signing of a peace agreement in August last year.
“Wau today is in an emergency state, nobody knows what is going on here in Wau. There are many cases of rape but they have not been reported to the hospital or any other institution because these are soldiers who raped them and people fear to report,” said an activist who did not wish to be identified because she has been arrested before by security personnel.
Human Rights Watch (HRW), which carried out a research mission to Wau in April, described “repeated harassment, looting and assaults, including killings and rapes,” saying that ethnic Fertit civilians were targeted by security forces in villages and neighborhoods around the city. “Three soldiers raped a 60-year-old woman in April just outside of Wau, while her nephew was forced to watch,” HRW reported, citing an interview with the woman’s niece.
In another case, five soldiers in December raped a 28-year-old woman who was two months pregnant: “They took her to a compound and raped her. Her boyfriend... was with her. He was badly beaten,” the rights group reported, citing an interview with the woman’s father. After filing a police report and seeking medical treatment, the woman and her father were detained and intimidated by soldiers.
Dozens of other women in Wau have also been threatened and attacked this year and need assistance, the same South Sudanese activist told Radio Tamazuj. “For example, in one area, you get over 40 women and girls raped. They rape them in front their husbands.... We need urgent investigation by NGOs on these ongoing crimes taking place in Wau,” said the activist.
“The presence of UNMISS in Wau is very weak... Now only humanitarian NGOs are trying to go out reaching people but again were stopped not to move outside Wau,” she said. The activist complained that cover-ups and under-reporting of sexual violence were inhibiting response efforts.
Even in the capital Juba, rape survivors have sometimes struggled to access medical treatment, particularly those who are not living inside one of the ‘protection camps’ run by the United Nations. In an interview, an SGBV specialist working for an NGO in South Sudan said that a number of rape survivors at the Mahad displaced settlement, for example, did not access medical care for more than a year after they were raped in January 2014.
“A lot of them had also sustained massive physical injuries in the course of being gang-raped. Because none of the survivors I spoke to was an individual rape. All of them were gang rapes. All of them had injuries on their arms, or their legs, or had been burned in the process. So even those injuries had not been attended to,” said the researcher, whose organization did not wish for her to be named.
She also pointed to signs of mental stress among people she had interviewed. “Across the three field sites that we visited there was a clear mental health effect for survivors who hadn’t been able to access medical care – not knowing whether they had contracted HIV or STIs for them was a huge problem and a huge mental burden, in the way that they described it.”
One factor discouraging women from accessing treatment, both in Juba and elsewhere, is a mistaken belief that rape victims must complete the ‘Police Investigation Form 8’ prior to getting treatment.
“While there is technically nothing mandating that survivors go to police to get this Form 8 before going to the hospital, the perception among police, hospital workers and even community members that we interviewed is that victims (A) have to go to the police to open a case and get Form 8; and then (B) go to the hospital. So this was actually a deterrent sometimes from seeking medical care,” said the same researcher.
“Hospitals would sometimes turn away a woman if she’s not in possession of the proper paperwork, which outside of urban areas isn’t available,” she added.
Another NGO worker in Juba, who works in the medical field and responds to rape cases in the UN protection camps, says that services are available there such as medicines for post-exposure prophylaxis against HIV and other sexually transmitted diseases. Survivors can also access psychological support services as well as discussion groups and women’s safe spaces where activities are sometimes offered.
However, the health worker said that the ‘protection sites’ are also sometimes a trap for women who have been raped by someone not on the outside but within the site. Since women belonging to the Nuer ethnicity usually fear to wander out of the protection site into Juba city itself, they are left with little choice but to continue living in an environment in which they feel unsafe.
“It is really very hard to help them, because they are living together with the perpetrators and this person is telling you, ‘my life is completely at total risk.’ So she has come to you and now there’s no any place to take that person to, you cannot take that person outside the PoC [protection site], it’s also risky, so this is a major challenge,” said the health worker.
The situation is similar in Bentiu, where some victims have been raped outside of the protection site while others are attacked within it, and where health workers report that many rape victims are not getting timely treatment. Anissa Dickerson, an American midwife with Doctors Without Borders (MSF) in Bentiu, told a journalist with NPR recently, “We see mostly women who were raped two, three, sometimes six months ago.” She added, “We see women who have walked three days to get here trying to get away from violence or leaving their village because there’s no food available anymore.”
Skye Wheeler, who carried out research about a year ago in the same Bentiu camp for Human Rights Watch, described a similar situation at that time, though by then the camp was “in chaos” with massive influxes of people fleeing a government military offensive. Humanitarians were “overwhelmed,” Wheeler recalled, and the camp was overcrowded and desperate. “We documented many cases of rape which was used as a tactic by the government forces and allied militia to clear civilians from villages, together with burning huts, beatings and killings,” she said.
“Because of the difficulties in traveling long distances by foot after rape few women that we interviewed had arrived in time to get post-exposure prophylaxis for HIV prevention which needs to be taken within 72 hours of exposure.”
Wheeler also pointed out that women continued to face the threat of rape even after reaching the UN’s Bentiu protection site. “We found that old women were going to collect firewood... to try and protect younger women from rape. Women told us that they were afraid of going to poorly-lit latrines at night with doors that were not lockable.”
She added, “We generally found that many women did not know about services that were available, suggesting not enough was being done at the time to spread awareness. There was definitely a shortage of counseling or case management of rape cases, even if women were able to access emergency care.”
Since then, however, Doctor Without Borders have scaled up “expanded programs including counseling services to survivors and community sensitization” in Bentiu and other conflict-affected areas. These programs have been rolled out in Leer, Bentiu, Lankien, Malakal and Doro, the aid group said in an email.
“Patients receive treatment in a private room... Anyone who comes to access MSF services are provided with medical treatment for injuries sustained as a result of sexual violence, post-exposure prophylaxis to limit the potential risk of HIV transmission and provided with access to treatment for prevention of sexually transmitted infections (STI),” explained the medical aid group.
Other aid groups working to help rape victims include International Medical Corps (IMC) in the Akobo area. “IMC was doing quite well actually in raising awareness around access to medical services for survivors of sexual assault,” said an observer who carried out research in the area. “Outside of Akobo town there were gaps but in town they were doing well to provide services to the extent that they could.”
The scope of the problem is hard to estimate. Human rights groups have reported that hundreds of women have been raped, but data is hard to come by. MSF says that it cannot estimate the prevalence of sexual violence in South Sudan based on its medical data, saying that “stigma and barriers to accessing care” prevent a clear correlation between the two.
Even so, MSF says the number of sexual violence survivors whom it treats “are, almost certainly, only the tip of the iceberg in terms of the overall scope of the issue.”
Many government health workers in South Sudan go months at a time without pay. When they are paid, their salaries are worth only a fraction of what they were before the civil war started, owing to inflation and money-printing resorted to by the government to fund its war efforts.
A registered nurse is entitled to a salary of about 2,000 SSP monthly, which is worth less than $60 at the official rate, or about $2 per day. A nurse with only a certificate is entitled to only 1,500 SSP per month, which is about $40 per month. Medical doctors in Juba fare hardly better, receiving only 2,500 SSP, while doctors in more remote field locations are also entitled to allowance and incentive depending on the location. Medical consultants earn 5,000 SSP.
High costs of commuting to work must be deducted from these earnings. In recent interviews, nurses in Juba frequently complained of bus fare hikes owing to a citywide fuel shortage. This makes it difficult for a nurse who shows up to work every day to even avoid losing money in a month, given the costs of commuting.
“The welfare of staff really in South Sudan is still a big challenge, so now retaining these staff in the hospital is really a problem,” said Ayol Mach Ayol, a gynecologist at Bor Hospital. “The financial challenges are really chasing us away.”
Medical interns who work at Juba Teaching Hospital led a strike in May over poor working conditions and lack of pay. These fresh graduates have been awaiting a temporary appointment, but due to austerity have been given nothing, and were told to continue working as volunteers if they wished.
Juba Teaching Hospital, South Sudan’s main referral hospital, has lacked electricity for more than two weeks in May. In interviews, nurses at the hospital seemed extremely upset by this, saying patients have been suffering and dying. Minister of Health Riek Gai Kok says the electricity for the hospital is not his responsibility, blaming the city utility services, according to remarks broadcast on SSTV.
A senior government official who spoke to Radio Tamazuj about this on 22 May said the situation at the hospital was “beyond human imagination.” He says that relatives of patients seeking operations have been compelled to bring fuel to run a generator so that surgeons could have light to perform the operations.
“This is a situation which I have never witnessed even at the time of war when this hospital was under the rule of successive Sudanese governments in Khartoum,” said the official.
“Now if the family members and the relatives of the patients are the ones to provide fuel, what about those with no capacity to provide fuel?” he asked.
Jamila Saki, the president of the Association of South Sudan Nurses and Midwives, made similar remarks on the occasion of Nurses and Midwives Day, celebrated in Juba on 12 May. She said the situation of nurses and midwives is worse now than even it had been before secession in 2011. Saki said that health workers have not been paid and are owed three months salaries.
In spite of these challenges, and with little reward, many health workers across South Sudan continue to serve their people. We spoke to nurses in Juba to find out what had motivated them to join the profession:
There are at least 80 aid organizations working in healthcare in South Sudan, most of them international NGOs, besides scores more working in other fields such as nutrition, education and sanitation.
Most of these organizations have offices in Juba for coordination purposes: getting visas and permits for staff, facilitating field travel and logistics, and liaising with government and donors. Additionally, many NGOs operate residential compounds for international staff.
The typical NGO compound in Juba has one or more office buildings, parking space for some Land Cruisers, sometimes a container or two as extra office space or storage, a high cement wall topped with razor wire, and one or more unarmed security guards at the gate.
Rented property in Juba is not cheap, particularly for land that has already has been developed: Some NGOs’ rental costs in Juba can run to $50,000 or more per month. Costs for security and water must be added to this, plus fuel to run generators nearly constantly owing to the lack of city electricity and a subscription service to a satellite internet service.
Even though NGOs have been a permanent fixture of South Sudanese society for as long as most people can remember, they tend to operate on the premise that they are only outsiders passing through, preferring to rent instead of buy or build, and avoiding acquiring assets. And there is little evidence of attempts at collective bargaining or pooling resources. This approach differs markedly from that of foreign embassies, which secure land through sovereign arrangements, and that of the UN Mission, which acquired temporary land rights “without cost” under its Status of Forces Agreement. Likewise, mission organizations involved in relief work - the Catholic Church, for instance - sometimes have no rent costs because they acquired land decades ago.
Yet in spite of the high costs of renting, international healthcare organizations in South Sudan seldom share compounds. An evaluation of the two USAID-funded programs operating in Central and Western Equatoria, run by companies Jhpiego and ABT Associates, cited this as a matter of concern. “There is a duplication of overheads as each program has its own offices, support staff, vehicles and equipment,” reads the white paper, which was prepared by MSI International.
MSI says it sent an assessment team to four counties and two state headquarters and found “no examples of the programs co-locating with each other, or with government. As well as the cost implications, this has an impact on day-to-day coordination.”
Another organization that carried out research on the health sector in South Sudan found that the massive and costly NGO presence in Juba was due in part to the one-NGO-per-county model in the health sector. HEART, a consultancy that produced a mid-term review report for the UK-led Health Pooled Fund last year, recommended that services be consolidated under a smaller number of NGOs.
“The county model seems highly appropriate as the basis for delivering support to health facilities. However, to date this has been somewhat inefficient with central IP [Implementing Partner] management costs of around 39% of total spend. Any redesign [of the Health Pooled Fund] should consider the possibility of introducing state-based contracts... in order to reduce the number of contracted organisations and thus overhead costs,” HEART stated.
All of this amounts to a situation where a substantial amount of donor funding meant for healthcare services is going toward the overhead cost of operating scores of offices and residential compounds in the South Sudanese capital Juba.
Besides the actual costs, the compound culture in Juba and elsewhere reinforces a second problem for humanitarians, which is that it isolates them from the community. Most of the organizations renting compounds in Juba do not operate aid programs in Juba itself, but rather in ‘the field’. This has left many Juba residents perplexed as to what all of these NGOs do. One common attitude is that the NGOs are a way of creating jobs for foreigners. Another attitude, perhaps less pervasive but one propounded by President Salva Kiir, is that the ‘so-called’ humanitarian organizations have political motives for their long sojourn in Juba.
Such perceptions have very real effects on aid groups’ ability to operate. In a vote earlier this year, parliament passed a bill that would severely restrict the number of foreign aid workers in the country, if enforced. Supporters of the bill see it as a necessary corrective the perceived excesses of the aid industry; critics, on the other hand, say it would threaten the survival of aid operations that are a lifeline to millions.
Diana Felix de Costa, author of a 2012 study on aid culture in South Sudan, says that high crime in Juba has led to a culture of “defensive living” among aid workers: “bunkerising is becoming institutionalised,” she writes.
“The resemblance between fortified aid compounds and prisons is remarkable,” says De Costa. “You can live all your life in Juba without leaving the compound… Go to work, exercise, shopping, partying,” she adds, quoting a UN expat.
Ferdinand von Hapsburg-Lothringen, a former UN advisor, says that the international community has struggled to understand South Sudanese society even after decades of engagement.
“The international community has long existed in this particular context and has rarely truly understood the nature of life and violence [in South Sudan], contained in its compounds, living in its own particular culture and rarely penetrating the depths of this complex history,” he writes in a recently published article.
“Should we care to truly invest in supporting the South Sudanese in their long journey towards peace and reconciliation, we will need to start by truly listening to them,” adds von Hapsburg.
Looking to cut costs
In the meantime, some donors are already taking steps to try to cut back overhead costs. Health Pooled Fund, for example, told Radio Tamazuj that it is currently looking to make changes to its one-NGO-per-county model, expecting a consortium system to be rolled out later this year whereby three or four aid groups including a national NGO will manage healthcare in larger geographic areas.
“If you have one county, one project, you have to have everything: you have to have the finance, you have to have the office, the reporting, and so on,” explained HPF team leader Dr. Damianos Odeh.
“[Whereas] if you have three or four [NGOs per state], it’s one unit that looks after all three or four [counties], instead of each unit one, one, one. So they will save a lot in terms of staffing, in terms of the overhead support that they are getting. It’s economies of scale, to be frank. In some small counties in the past the entire thing was one or two clinics in a county. And to have a whole system to cater for that – it’s not very cost effective.”
“So if you group them together, you can get a lot of savings,” concluded the fund manager.
The Three-Ring Circus
To understand how the donor-supported health sector has worked in South Sudan in recent years, think of a three-ring circus. Conceived by donors and health ministry officials at a workshop in November 2011, the system is a three-way division of labour among lead donors: the World Bank provided funding for primary healthcare services in two states, the US Agency for International Development in another two, and the multi-donor Health Pooled Fund (HPF) headed by the UK Department for International Development (DFID) in six states.
In each of the three rings, dozens of aid groups are busy performing – most of them international NGOs. About ten aid groups work with World Bank funding in South Sudan’s northeast – Jonglei and Upper Nile states; six or seven others historically operated with USAID funding in the southern states of Central and Western Equatoria (though this is now changing); and more than a dozen aid groups work with HPF funding in the rest of the country. Some aid groups operate in multiple spheres, relying on different donors in different areas.
At the heart of each sphere are the fund managers or lead agents – the ringmasters, if you will – who are tasked to ensure that order is kept and that the NGOs perform. In the UK-led sphere, the British chose the British company Crown Agents as their fund manager; in the US-led sphere, the Americans chose the American company Jhpiego as their fund manager, and in the World Bank sphere, the World Bank chose the US-based aid group IMA World Health, which is a key implementer in its own right but also acts as a de facto fund manager by issuing sub-contracts to more than a dozen other aid groups and county health departments. USAID also contracted a second American company, ABT Associates, to run a second program within its sphere.
Although each donor sphere has historically worked a little differently, in the main the process is broadly similar, involving a flow of donor funds, via a middleman, to the implementing organizations, which are usually international NGOs or local health providers such as county health departments. At least $480 million has already been allocated by donors to these programs since their inception.
In principle, the three lead agents or fund managers are meant to work closely with South Sudan’s Ministry of Health. Each grant scheme has built-in mechanisms to ensure that happens – IMA World Health is actually a contractor of the ministry itself, for example, while the Health Pooled Fund has a steering committee chaired by the ministry and co-chaired by DFID.
Makur Koryom, Undersecretary at the Ministry of Health, explained the arrangement in an interview: “The duties and functions of the partners have been clearly defined and demarcated. The government identify the needs where the services are required and undertakes direct supervision, the donor partners provide funds and the implementing agencies undertake the actual work of the implementation.”
From its founding, the system was billed by donors as an improvement on earlier aid schemes, with a focus on collaboration between NGOs and county health departments, coverage of the entire country, and a neat division of labour by region and county to prevent duplication of effort. With usually one NGO per county, no single county goes without support, nor does another have too many providers.
Complicating the system, however, is that some NGOs operate outside the three-ring framework. Donors conceived the three-ring system in the period after South Sudan’s independence, expecting that the government would be able to take over increasing responsibility for healthcare. However, with the outbreak of civil war in December 2013, a major humanitarian disaster hit even as government shifted ever more of its spending away from services and toward military spending.
This resulted in an influx of new humanitarian funding. Two of the largest organizations to operate outside of the three-ring system are Doctors Without Borders (MSF) and the International Committee of the Red Cross (ICRC), which have their own funding mechanisms. They operate on a humanitarian model and are concerned with addressing emergency needs and not in building up county health departments or other government systems.
Others that fit this model include NGOs funded through the US Office of Foreign Disaster Assistance and the UN Consolidated Appeal Process, which secured so far more than $53 million for healthcare operations this year, according to data kept by the UN agency OCHA. Some aid groups receive funding both under the three-ring system and through humanitarian mechanisms. CARE International, for example, is the implementing partner for the Health Pooled Fund in parts of Unity State but has also received funding for operations there from the UN Common Humanitarian Fund.
In practice, this system involves so many organizations operating under so many different funding mechanisms that it has become unwieldy. For instance, USAID-funded ABT Associates, which runs trainings for government health managers in Western Equatoria (WES) and Central Equatoria (CES), reported in March 2015 that it struggled to even keep track of all of the stakeholders within the two states in its area of operation. “There has been an influx of stakeholders to provide humanitarian support to the health sector in WES and CES, with many of the stakeholders moving in and out abruptly. This development has made it a challenge to maintain an updated stakeholders’ mapping database,” said the organization.
In this complex environment, NGOs and donors have devised mechanisms to help the many parts of the circus work together. One common practice is for organizations to hire international personnel whose sole responsibility is coordinating with and reporting to other “stakeholders.” A quick look through a contact list of the Health Cluster - a coordinating body of different stakeholders - shows that ‘Health Coordinator’ is a common function, while most NGOs also have a function such as ‘Grants Coordinator’, which is a role that involves dealing primarily with donors or potential donors.
Managing information flows, fulfilling reporting obligations and running the treadmill of competitive bidding and proposal-writing is a full-time job for many aid workers, and a full-time job for many on the donor side as well. The costs to the system are significant. Fund management for the Health Pooled Fund itself, for example, has cost donors at least £12 million over the last three years, according to DFID’s website, besides staffing costs at NGOs themselves. And the World Bank has allocated more than $8 million in recent years to strengthen the health ministry’s Directorate of Planning and Coordination to “plan, manage and monitor grants and contracts” with NGOs and other service providers, according to World Bank documents.
Aid agencies that win grants or contracts from donors in the healthcare sector sometimes have to reapply for funding just months later in order to keep their programs up and running. One aid worker who worked in management told Radio Tamazuj that the World Bank required funding applications every quarter, while also complaining that the Health Pooled Fund imposed “very heavy” reporting requirements.
The aid worker, who preferred not to be named for fear of damaging institutional relationships with donors, pointed out that such reporting requirements are costly and time-consuming. “If you want that level of accountability you have to fund it,” she said.
For their part, donors are moving to consolidate together two of the three main spheres in this system, aiming to reduce overhead costs and reduce the paperwork involved in running scores of contracts with aid agencies across three different reporting systems. Since last month, a handful of aid groups within the USAID sphere have been moved under the Health Pooled Fund, and the US agency plans to divert its funding from Central Equatoria and Western Equatoria into the multi-donor fund rather than continue to run it as a separate fund.
Once complete, this process would give the Health Pooled Fund a mandate in eight of ten states and potentially position it to roll out services nationwide, thereby ending the three-way division of labour among donors that has been in place since late 2012.
Since 2013, three primary middlemen have acted on behalf of the leading international donors in South Sudan’s healthcare sector: Crown Agents, Jhpiego, and Inter-Church Medical Assistance, better known as IMA World Health. They have served as key conduits of funding for primary healthcare in South Sudan, awarding contracts to implementing aid groups, overseeing how funds are spent, and reporting information back to the donors.
Jhpiego is an organization affiliated with Johns Hopkins University in Baltimore, Maryland, USA, which has managed approximately $85 million in USAID funding. The fund, known as the Integrated Service Delivery Project (ISDP), has supported primary healthcare in two states - Western and Central Equatoria. Three other organizations worked with Jhpiego within the fund secretariat: Save the Children, John Snow, Inc. and PSI.
The Jhpiego consortium in turn awarded funding to several aid groups actually operating in the two states, including Adventist Development and Relief Agency, Mundri Relief Association, Catholic Medical Mission Board, Action Africa Help International, Johanniter International, American Refugee Committee and World Vision.
A separate US-funded program aligned with Jhpiego’s work but not directly managed by it is the Health Systems Strengthening Project (HSSP), a $25 million five-year project run by ABT Associates, also based in Maryland. The work of ABT Associates in the same two states is focused on training and building capacity of government institutions including county health departments.
The multi-donor Health Pooled Fund, meanwhile, is managed by a consortium of companies led by Crown Agents. Donors include Canada, Sweden, the European Union and the United Kingdom, which acts as the lead donor. Australia has also supported the HPF, but will not continue to do so in the second phase of the program. Crown Agents’ partners in the HPF secretariat are Health Partners International, Health Information Systems Programme, Montrose, SKILLS for South Sudan and Charlie Goldsmith Associates.
Crown and these partners take a cut of about 10% of the fund in order to manage it, according to data published on the website of the UK Department for International Development, which shows that DFID has paid to them at least £12 million since 2013, out of the total HPF-1 of about £120 million. This amount includes offices costs, staffing costs in Juba and in the home offices, short-term consultants, as well as workshops and seminars, according to a HPF staff member.
Most of the rest of the money has gone to aid organizations working in six of South Sudan’s states, for example, World Vision, Save the Children, IRC, CARE, GOAL, Healthnet TPO, Merlin, CCM and others.
The Health Pooled Fund has historically covered only six states, staying away from areas already supported by World Bank or USAID. Now, however, two of the three primary funds managers are joining forces - Crown Agents and Jhpiego. Under this new arrangement, USAID funds that had been managed by Jhpiego separately will now instead be merged into the HPF; implementing partners of Jhpiego have already been contracted by HPF since April.
This expands HPF’s mandate from six states to eight and significantly increases the size of the second phase of the Health Pooled Fund, or HPF-2. One source said the USAID contribution could bring the total size of HPF-2 up from £88 million to approximately £130 million.
This merger represents a significant change in the “three-ring” system governing donor engagement in the primary healthcare sector since 2013, effectively consolidating two of the three major funds under one roof. However, the third major fund in South Sudan, established by the World Bank, is unlikely to merge with the other two owing to significantly different funding modalities.
Covering two states of South Sudan, Jonglei and Upper Nile, the World Bank’s Rapid Results Health Project works via the South Sudanese Ministry of Health and aid group IMA World Health, which is also based in Maryland, USA.
IMA’s role differs from that of Jhpiego’s and Crown Agents’ in two key respects: (1) It directly implements health services in some areas; (2) It works under the Ministry of Health rather than directly under the donor.
Nonetheless, IMA runs sub-contracts worth millions of dollars with NGOs and county health departments, which makes it effectively a fund manager much like Jhpiego or Crown Agents.
The aid group is considered a contractor of the health ministry, and is managed by a special unit within the ministry. World Bank passes funds directly to IMA, but only after sign-off by the ministry.
South Sudan’s finance ministry considers World Bank funding for this project a supplementary part of the government health budget. This distinguishes it from the “off-budget mechanisms” of HPF and ISDP.
In effect, however, much of the World Bank funding goes to international NGOs rather than government clinics or institutions. IMA manages approximately $54 million in World Bank funding for its own operations and those of its contractors, which include SMC, CARE, IMC, Cordaid, GOAL and Relief International.
Inside the management of South Sudan’s largest donor fund
At the heart of South Sudan’s health sector is the Health Pooled Fund (HPF), covering six states – and now expanding to eight – and managing tens of millions of UK pounds donated by the British government, Canada, Sweden, and the European Union.
Over three years of implementation, begun in peace and continued in war, the HPF has needed to adapt to major challenges even as the lead donor DFID has see-sawed over how the fund should be managed and by whom.
The British government and other donors, after threatening to fire the HPF fund manager last year, are now moving forward with a plan to pour about £130 million more into the fund under the management of the same company.
Crown Agents, which manages the HPF, acknowledges ‘huge’ challenges in accomplishing the aims of the HPF and admits it has needed to adapt its approach over the course of the project, but it points also to major achievements in sustaining a healthcare system buffeted by war, disease and fiscal and economic crises.
“This Health Pooled Fund is really the hope for the country,” says Dr. Damianos Odeh, Crown Agents’ Team Leader for the HPF, citing the size of the fund and its flexibility to adjust to emerging needs.
The HPF has supported government clinics, hospitals and NGO clinics in the entire Bahr al Ghazal region, Eastern Equatoria and in accessible parts of war-ravaged Unity State throughout the civil war since 2013. HPF has improved the supply of drugs and stocking methods in these areas, set up ambulance services and operations theatres in areas where they had never existed before, and made gains against debilitating conditions such as obstetric fistula.
The program is massive, supporting one aid group per county. “Each of these counties is a project,” explains Dr. Odeh. “Right now I have over 60 contracts, and soon will have much more as the two new states are on board with hospitals, etc. Each one of those is a life of its own as a project, because you need to do audits, you need to do verifications, you need to do forecasting.”
Complicating matters, the HPF secretariat itself is staffed by a consortium of organizations and companies working under Crown Agents, not by Crown Agents personnel alone. These include Health Partners International, Health Information Systems Programme, Montrose, SKILLS for South Sudan and Charlie Goldsmith Associates.
At times, Crown Agents have struggled to manage a project of such scale and complexity, according to audit reports. A project report by the British development agency DFID in 2015 reported “a number of problems with project management both between the project office in Juba and the [Crown Agents] headquarters in United Kingdom and within the Juba project office including communications, timely management of contracts, [and] slow disbursement of funds.”
Similarly, a report by the consultancy HEART, which DFID commissioned to produce a mid-term review of the project, highlighted a number of the same issues, charging that the HPF management team in Juba was overstretched, that the Crown Agents management in the UK had caused delays in signing contracts, and that the company was sometimes slow in communicating with its implementing partners.
Problems that had surfaced during the first year of implementation continued into the second, according to the report, and in June 2014 DFID formally raised concerns “about the quality of Crown Agents’ UK programme management and the impact that this was having on the operations in-country.” HEART also pointed to some ‘high risk’ financial management patterns, including lack of a formal budget review process, lack of analysis of financial reports and late responses to queries from contracted aid groups.
Crown Agents’ headquarters said in a statement to Radio Tamazuj that the HPF has been a “challenging programme,” adding that it has set up mechanisms to learn from “challenges overcome.” Going forward, Crown said that it plans to increase its focus on monitoring and evaluation as well as provide real-time data on its grants to the donor.
“As project managers, Crown Agents is providing DFID with improved visibility and increased accountability through our grant management system, which incorporates a real time data access dashboard giving more transparency and better financial management,” reads the statement in part.
For his part, Dr. Damianos Odeh, the HPF Team Leader, acknowledged in an interview that the “the staffing design was very thin on the technical side” at the Juba level, saying Crown Agents has worked to address areas of concern since the last audit.
He explained that he has hired experts in technical areas such as maternal and neonatal health, hospital management, equipment and pharmaceuticals in order to better support implementation. “I needed those kind of skills which were not part of the original project design,” he explained, noting that initially he did not have the flexibility to hire more staff of this kind.
The Crown Agents official also pointed to some factors that made it challenging to manage so many aid groups, including poor staff retention at the implementing NGOs as well as an experience gap, in some cases, at NGOs more accustomed to emergency interventions than in strengthening health systems. “The finance teams on the NGO side – they change so rapidly. I don’t know why, because every six months a new director, a new this – maybe it’s too much, too stressful, we have to continue to train and orient. And this is not our job. The government said: this is not your job to build the capacity of international NGOs. Well, it is our job to make sure that they understand the project and do it right.”
Dr. Odeh further explained that a number of external factors put strains on the budget of the HPF, citing the national drugs shortage and the need to renovate dilapidated facilities. The original plans for HPF called for the HPF-supported aid groups to source their drugs from a central USAID-led project, so that they would not bear responsibility for procuring drugs themselves. “That turned out not to be the case,” he recalled. “We had difficulty getting the drugs from the other projects for a variety of reasons and so we had to start by allowing our IPs – implementing partners – to buy drugs.”
“We really needed to change the project to allow for the drugs and the transportation cost of the drugs was very, very high at some point,” he added. “We had allocated the budget on the assumption that drugs would come from a different source. The drugs did not come from a different source and even when they were brought, procured centrally, each area had different needs so we needed to allow the implementing partners to buy drugs as needed.”
By 2015, as the HPF struggled to supervise more than a dozen aid groups in the midst of a humanitarian crisis, a crumbling public health sector and a collapsing currency, DFID began to openly question whether Crown Agents was the right company to continue managing the fund. Citing management issues, the British agency warned starkly in a review published last year, “One possible action could be that the CA [Crown Agents] contract will be terminated.”
Humanitarian conditions in South Sudan continued to worsen throughout 2015 as heath workers battled a cholera outbreak, an exceptionally severe malaria season and a huge caseload of malnourished patients. In August, a British government office known as Abercrombie House in the town of East Kilbride in Scotland issued a notice, little remarked in South Sudan, that it was seeking a new company to take over management of the Health Pooled Fund.
The HPF would end in March 2016, explained the procurement notice, but the donors wanted to continue the programme with a “lightly revised design.” The so-called phase two of the Health Pooled Fund, or HPF-2, would start in April 2016 and run for two years. The expected £88 million program would finance aid groups and health workers at the front line of South Sudan’s healthcare crisis.
“This notice represents the start of our market engagement for this procurement,” reads the August advisory. Following this exploratory step, DFID made a second announcement in December 2015 inviting companies to submit preliminary information to be considered in the bidding process.
IMA World Health, the lead agent of the World Bank health fund in Jonglei and Upper Nile states, was prepared to bid against Crown Agents for the job, sources told Radio Tamazuj, revealing that the aid group had formed a consortium with consulting firm Mott MacDonald, BBC Media Action and Charlie Goldsmith Associates to take on Crown Agents, and that they were involved in the preliminary stage of bidding before the tender was canceled. IMA itself confirmed this to Radio Tamazuj, saying it would have made “radical” changes to the HPF if they had won the bid.
Dr. Mounir Lado, the top IMA official in South Sudan said, “IMA World Health proposed an innovative and responsive program that builds on the best practices and lessons learned of Rapid Results Health Project (RRHP). Concurrently, IMA proposes radical changes that will improve country ownership, health facility performance, and health outcomes in new focal areas of maternal mortality and nutrition.”
“The plan was to work with strong partnership with the Ministry of Health... while drawing technical expertise from new partners, streamlining human resource management and payment systems into existing ROSS systems for maximum harmonization; scale up emergency obstetric and newborn care... [and] implement an integrated nutrition program,” Dr. Lado added.
Radio Tamazuj was unable to verify which other companies or NGOs other than the IMA-led consortium responded to the British tender, although one source said an Indian firm was also preparing a bid.
However, in March 2015 the British government abruptly reversed course, canceling the tender and informing organizations that had submitted pre-qualification questionnaires that they had decided that their best option was to extend their contract with Crown Agents.
DFID officials did not provide answers to questions from Radio Tamazuj sent nearly two months ago about the HPF and cancellation of the tender process, nor to follow-up questions sent 16 May. A DFID spokeswoman said 20 May that the department was working to prepare answers, but by publication time none had been received.
Radio Tamazuj specifically sought to know from DFID whether it was unusual to award a contract of £88 million without tendering it. This was never answered. However, a review of relevant DFID documents indicated that the original terms of reference for the 3.5 year deal with Crown Agents permitted an extension by two years.
Some observers in the health sector said they were surprised by the British decision to cancel the tender, while others thought it made sense. “DFID yanked the rug out at nearly the last moment,” observed an aid worker who was critical of the HPF management. “There was always the awareness that DFID prefers to deal with existing partners than take on new ones - they prefer the devil they know to the devil they don’t.”
“Easier to stick with a struggling horse than change mid-stream and risk losing any gains,” commented a more sympathetic relief worker who has worked on the donor and policy level in South Sudan. “Massive projects like that take months and months to set up,” she added.
Meanwhile, HPF officials are working on implementation of the HPF ‘phase two’. Asked about how the HPF-2 will be different from HPF-1, Crown Agents’ team leader said, “It’s a matter of emphasis as opposed to a major change. The biggest change is the introduction of the nutrition as a stronger element.” He added that family planning also will be more strongly emphasized as well as standards and quality of care.
“We will continue to have the hospitals, we will continue to have primary healthcare, we will continue to work with the community,” added Dr. Odeh.
Crown Agents’ headquarters also pointed to plans for “increased focus on gender and social inclusion” as one of the changes in the new HPF-2, as well as expansion of the fund into Western and Central Equatoria and greater flexibility to cope with emergencies and conflict.
Dr. Odeh stressed that the HPF still has a big role to play in the future of healthcare in South Sudan. “All the challenges and issues are huge, but we are tackling them on a daily basis and it really is working,” he said.
In Name Only
The World Bank at the centre of a humanitarian crisis
Akobo County Hospital in South Sudan’s Jonglei state is running out of medicine.
“We haven’t received any drugs since last year,” one health worker wrote Radio Tamazuj in a recent email. “When patients come to hospital, we have nothing to offer them... You cannot even find injection needle in Akobo hospital.”
The dire situation is despite the fact that Akobo County Hospital is part of a 63 million dollar World Bank-funded initiative called the Rapid Results Health Project.
The RRHP is meant to support aid groups and county health departments in South Sudan’s Jonglei and Upper Nile states. But it is funded through South Sudan’s national government, and Akobo County, like about a dozen other counties in Jonglei and Upper Nile states, is controlled by an opposition group. Those counties are also among the most war-affected areas in South Sudan, either because they have seen fighting or are hosting populations that fled from frontline areas.
The World Bank designed the RRHP in 2012 - a time of peace - with the assumption that the government in Juba would be a partner throughout. Yet four years on, with Upper Nile and Jonglei devastated by conflict and rebel groups controlling large swaths of territory, the design of RRHP remains largely unchanged.
The result is the hugely challenging task of achieving a World Bank program designed in peace but implemented in war.
In 2012, the World Bank decided that the Ministry of Health should be the centerpiece of a network of health providers in Upper Nile and Jonglei supported under its funding. Even though the government was not ready to take over all health services itself, the Bank reasoned, it could at least begin to take a greater role in monitoring the performance of NGOs working in the health field, and learn to manage contracts for service providers such as NGOs.
The result was RRHP, which grew into a project with a budget of 63 million dollars managed by the Ministry of Health’s Directorate of Planning and Coordination, according to the World Bank’s original concept paper for the RRHP.
The Bank initially allocated $5 million for building the capacity of this management unit (later increased to nearly $9 million) while giving another $23 million (later increased to $54 million) for actual service delivery functions. According to the project design, the service delivery money would not be spent by the health ministry itself but would go to a large non-governmental organization called Inter-Church Medical Assistance (IMA World Health), which would actually run clinics and health services, while also sub-contracting to other NGOs.
Under this arrangement, World Bank passes funds directly to IMA, but only after approval by the Ministry of Health, while IMA sub-contracts to relief organizations including GOAL, Cordaid, Relief International, SMC, IMC and others, one per county, as well as to some county health departments. Effectively, this has made IMA into a fund manager much like Jhpiego and Crown Agents, which have managed the USAID and DFID-led funds in other states. The key difference in this case is the involvement of two middlemen - the government and IMA - rather than only one.
Throughout the program, IMA and other contracted aid groups have worked alongside civil servants to build the capacity of county health departments, and to support them with incentive payments and other forms of assistance.
Yet when war broke out, this system was tested severely. The twin disasters of war and hunger shattered the health system in Upper Nile and Jonglei. In many project areas, health workers were scattered or fled. This put World Bank-funded organizations at the center of a humanitarian crisis, though the RRHP’s funding framework was originally designed for a stable operating environment.
While many aid donors shifted their funding from development partners to emergency NGOs, the World Bank stayed the course, continuing to fund the RRHP through the national government, though that same government was accused of actively undermining the health services in opposition areas of Upper Nile and Jonglei.
In 2015, there were direct assaults on health care in Upper Nile and Jonglei, including the bombing of a hospital in Kodok and the deliberate blockade of medical supplies to the rebel-controlled west bank of the Nile last year. And in early 2016, a militia raised by the governor of Boma State was accused of looting a Doctors Without Borders clinic in Pibor. “The MSF medical centre was the only functioning health centre in the entire region,” the aid group lamented.
What’s more, the government threw up blocks to the very World Bank projects it was meant to implement. For instance, after war broke out, the government stopped sending salaries to health workers in opposition areas. This made the World Bank-funded capacity-building programs impossible at county health departments, according to an aid worker who spoke to Radio Tamazuj after leaving one of the NGOs supported under the World Bank project.
“You can’t meaningfully capacity-build,” she said of her organization’s work in the rebel zones. She also said that wrangling over money among World Bank, Ministry of Health and IMA had frequently caused delays in planning and implementation of programs by sub-contracted aid groups. “[The donors] need to accept that the system has fallen apart, you need to go back to a humanitarian response.”
IMA itself, asked whether there had ever been a significant delay when the government failed to disburse timely funding to the project, responded in a statement to Radio Tamazuj, “The Ministry of Health and Finance only process the paperwork (verifying what IMA requested); we are paid directly by World Bank, so availability of funds for payment was never an issue. Payment terms are tied to deliverables, rather than a calendar cycle.” A second source, however, who requested anonymity, seconded claims that the health ministry had created long delays in working out payments, and said it threw up other obstacles to implementation as well.
The source twice called the partnership an administrative “nightmare”, saying renewal of the program was usually particularly difficult. “The WB and [Ministry of Health] would delay and delay,” said the source, claiming these delays at one point even prompted layoff notices within the project because it took too long agreeing to an extension. At most, the project was only renewed for periods of several months at a time. “Everything involved in the WB and [health ministry] management of the RRHP program was a disaster,” added the source.
Asked about such criticisms, the World Bank responded in a statement to Radio Tamazuj saying, “The World Bank’s resources for financing of health in Jonglei and Upper Nile states are not infinite. Financing is provided according to the availability of resources and is reflected in the contract and work plan of the implementing partners, which are renewed based on availability of funds and performance. This methodology also reinforces the World Bank’s capacity to institute an effective checks and balances system.”
Opposition politics have also complicated implementation in the World Bank target area. Faced with shortages of South Sudanese medical specialists, aid groups that wanted to bring qualified personnel from Uganda found that it was too unsafe for them. Samuel Char Mayien, a senior staff at the Akobo Hospital, which is run by International Medical Corps, explained in an interview last year that the organization previously hired experts from Uganda, but it became difficult for Ugandans to come to the SPLA-IO controlled area because of Uganda’s role in the civil war. He said the position of X-ray technician, for example, stayed vacant after repeated efforts to find a qualified South Sudanese technician in Akobo failed.
Alex de Waal, author of several books on Sudan and humanitarian disasters, commented: “The World Bank was really not set up to operate in conditions like this. It is an inter-governmental organization and only deals with governments. It has no mechanism for operating with impartiality or neutrality in a situation in which there are entities controlling territory and populations, that are not governments.”
But IMA said in a statement to Radio Tamazuj that its dependence on government-managed funds never impinged on its humanitarian neutrality: “IMA World Health works with a variety of partners all for the same goal: to achieve health, healing and well-being for all. This includes partnership with the government. At no time has our humanitarian mission been compromised, as ensured by our accountability to the donor.”
A partnership in name only?
Radio Tamazuj asked IMA World Health and the World Bank about whether the Ministry of Health has been an active partner in delivering services to the many opposition-held areas in Jonglei and Upper Nile states, the two states covered by the World Bank project.
IMA responded: “The Ministry was active before the conflict. However, during the crisis, humanitarian services were delivered by partners who serve in the opposition-held areas with IMA coordination.”
The World Bank responded: “The Government of South Sudan is the guardian of health services to the people.”
“Project implementation is bound by the legal agreement signed between the World Bank and GoSS. The implementing arrangements for the World Bank projects including this one supporting the Upper Nile and Jonglei states are such that overall implementation is led by [IMA World Health].”
According to the World Bank, the government plays an oversight role over the NGOs while the World Bank “supervises the overall implementation of the project.”
For his part, author Alex de Waal compared the situation to the World Bank work in Somaliland, where the government in Mogadishu approves and receives funding for projects even though it has no control over the area.
“The same logic holds in South Sudan: the World Bank can only use the [Juba] government as its partner in its operations, irrespective of whether in real terms the government can actually operate in those areas [under opposition control]. What this shows is that the World Bank isn’t set up for this kind of situation,” said De Waal.
In spite of the challenging environment, IMA says it has achieved some notable successes in the project. Among these, it cites a pilot in Upper Nile State to harmonize salaries of government and NGO health workers, which effectively reduced the NGO salaries while increasing the salaries of government workers. “While this risked HR migration from NGO facilities, the overall harmonization process ultimately created a net positive gain for the State Ministry of Health in relation to recruitment and retention of employees and later was roll out by the National Ministry of Health,” said Dr. Mounir Lado, the head of IMA in South Sudan.
The aid group also points to investments it has made to help county health departments (CHDs) take leadership and ownership over services. “In eight counties, IMA contracted directly with CHDs” to lead implementation at primary health clinics. To help the county governments, the aid group embedded technical advisors and support.
Dr. Lado explained, “IMA’s CHD-led counties are showing strong improvements in record keeping, reporting, and logistics thanks to help from technical advisors. Aside from being significantly cost-effective, the CHD-led County Implementation Model proved critical during the onset of conflict in December 2013, when most NGOs were evacuated but CHDs continued providing minimally interrupted services.”
He also says that the project’s model of using performance-based contracting and incentives has improved staff performance and retention. “This helped foster a culture of teamwork and joint success,” he said.
Gelila Woodeneh, a communications officer for the World Bank, pointed out that the project has improved antenatal care, provided measles vaccination to 131,000 children, distributed more than two million mosquito nets and improved per capita outpatient visits from 0.1 to 0.49 per year, among other successes.
“All this takes into account that Upper Nile and Jonglei had the most minimal attainments in terms of health indicators at the time that the Bank started financing the delivery of health services,” she said.
Photo credit, top: Kodok, Upper Nile, where a hospital was attacked in 2015 (ICRC/Pawel Krzysiek)
How donors lost millions in South Sudan's forex market
December 2015: The dollar is trading at 18 to 1 in South Sudan’s black market. Juba is beset by rumours, some of war, some of peace. In spite of a peace deal signed just months before, nobody is sure whether it will hold – fighting has even spread to new areas. Traders are reluctant to part with hard currency that can easily be moved out of the country if things take another turn for the worse.
Government oil revenues are one source of dollars on the market. But dollars brought in by the hundreds of foreign aid groups responding to the war are also a major part of overall forex volumes. Yet in commercial banks in the capital Juba, aid groups trade millions of dollars into South Sudanese pounds (SSP) to fund their local operations at a rate no better than 3.16 to 1, thanks to a central bank which fixes the official exchange rate of the SSP regardless of its market value.
The dollars brought in by the aid industry are not put out for resale at anywhere near that same rate. In fact, the large banks like Equity and Kenya Commercial Bank seem to have barely enough to honor the deposits of their own account holders - they strictly limit withdrawal amounts. And the foreign exchange bureaus, many of them owned by government officials, never seem to have any dollars at all. Instead, men loitering about near the forex offices hold out wads of greenbacks for sale at more than five times the central bank rate, in plain view of passersby.
In interviews, currency traders admit to back-channels from the central bank onto the black market. The International Monetary Fund complains that the number of licensed forex bureaus is “excessive,” warning of lax controls and opportunities for corruption. The son of the central bank governor is reported to be involved in currency trading. Even government officials openly accuse the banks of receiving money at the official rate and selling it at the black market rate for a hefty profit.
“There are banks working in the black market,” Cabinet Minister Martin Elia Lomuro tells Radio Tamazuj.
“Much of this corruption has taken root from this bank. Where do people get the hard currency to go to the black market with it?” says President Salva Kiir at a central bank function.
In the meantime, would-be buyers, including import businesses, are starved for hard currency, preventing them from bringing in food and fuel from neighboring countries. Commodity prices rise, further driving the humanitarian crisis. “Most traders report that they cannot access foreign currency at profitable rates, even though most say that, in principle, they have the capacity to bring in more goods,” reports the Humanitarian Policy Group (HPG).
Only a select group of officials, forex bureaus, and well-connected companies are able to access dollars at the privileged bank rate. Among them are the president’s cousins, chiefs from his village, political supporters, his press secretary, his business partners and a network of little-known companies. Even multinational corporations like SABMiller and MTN struggle to access forex at the official rate.
Nearly a billion dollars flow out of the Central Bank at the privileged rate, yet where the money went remains a mystery.
This dual rate system operated throughout two years of civil war in South Sudan. As the pound lost more and more value on the black market, the central bank rate remained unchanged, month after month.
Amadou Sy, a researcher on African economies at the Brookings Institute, says that the South Sudanese currency was “overvalued” during this period. “For a long time there has been a significant gap between the two rates, an indicator of the overvaluation of the official exchange rate,” he wrote in an article.
Eventually, however, the system began to break down. With the treasury depleted and the economy exhausted, the Bank of South Sudan announced a major policy change taking effect 15 December 2015, exactly two years after the start of the civil war. Amadou cites “the price of oil falling below $40 per barrel” as a factor behind the decision. Abruptly, the central bank abandoned its fixed exchange rate of 2.96 and adopted the black market rate of 18.5 – a drop of 84% overnight. The selling rate at commercial banks that same day rose from 3.16 to 20.5, which is also a change of about 84%.
What this means is that aid groups that traded for SSP at the fixed rate in the final month before the devaluation may have lost as much as 84% of the real value of everything they exchanged. Their losses on the forex market in the preceding months were hardly better, as the pound to dollar rate had been rising steadily, passing 12:1 in July, for example, and 16:1 in September.
After the bank’s decision to float the currency, the SSP has continued to weaken against the dollar. As of May 2016, the central bank lists the rate at 32:1. But the discrepancy between the bank rate and street rate is now much smaller than it was before the float. This marks the end, in large part, of the dual rate system.
How much money did the donors lose?
While it lasted, the dual rate system amounted to a massive tax on donor funds for healthcare and other services in South Sudan. Not all donated funds were affected, because some aid sector expenses are incurred in foreign currency - for example, expat aid worker salaries, headquarters expenses, and purchases of equipment or supplies from overseas. But millions are still traded by aid groups into SSP to support local procurement and operations, and to pay local workers.
How much aid money exactly was lost in this sense would be difficult to estimate without increased transparency on the part of donor governments and aid groups, but a look at just one donor gives some idea of the scale of the problem. British spending on healthcare in South Sudan was at least £24 million in FY 2015/2016, an average of £2 million per month, according to the DFID website. Even if only a quarter of these funds were expended in local currency, that would amount to £500,000 per month exchanged into SSP.
In the first month of the fiscal year, April 2015, one US dollar traded for SSP 8.8 in the black market, according to a World Food Programme monitoring bulletin for that month. Therefore £500,000 would have traded for approximately SSP 2.34 million at the commercial bank rate of 3.16. Calculating by the street rate, however, the same amount was actually worth about SSP 6.5 million, a difference of more than SSP 4 million.
Later in the year, the impact on the donor programs became even more severe. By September, the SSP had plummeted to 16.5 to the dollar. The ‘real’ value or street value of a half million UK pounds at that time was therefore worth about 10 million SSP more than the same amount priced at the bank rate.
What these calculations show is that British-funded aid groups would have had millions more SSP for their operations had the South Sudanese central bank floated the currency earlier.
This example is meant to be illustrative only; at press time, Radio Tamazuj had not secured sufficient data to estimate with accuracy how much aid money was lost on the forex market that would have otherwise gone toward healthcare services.
But what is clear is that relief and development officials were well aware that they were losing millions through this dual rate forex system. Indeed, long before the devaluation in December 2015, aid officials had taken to calling the parallel rate system a “tax.”
“The official rate absorbs 2/3 of the value,” an aid official worried in a May 2015 email after a meeting with ECHO, the humanitarian donor arm of the European Union. “Anything we do fuels the corruption ... Humanitarian operations are in a way supporting that corruption.”
Balázs Horváth, the director of the UN Development Programme in South Sudan, and Frederick Mugisa, an economic advisor for the same UN agency, briefed the UN Humanitarian Country Team on the deteriorating situation in January 2015. “Conversion at official exchange rate imposes an increasing ‘tax’ on humanitarian spending,” they said in a powerpoint presentation.
“War effort continues, crowding out social spending and exacerbating unsustainable spending... [the] exchange rate ‘tax’ [is] an incentive against local sourcing paid for in SSP,” stated Horváth and Mugisa. “The cost of delivering humanitarian assistance could well increase,” they warned.
Of course, aid groups had no option but to exchange dollars at banks at the authorized rate or halt their programs. Some aid groups tried to mitigate the impact of the ‘tax’ by cutting back their spending in SSP, switching to dollar payments for their South Sudanese staffs and sourcing supplies from abroad rather than locally. But no organization in South Sudan can operate without using at least some of the local currency on a regular basis.
Moreover, some of the donor interventions in the healthcare field, in particular, were designed to support government health workers whose salaries or incentives needed to be paid in South Sudanese pounds. World Bank, Health Pooled Fund and USAID programs all included budgets for support of this kind. The dual exchange ‘tax’ rendered these types of donor interventions far less effective – by the time your average midwife or nurse got her salary, it was worth far less than the donors had put in. And given the rising price of foods and other commodities, workers struggled to make ends meet anyway.
An HIV/AIDS counselor in Akobo, for example, complained that the World Bank-funded aid group IMC was not giving enough to the local health workers. “International Medical Corps (IMC) which supports the County Hospital in Akobo is giving us some incentives. However, it’s very small. They paid us 600 SSP and you know how pounds’ value depreciated throughout the country. We always ask them to increase our incentives but they turned down our call,” he said.
The result of the dual exchange rates was a system where millions of donor dollars were diverted to banks while the rank and file health workers meant to benefit could not even afford food on the table.
The World Bank denied that exchange rate losses were even an issue, saying in a statement to Radio Tamazuj that its implementing partner IMA World Health “defines its budget in USD as they are disbursed in USD. Therefore, there was no gain or loss as budgets are designated in USD as disbursements and payments to the implementing partners are done in USD.”
On the other hand, Dr. Damianos Odeh, who has managed more than £120 million of donor funds as Team Leader of the Health Pooled Fund, acknowledged that the dual rate system was seen as a “huge issue” for some NGOs and their staff whose contracts were written in pounds. He recalled that health workers that were paid in SSP “started leaving for anybody that would pay them in dollars, and this became a huge issue.” For this reason, the HPF authorized implementing organizations to make payments in dollars, he said.
Dr. Odeh estimated that the HPF was making monthly disbursements to NGOs of about four to five million GBP toward the end of 2015, but he said he was not sure off the top of his head how much of that the aid groups were actually exchanging into SSP. “When they buy fuel and they repair cars and they pay for internet, all of this... they’re paying in, probably in SSP... certain things they may be paying in dollars.”
But he pointed out that he had not been in a position to dictate policy to the government: “As far as I am concerned, I am the Health Fooled Fund, the HPF, not the IMF [the International Monetary Fund].”
The World Bank, asked whether it had ever made a study estimating the value of the exchange rate losses of the Rapid Results Health Project, said the question was “Not applicable,” referring to its policy of disbursing funds to IMA World Health in dollars.
IMA, however, told Radio Tamazuj that it supports salaries for NGO and government health workers in 24 counties, and some of these salaries are paid in SSP. Overall payments to CHDs and NGOs are about $1.4 million per month, according to figures provided by IMA.
‘Fueling the war economy’
Some aid officials worried not only about losing millions on the forex market, but also about whether their involvement was potentially fueling a war economy. “[A] significant proportion of dollars entering the country is through aid,” wrote one NGO official in a May 2015 memo. “Feeds the system.”
“Access to dollars at the official rate is closely linked to corruption, power and nepotism, as well as the war economy,” wrote Irina Mosel and Emily Henderson, two researchers for the Humanitarian Policy Group, in a working paper published in October 2015.
“As such, aid agencies may be fueling the war economy by inadvertently providing additional support to those already privileged by a corrupt system,” they claimed.
Some economists, on the other hand, felt that the spending by the aid groups and development organizations was in the interest of peace, helping to fill budget gaps left by government overspending on ‘security sector’ and thereby averting economic collapse.
Indeed, some aid groups, notably the UN’s development programme, actually pushed for more spending at the official rate, not less. UNDP warned in the same January 2015 briefing that high inflation and a government fiscal crisis could result in even more violence, and therefore called on aid groups “to continue to fill the gap,” not just in providing emergency relief, but also in capacity-building, job creation, and early reconstruction efforts.
Such efforts, the UNDP economists reasoned, would mitigate the risks associated with a declining economy, namely, unpaid soldiers and civil servants, unemployed youths, and discontented communities.
Whatever the effect of the aid economy on the broader conflict situation, one thing is clear: the forex owners and banks that handled tens of millions of aid dollars at the privileged rate - ‘the Taxmen’ - benefited enormously.
Riek Gai Kok has served as minister of health in South Sudan. Gai has a background as both a pharmacist and a politician with an ability to collaborate with leaders of many different stripes.
Gai, since his appointment in 2013, has been charged with coordinating the country’s response to increasingly severe challenges, including cholera outbreaks, increased cases of malaria and, now, a shortage of essential medicines – all while dealing with some of the worst health indicators in the world. His ministry has also had to contend with outbreaks of measles, kala-azar, malaria and meningitis.
Though the government’s health response is largely dependent on the donor community, the ministry under Gai reported that it had delivered medicines and supplies to treat 2.4 million people in 2015. The ministry also reported it provided basic healthcare to 1.8 million people last year and coordinated support for four national and sub-national immunization days, which reached four million children in total. In addition, the ministry introduced a polio vaccine into the routine immunization schedule.
Among the ministry’s most-touted initiatives was the establishment of South Sudan’s first national blood bank, which opened in 2014. Especially critical in emergencies, the blood bank was an integral partner in the response to the 2014 fuel explosion outside Maridi in Western Equatoria, which injured 160 people, alongside the more than 180 who were killed. People seriously injured in the explosion received significant assistance from the blood bank.
Gai’s medical career began before his political one. There is some dispute over whether Gai was born in Upper Nile state’s Maiwut County, meaning he is from the Chieng Dak section of the Jikany Nuer, or in Jonglei state’s Akobo County, which would make him Lou Nuer.
He was selected to be part of a small group of southern Sudanese to study pharmacology in Egypt on a government scholarship to Alexandria University from 1977 to 1981. He subsequently served as the chief pharmacist of Malakal Hospital from 1983 to 1985.
He then continued his studies at Strathclyde University in Scotland from 1985 to 1986, working toward a master’s of science in pharmacology.
Upon completion, Gai returned to Sudan, where he worked as pharmacist in Khartoum before joining the Sudan People’s Liberation Movement/Army (SPLM/A) around 1989. He graduated in 1990 from military orientation training at the SPLA Institute for Military, Political and Ideological Studies in Bonga, Ethiopia.
From 1990 to 1992, he coordinated medical supplies for the rebel group. When the SPLM split in 1991, he remained loyal to founder John Garang initially, before defecting in 1992 to join the Nasir faction under the overall command of current First Vice President Riek Machar.
From 1992 to 1994, he coordinated the Relief Association of South Sudan, the humanitarian wing of the Nasir faction, before becoming its executive director at the end of 1994. He ran the association until 1997.
Beginning in the late 1990s until 2001, he served as governor of Jonglei state, as well as spokesperson of the South Sudan Independence Movement/Army (SSIM/A), under Machar’s leadership. He was subsequently appointed minister of animal resources and fisheries in the national government of Khartoum, a position he held from 2001 to 2003.
Until 2005, he served as president of a coordinating council of southern Sudan’s 10 states. This appointment followed the decision of his predecessor, Machar, to abandon the position and rejoin the SPLM in 2001.
After the 2005 Comprehensive Peace Agreement ended the north-south war, Gai represented the Akobo area in the Sudanese parliament from 2005-07, headed Sudan’s ruling National Congress Party (NCP) southern sector and was a presidential advisor to Sudanese President Omar al-Bashir from 2005-11.
On July 7, 2011 – two days before South Sudan’s official independence – Gai and other southern politicians from the NCP held a press conference in Juba to declare their defection from the NCP to the SPLM.
After independence, Gai served as a member of parliament representing Jonglei State until his appointment as health minister in 2013.
One issue that aid groups in South Sudan are terrified to talk about is also one that is fundamental to understanding the current crisis in the healthcare system: the Establishment Order.
The decree is so controversial that one South Sudanese man was recently arrested by police in Aweil just for expressing a view on the matter in conversation with his friends.
Issued in October 2015 as a presidential decree, the Establishment Order cancelled South Sudan’s ten states and replaced them with 28 new ones divided largely along ethnic lines.
The order came without warning and without any prior planning by state and county health officials. Just the month before, the parliament had passed the Appropriation Act 2015/2016, which allotted budgets according to the ten-states structure.
Yet no accompanying legislation was issued with the Establishment Order to nullify the existing state budgets and structures, nor any guidance on how to divide budgets among the 28 successor governments. Nonetheless, President Salva Kiir directed governors to form committees to divide state assets and personnel.
The Establishment Order caused an immediate sensation. Supporters of the order saw it as a way of letting tribes manage their own affairs, creating more jobs and bringing services closer to the people, while critics said it was blatantly illegal, aimed at creating ethnic enclaves and annexing land to President Kiir’s Dinka tribe, and dodged the government’s obligation under the peace deal to concede two of ten governorships to the opposition.
Whatever its merits, the order initially hung in limbo for more than two months until Christmas Eve, December 2015, when Kiir issued a follow-up decree appointing 28 new governors for the new states, removing the last of South Sudan’s elected governors, and declared the old states defunct. Two months later, he issued another decree dividing the existing counties into smaller units. Twic State, for example, which comprised only the former Twic County, was divided into six new counties.
These decrees clarified the situation in one major respect: they demonstrated that the government was deadly serious about the Establishment Order. But otherwise they threw the already shell-shocked civil service into confusion. Some states went months without health ministers. Others began laying off workers en masse on the basis of ethnic affiliation.
Still elsewhere, under-resourced state and county health staffs were divided and dispatched to remote towns and villages where health departments that existed on paper had no budgets, vehicles and equipment, and sometimes not even a building to work from.
Michael Nyang Malueth, the director-general at what used to be the Warrap State Ministry of Health but what is now called the Gogrial State health ministry, says that government health departments and facilities like the Kuacjok main hospital are now experiencing a severe shortage of qualified health personnel.
“The number of the staffs that were in the headquarters are split now into three so we have some colleagues who went to Tonj and Twic states that actually left a very big vacuum in Gogrial state,” he said in an interview in May.
“Not only at the headquarters of the ministry of health but when you go to some facilities we have staff who were working at certain levels in Gogrial state and because of this divisions now they were asked to go to their respective new states and this has also left a very big gap in the facilities where they were working,” said Nyang. He added that budget constraints make it difficult to recruit new people to fill the positions of those who left.
Similarly, in Yambio, which previously hosted the state health ministry covering all of Western Equatoria, many staffs have left in order to create new ministries in three smaller successor states. ‘Gbudwe State’ Health Minister Lino Utu told Radio Tamazuj, “There is a shortage of doctors at the main hospital in Gbudwe State. Actually after the division of Western Equatoria into three, some people whether from Amadi or Maridi states, those people have gone.”
“Even in the ministry of health, those who remained are not many,” added Utu. “One doctor treats about 1000 to 2000 or 3000 patients, so it is very hard work.”
In Wau, capital of Western Bahr al Ghazal, which has been divided into two states, hundreds of civil servants are being pressured to leave their jobs and relocate to Raja, capital of the new Lol State. Civil servants interviewed by Radio Tamazuj in May said that the Lol State government wants to force people of certain races to come to Raja by making their salaries available only there. They have called for the civil service to be divided on an administrative basis rather than an ethnic one.
This all amounts to a situation where government institutions are multiplying even as the existing pool of health workers struggles to get by on increasingly devalued salaries. A midwife student at Yei training institute, for example, said in an interview that after her studies she will not work in a government-run health facility until better incentives are put in place. “How can I work and get only get 280 South Sudanese pounds per month?” she asked.
Ayol Mach Ayol, a gynecologist at the Jonglei State hospital in Bor said, “The welfare of staff really in South Sudan is still a big challenge, so now retaining these staff in the hospital is really a problem... the financial challenges are really chasing us away.”
Back and forth
Even as new state health ministers struggle to set up their new ministries and manage changes in the civil service with little or no resources, some politicians predict that the 28 states are doomed.
Mabior Garang, a member of the armed opposition who was appointed water minister in April, questioned the viability of the new system. “Even just from a management of change level... abrupt establishment of states in South Sudan without criteria or budget is foolhardy,” he said. Mabior’s colleague Ramadan Hassan Baku, who heads the ‘federalism’ dossier for SPLM-IO, told Radio Tamazuj that the party leadership will never accept the new system. General Johnson Olony, who heads a Shilluk militia in Upper Nile, has threatened to go back to war over the decree, saying it annexes Shilluk land to the Dinka.
The new ‘unity’ government itself remains divided over the issue. South Sudan’s petroleum minister, Dak Duop Bichok, told a Nuer-speaking church gathering in Juba on 22 May that he expects the Establishment Order to be reversed. He pointed out that it is not part of the August 2015 peace agreement, which is the supreme law of the land. “We have agreed to implement the agreement without removing any comma, full stop.”
At the local level in some areas, meanwhile, health structures remain much the same as they were before the Establishment Order, in spite of confusion at higher levels of government. In President Kiir’s home state of Warrap, for example, which is now divided into Tonj, Gogrial and Twic states, county health departments are operating as before.
“Gogrial West was having nine payams which were all promoted into nine counties and therefore it is the county health officer of former Gogrial West that will be in charge for a while until July when the new budget is coming in, then the Ministry of Health will be in a position to see that if there are competent people who will be assigned to be county health officers for newly created counties,” said Michael Nyang Malueth, the state director-general.
“The same thing also applies to the former Gogrial East County health officer. He is the one responsible for the four newly created counties in Gogrial East,” explained Nyang.
A similar situation prevails in parts of Jonglei and Upper Nile states, where the World Bank-funded Rapid Results Health Project is designed to allow for collaboration with county health departments.
Inter-Church Medical Assistance (IMA), which manages contracts under the World Bank project, says that it is still running contracts with eight county health departments in Renk, Melut, Akoka, Malakal and Manyo. Asked whether the recent boundary changes of affected IMA’s work with the county health departments, Dr. Mounir Lado, IMA Country Director, explained, “The current contract which is ending in June 30th is taking care of the old counties (24) so the recent changes have not changed much in terms of budget to date. Things could change in a future iteration of RRHP.”
IMA’s donor World Bank, for its part, seemed unaware of changes to county structures, telling Radio Tamazuj in an email 26 May: “As per the legal agreement signed with the GoSS dictates, the World Bank provides assistance on a county by county basis. The restructuring did not alter the existing county structures and the World Bank’s plan to provide assistance has not been altered either.”
Another donor official, in an interview, said that donors have told aid groups not to act in a way that legitimizes the 28 states, though they are coordinating with the new states’ officials on a technical level. “It is a big problem and I feel it is wasting the resources of the government to go through that process,” said the official.
National government officials interviewed recently by Radio Tamazuj about the Establishment Order acknowledged that it is a controversial issue within the new transitional government and reported that no solution has been reached to-date, but they say it will be discussed.
“It will be discussed by the transitional government,” said Presidential Press Secretary Ateny Wek. “The problem of 28 states is not a problem for Upper Nile only, it is a dispute in various areas in South Sudan, so it is a priority for the transitional government of national unity,” said Minister of Energy and Dams Dhieu Mathok.
Loyalists of President Kiir, however, are sensitive that the debate over the 28 states not play out in public. Cabinet Minister Martin Elia Lomuro recently lashed out at foreign embassies in Juba for alleged interference in internal affairs. His statements came after the Council of the European Union urged “the suspension of any action on implementing the Presidential Decree dividing the country into twenty eight states until a Boundary Commission comprising all parties to the Agreement had proposed states and their boundaries.”
The UN Mission in South Sudan, UNMISS, and the international commission set up to monitor the peace agreement, JMEC, have also refused to recognize the 28 states, saying they are not part of the peace agreement signed last year.
Whatever the ultimate fate of the Establishment Order, it has already had major effects on health systems structuring and staffing. Stakeholders in the health sector are still struggling to come to terms with the implications of the decree.
Yei’s health minister Kogo Manase is worried by the situation. Speaking at a recent function marking Nurses Day, he complained that he struggles to retain health workers at government health facilities owing to poor pay. “There are two sectors in a government and these are education and health. If we don’t pay attention to these sectors don’t call yourself a government,” he said.
We asked nurses in Juba: What do you think should be done to improve the healthcare system? Watch the video to see what they said.
Response from the World Bank:
The World Bank has issued an 8-point statement responding to the article “In Name Only,” which forms part of this series. The statement shared with Radio Tamazuj on 2 June by Gelila Woodeneh, a communications officer for the World Bank in Ethiopia, refers to eight areas in which the Bank considers there to have been misleading statements or “factual discrepancies” in the reporting.
Among these, the bank says that the World Bank funding is “an emergency operational funding mechanism to support health service delivery for primary health care services,” and not a “humanitarian support action,” saying these two approaches should not be confused.
The statement reads in part, “The assertion that the model being used is outdated is as erroneous as it is misleading. Your report wants to actively compare the model the World Bank is using to that commonly used in a humanitarian situation, which the HRRP is not. Regardless of the situation an element of systems support needs to be present to ensure that when peace returns, there is a baseline to build from and you cannot ignore the facts and assume systems are not relevant in the context of South Sudan.” The full statement has been published on Radio Tamazuj’s website and is accessible here.