Cablegate: Southern Sudan - Health Sector Transition Update

DE RUEHKH #1832/01 3251603
P 211603Z NOV 07





E.O. 12958: N/A


KHARTOUM 00001832 001.2 OF 003


1. Over the past three fiscal years, USAID has been able to steadily
and responsibly decrease its non-food humanitarian budget from USD
88.3 million in Fiscal Year (FY) 2005 to USD 69.5 million in FY 2006
and USD 61.9 million in FY 2007 in anticipation of the eventual
transition from relief to development in Sudan, excluding Darfur.
In FY 2007, USAID's humanitarian investments focused on preparing
for the transition from relief to development, including
transitioning projects to USAID's development programs, the
Multi-Donor Trust Fund (MDTF), other development donors, and the
Government of Southern Sudan (GOSS). These efforts have
concentrated on the health sector, but transition planning
discussions and efforts are also underway in the food security
sector. This cable provides a progress report on health sector
transition efforts to date for USAID programs in Southern Sudan.
End Summary.

Health Sector Transition Efforts to Date

2. For two and a half years USAID -- including USAID's Office of
U.S. Foreign Disaster Assistance (USAID/OFDA), the Bureau of Global
Health, Africa Bureau, and USAID/Sudan's development health team --
have worked together to plan a step-by-step transition of USAID's
health programs in Southern Sudan. USAID/Sudan and USAID/OFDA
jointly organized transition workshops with the Ministry of Health
(MOH) and USAID implementing partners in March and August 2005, as
well as in June 2006. The August 2005 workshop produced
relief-to-development checklists for use by all humanitarian health
partners, and laid the groundwork for transitioning a few counties
from USAID/OFDA funding to USAID/Sudan funding. Under this plan,
one county transitioned in 2005, two in 2006, and one more county is
planned for 2008.

3. In FY 2007, the USAID transition planning process made
significant progress:

--The first-ever National Health Assembly for Southern Sudan helped
illuminate gaps in the sector, particularly the need to focus on
strengthening health systems management, capacity building,
salaries, and service delivery at the county level.

--Between FY 2006 and FY 2007, USAID/OFDA was able to go from
supporting 322 health facilities to 232 health facilities in
Southern Sudan. Very few of these 90 facilities have shut down as a
result. Those facilities that did shut down did so because of
reasons other than the loss of USAID/OFDA funding, such as
insecurity and the migration of IDPs. Facilities have been handed
over to longer-term forms of support, including the GOSS MOH and
other donors. It is important to continue to monitor the success of
this handover and analyze lessons learned.

--In June 2007, USAID bought into a contract with the health
non-governmental organization (NGO) consortium BASICS that will
analyze the health sector in Sudan. BASICS will identify and
analyze potential transition funding gaps, facilitate coordination
among USG stakeholders, conduct a health facility mapping exercise,
and organize a transition workshop for all stakeholders in early
2008. BASICS has facilitated similar transition efforts for USAID
programs in Liberia with positive results.

--In the coming weeks, BASICS will produce a prioritization matrix
for USAID to use in making funding decisions for the health sector
in FY 2008. The matrix is based on factors including the volume of
returns to target areas, potential for conflict, and availability of
health care.

4. USAID believes that the transition dialogue should be centered on
providing the most strategic assistance possible in the health
sector, capitalizing on the strengths of each office, and ensuring
that planned humanitarian and development investments complement
each other and facilitate effective transition to Sudanese
structures and achieve maximum impact. This effort is larger than
the context of USG health programs, involving all stakeholders under
the leadership of the GOSS MOH, including other donors, the UN, and
the NGO community.

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Transition: Opportunities and Obstacles

5. The current state of the health sector in Southern Sudan presents
several opportunities for transition:

--The GOSS MOH has a unified vision and sense of ownership at the
central level. For example, the MOH has developed seven national
policies and guidelines, including the infectious disease and
surveillance response guidelines developed in conjunction with the
U.S. Centers for Disease Control and Prevention (CDC), the Maternal
and Reproductive Health Policy developed by a USAID implementing
partner, and the Human Resources for Health Policy developed with
assistance from USAID/Sudan.

--The MOH is staffed by a strong cadre of officials at the central

--The health sector enjoys an active and committed group of
implementing partners.

--Stakeholders and donors have committed program funding that will
continue through the end of 2008/2009.

--There exists the strong potential for state-level coordination
through the MDTF Health Umbrella Program and its mechanisms. This
program will contract lead agencies for each state to coordinate the
health sector for that state.

--Sound transition models have been developed and will be tested.

6. While opportunities for success exist, the prospects for a smooth
transition of the health sector in Southern Sudan do face
significant obstacles:

--Funding to the GOSS MOH, in both the regular budget and the MDTF
funds, is not adequate for primary health care services and systems
at the county level. Currently, most of the available funding is
committed to the central and state levels.

--No funding has been committed or budgeted by the GOSS MOH to pay
health worker salaries at clinics.

--There is an acute shortage of qualified Sudanese health personnel,
even taking into consideration candidates who might be found in the
diaspora. This problem is compounded by the lack of funding for
salaries as it is hard to retain even existing qualified staff.

--Localized conflict continues to impede access and implementation
of health services.

--Managerial and technical capacity among MOH staff at all levels is
still fairly low.

--Logistical challenges and high costs will continue into
foreseeable future and impede sustainable health care service
delivery as well as transition.

--Delays in contracting lead agencies in the ten states have slowed
efforts to coordinate health services and plan for transition.

7. Despite the opportunities, there are major short- and long-term
gaps that need to be addressed before the MOH can realistically be
expected to assume full responsibility for the health system. These
gaps need to be addressed in a parallel and coordinated fashion,
which will take considerable coordination among donors, implementing
partners, central and state ministries of health, and the MTDF lead
agencies. USAID is working to facilitate this coordination and
promote a broader dialogue on transition among all stakeholders
during the health transition workshop planned for early 2008.

Next Steps

8. In the coming weeks, transition planning will continue as USAID
and BASICS staff continue to collect, interpret, and analyze data to
build a transition database that will reveal the transition funding
gap among USG-supported facilities. BASICS and USAID will also
conduct a facility-by-facility analysis to examine issues of access,
underserved populations, and adherence to the basic package of
health services standards. This analysis will be based on

KHARTOUM 00001832 003.2 OF 003

methodology used by BASICS in the Liberia health transition planning
process. The database containing the USG facility analysis will be
handed over to the MOH for incorporation into the common database
that contains information on other facilities. BASICS will create
graphical depictions, such as maps and charts, of information to
illustrate the current state of the health sector and guide the
transition process.

9. In preparation for the transition workshop planned for early
2008, USAID and BASICS will prepare background material and develop
and design the workshop approach alongside the GOSS MOH and other
donors. USAID has met with the MOH and identified a preliminary
timeframe for the workshop, scheduled for February 2008 in Juba, and
in the coming weeks will work together to identify a venue and
organize other logistics, including finalizing the participant list.
USAID and the Joint Donor Team in Juba will convene a meeting of
all relevant donor representatives in the next few weeks to discuss
support for the workshop. The workshop will begin by focusing on
the four states for which lead agencies will soon be contracted by
the MDTF and will include all stakeholders, including donors, NGOs,
and representatives from the central, state, and county ministries
of health.


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