Context in which HPF priorities are set
After the signing of the Comprehensive Peace Agreement in 2005, the Southern Sudan government and the development community gave priority to building a functioning health system. Essential governing institutions were established at national and state levels and a policy framework was developed with extensive involvement of external actors. Post-independence, the newly established GRSS renewed its commitments to universal health coverage and continued the development of its health policy frameworks. Health policy frameworks such the HSDP (2012-2016), National Health Policy (2015-2024), and a revised BPHNS (2011) were developed with extensive involvement of external actors.
Due to the sustained conflict, health needs remain vast. In addition to high maternal mortality, communicable diseases are a leading cause of morbidity and mortality, including lower respiratory infections, diarrheal disease, and tuberculosis . Neglected tropical diseases are endemic and HIV affects an estimated 3% of the population. Though not quantified, non-communicable diseases also contribute to the disease burden, including cardiovascular disorders, diabetes, mental health disorders, violence related trauma, and substance abuse. Estimates indicate that 83% of the population lives in rural areas and 44% live within five kilometers of a functional health facility, posing a considerable barrier to service delivery) .
The protracted crisis has also significantly impacted the health system and service delivery remains weak. There is a significant qualified staff shortage, inadequate facilities, limited management capacity, high turnover of health authorities, and weak accountability systems. The estimated density of doctors and nurses is 0.15 and 0.25 per 10,000 population, respectively . Furthermore, on-going clashes due to political conflict and local community rivalries affect the accessibility of health facilities.
The health sector heavily relies on external support. Government expenditure is 11% of the total health expenditure, while development and humanitarian partners finance 62%. Out-of-pocket health expenditure fills the remaining gap (22%) . Besides HPF there are several other health and nutrition funding mechanisms. The World Bank funds the Provision of Essential Services Project, which supports health facilities in the two States not supported by HPF (Upper Nile and Jonglei). Furthermore, several vertical programs operate through bilateral agreements with the MoH, including programs for HIV, malaria, and tuberculosis by the Global Fund, a nutrition program funded by UNICEF, supplementary feeding commodities by the World Food Program, and a program for family planning and reproductive health commodities by the UNFPA. While the HSDP states that coordination is important for aid effectiveness , communication and integration remains a constant challenge. HPF is perceived as a main contributor in terms of service delivery as was reiterated by respondents.
...support is solely offered by HPF… so there is nothing that the MoH chips in terms of support for the health facilities, so basically HPF is running those health facilities. – HPF management
Content: the priorities set at national and local level
HPF3’s stated aim is to support the GRSS in delivering the BPHNS through the provision of services through a network of health facilities and community-based systems. Although elements of the HPF program have remained consistent, changes have occurred over the course of roll-out, reflecting a changing context, priorities, and interests. Informants revealed general shifts between the first to third phase and specific shifts in the creation of HPF3 programming. While HPF1 focused on post-independence health systems building, HPF2 focused on strengthening foundational structures from HPF1 and maintaining service provision facilities while in the midst of renewed conflict. In HPF3, the aim shifted to health system stabilization, with emphasis on local structures and community ownership. While HPF2 supported all facilities across the eight states to increase access to services, HPF3 reduced this number and halted support for facilities that were (partially) destroyed, located in deserted areas, offered a negligible number of health services in practice, or were close to similar or better functioning facilities to concentrate funding, decrease waste and improve quality of care at functioning facilities in populated areas. Another shift occurred towards an incentive payment system. Prior to HPF3, IPs paid health staff salaries, which created challenges as organizations paid different rates. HPF decided to use the harmonized incentive scale established by MoH to balance payments across counties. With this incentive scale in place, HPF switched away from paying salaries to paying incentives at rates stipulated by the government. This shifted the responsibility of paying health worker salaries to the MoH.
Within HPF3, explicit priority is given to the health of mothers, pregnant women and children under five, which covers only a portion of the BPHNS. Furthermore, the HPF3 service package emphasized and allocated funding to three significant components: 1) the Boma Health Initiative (BHI) supporting community health workers and community engagement, 2) GESI services supporting gender-based violence, clinical management of rape, family planning, and disability and mental health services and 3) immunization services. These service areas had not previously been key components in the HPF2 service package. For example the emphasis on GESI services was new in HPF3.
A new concept came up...from the donors where they want us to mainstream mental health and disability programming… This year there is funding that can be slotted in for GESI issues...when the EU came into the pool of donors. [The] additional funding...allowed them to reprogram some of the money and utilize it for these activities. – HPF management
Box 1 shows the overall prioritized service package for the HPF3, which IPs are contracted to implement. These services are delivered through a network of community health workers at primary health care units (PHCUs), PHCCs, and hospitals.
- Health education/counseling
- Child health
- Maternal and newborn health
- Reproductive health
- Communicable diseases
- First aid
- Disability/mental health
- Community health information system
- Curative services
- Chronic care
- Blood Bank/transfusion services
- Referral services
Box 1. HPF service package
Actors and their roles
Figure 2 shows the actors involved in HPF’s priority-setting and the funding, coordination and reporting flows among them. Funding streams from multiple donors, namely the United Kingdom's DFID (lead donor), Global Affairs Canada, the European Union (EU), the Swedish International Development and Cooperation Agency (Sida), the United States Agency for International Development (USAID), and Gavi, the Vaccine Alliance. DFID represents all donors and mainly sets the fund’s strategic direction. The MoH of South Sudan is the national health authority and a primary partner of HPF. It ensures HPF programming aligns with national health policy and strategic plans. The HFP fund is managed by a consortium of organizations, including Crown Agents (fund manager and IP contractor), International Procurement Agency (in-country warehousing and distribution), Montrose International (technical assistance in health service delivery, monitoring and evaluation, and communication), and the Royal Tropical Institute (operational research). The IPs are NGOs subcontractors engaged to provide and manage essential primary health care services through a network of health facilities and community based systems. IPs go through a competitive bidding process before being contracted. The SMoH is the link between the MoH and the CHDs and ensures that national policy is implemented at the local level. The CHD is the health authority at the county level. They work with the IP field teams to ensure facilities are operational and to collect information for the District Health Information System. Various international development partners (i.e. World Bank, UNICEF, Global Fund, and UNFPA) are also active in South Sudan implementing vertical and bilateral programs. Lastly, a health cluster aims to facilitate the coordination of funding flows within specific health areas to minimize the duplication.
Formal and informal institutions
A formal institution related to HPF is the formal partnership between the MoH, donors, and HPF, with the aim of supporting the GRSS in delivering the BPHNS across eight states. The pooled funding is channeled directly to and managed by the fund manager, who maintains oversight over all financial resources and IPs, reports on progress to donors, and communicates directly with the MoH on operational issues (Figure 2). The accountability mechanisms within these channels are shaped by formal contracts and arrangements between stakeholders to ensure the effective use of funds to achieve HPF’s key outcomes and deliverables.
Simultaneously, informal institutions are observed in the context of HPF. The formal institutional lines within the HPF structure are blurred because of MoH weaknesses in terms of coordination, technical capacity, and past misuse of funds. The donors provide substantial monetary and technical resources within the health sector via HPF and fill significant gaps regarding policy development and implementation. Although the donors and HPF work in collaboration with the MoH, the contracting mechanism, through an external fund manager, shifts a significant amount of power over the funds away from the MoH. Because funding remains outside the government system and national health budget, donors keep some decision-making agency, especially concerning fund management. According to a donor representative,
We have a strong division between the meetings where we invite the ministry and the meetings with just the donors… We do communicate and engage them quite often...this program cannot be implemented [without]. But we still keep, especially the decision-making power with the donors. I can't tell you the amount of assets that have gone missing. So we have to be very careful with how we program and how much decision-making the ministry has...
This is the reason why it's a separate project and it's not going through the government, in any other context we would do budget support and we would engage with the MoH like that. -- Donor
Although the MoH is integral to HPF’s formal governing structure, the donors and HPF retain control over funding and its use. This is also displayed in their push for important policy decisions. For example, DFID was key in negotiating and moving forward the implementation of the national harmonized incentive scale.
… [DFID] had a lot of the negotiations with the government and then [it was] finally published and adopted by the MoH... So that's one area that [DFID] pushed through and sort of used [its] leverage and the knowledge of the health sector in South Sudan to fight. – Donor
Furthermore, the weak stewardship of the national MoH impairs communication channels with state- and county-level authorities. In the dearth of sustained consultation, the MoH does not adequately represent local authorities and their priorities and does not effectively relay national policy change and decisions. This amplifies the exclusion of local actors in national level decision-making.
Interests and ideas among actors
HPF is made up of a complex web of actors at national and local levels with differing vested interests and motivated by particular ideas about health sector development. As lead donor, DFID is responsible for ensuring that HPF follows UK government commitments, which take a central role in HPF programming. A donor representative explained,
[DFID is] responsible to ensure that HPF fulfills the mandate of the UK government that is expected of HPF... So HPF is run using DFID rules and regulations… [DFID sets the] strategic direction for the program and then the program implements that strategic direction, so that it’s in line with the UK government priorities of health… - Donor
Donors must agree to adhere to DFID’s mandate and largely delegate their authority to DFID. However, individual donor interests do remain salient. Specific governmental/organizational requirements and mandates are considered in the creation of programming indicators. For example, donor interests to see improved tracking and results motivated the strengthened GESI component within HPF3’s service package. Overarching principles and ideals connected to larger donor government commitments to health drive these interests, in the case of GESI emphasising social inclusivity and gender-sensitive rights.
These donor interests and ideas diverge from those of the MoH. From the MoH’s perspective, the HPF program is a government initiative implementing the national BPHNS. This is grounded in their mandate as the national health authority and their responsibility for the implementation of national health policies, i.e. National Health Policy, BPHNS, and the HSDP, to strengthen the health system. While the MoH is encouraged to take ownership over the health sector, HPF funding is tied to external accountability measures and interests, which complicates this ownership. According to an MoH official,
There is nothing called HPF specific target or specific programming. There is one program and there is a government strategy in addressing the health issues and the key component we have now is the BPHNS and that includes minimum packages of health and nutrition...—MoH official
This misalignment was explained by an HPF team member,
“[It] has been [a] misconception that the Ministry has, that...HPF money belongs to the people of South Sudan… Last year one of the big wigs at DFID wrote a letter and said... this money is donor money…it is not contributed by the MoH, so nobody can make demands and use it the way they want.” – HPF management.
Local level interests also diverge from those at the national level. The interests held by the CHDs are driven by their local needs, including strengthening local health infrastructure and governance through full coverage of facilities and support for renovations, infrastructure, training, and capacity building. Local authorities also expected HPF3 to continue in the same capacity as HPF2, with full coverage of facilities, payment of health workers’ salaries, and capacity building for the CHDs. According to an IP team member, CHD key priorities are,
...related to capacity building, training… I think they are not so in line because most of the county authorities expected their routine of previous HPF to continue, for example, a lot of training...Also, most of the priorities of the county authority were focusing on renovations, building more facilities...more infrastructure, and then in HPF3 they are saying no, we don't have much support on building infrastructure... – IP management member
Consequently, as the primary implementers of HPF programming at the local level, IPs need to negotiate these given their interest to adhere to the contractual obligations and priorities set by HPF3. Having specific contractual obligations on the one hand, and locally embedded knowledge and experience on the other, IPs need to balance these when making decisions about programming at the local level. In the experience of an IP team member,
We follow the guidelines... because for us that is the donor and we have to follow their guidelines on what is their primary focus because they will come back and tell us this is what the donors want and so, we just have to adhere to them, even though you may have your own... experience... – IP management
Priority-setting occurred at the national and local levels. National level priority-setting occurred in discussions determining the programming for HPF3, while local level priority-setting decisions were made by IPs throughout the bidding process and program implementation. At the national level, the process spanned several months prior to HPF3 from July to December 2018. A business case was developed by DFID and donors, which explicitly weighed and appraised three options for HPF3’s strategic direction. A Community Health and Nutrition focus was favored over a Health Facility Infrastructure and National Health System Strengthening focus based on certain criteria: cost-effectiveness (cost/disability adjusted life years (DALY) saved), coverage, equity, and health system stabilization. A community level focus was dominant in terms of cost-effectiveness (lowest costs/DALY) and had a positive assessment for coverage and equity. While this option was considered limited in terms of health system stabilization and strengthening, the GRSS was deemed unable to invest in health and nutrition beyond paying health workers’ salaries. As a result, the priority set forth by DFID was to orient funding toward the protection of life-saving health and nutrition services for the largest possible population in South Sudan.
Priority-setting for the HPF programming service package occurred in a series of workshops (July-December 2018) led by DFID, including the Fund Manager, MoH and external actors including WHO, UNICEF and World Bank. Services from the BPHNS were selected to ensure HPF3’s objectives and outputs were met. Internal discussions occurred among the donors to align the package with their priorities. Broader consultative discussions also occurred with the MoH, the WHO, UNICEF, and the World Bank. In these discussions, the service package was reviewed against these partners’ activities to limit duplication. For example, funding for nutrition services was reduced because UNICEF is the key supplier of nutrition commodities and support for HIV services was minimized because the Global Fund provides HIV support through the UNDP. Lastly, the decision was made to reduce the number of facilities for HPF3, informed by an analysis of HPF2 facility data that showed no correlation between a high number of facilities and health outcomes. In general, it is not documented and thus unclear how prioritized services were discussed, weighed, and compared and whether this was completed in a systematic and rational way. Challenges were a lack of reliable data to inform decisions and the inapplicability of the BPHNS as a tool for priority-setting. The BPHNS was considered more as a ‘wish list,’ presenting a long list of interventions and without sufficient resources to be implemented. According to a donor,
[Donor priorities] had to be mirrored with the BPHNS, which is quite broad and wide and sometimes a bit vague. So, a lot of that would fit within the BPHNS. – Donor
At the local level, priorities are set by IPs in the context of local interests and realities. National level decisions regarding HPF programming resulted in a RFP. This document provided potential IPs with an operational document to guide the bid preparation process. Under its guidance, potential IPs prepared a concept note and subsequent technical and budget proposals for a specific geographical area (lot). The proposal, budget preparation, and negotiation process was complex, requiring the management of technical requirements from HPF and (often divergent) local priorities while facing resource constraints and a dynamic environment.
Due to un-updated census numbers and inexact facility locations and information, IPs were required to bring specific local knowledge and experience to produce a competitive proposal. IPs were also expected to engage with CHDs to understand local priorities. It was frequently difficult to incorporate these priorities because they often diverged from HPF requirements, including the number of facilities to support. Some budget areas, including GESI, family planning, BHI and staffing were also mandatory, therefore necessitating the deprioritization of other areas to accommodate budget allocation to these key areas. This was explained by an IP team member.
Because we were not able to cut from, say, family planning trainings, we couldn't cut from [GESI] trainings, those were mandatory. We couldn't cut any of the key identified staff... [and] BHI, because that had quite a prescribed set of activities… and we couldn't cut down on supervision either. So a lot of it came from the things that we had planned for facility management, [including] things like fixing up latrines, digging placenta pits, and doing small renovations. – IP management
IPs highlighted the absence of a “formula” and the complex and implicit nature of this process, as IPs negotiate and balance priorities until consensus is reached. This balancing act continued into the negotiation phase where the top-ranking NGO for each lot was invited for negotiations and given the chance to justify decisions in the proposal. This process took place between HPF, SMoH director generals, and the IPs. While this negotiation process was guided by explicit guidelines from the RFP, the resulting programming decisions were also dependent on the IPs’ ability to negotiate aspects of programming to maintain local buy-in. Although budget lines were relatively strict, some IPs explained that they could create some ‘decision space’ in their budget allocation. The number of facilities to be covered in a lot’s catchment area was a common point of discord because local authorities often contested the reduced number. In cases where controversy was high with the county-level officials, HPF agreed to raise the ceiling budget to accommodate more facilities.
...the donors' pressures are very strong on our budget...we [were] asked to be allocating a certain amount on GESI...GAVI...BHI, so the budget was bound. Then at a certain point when I told them...I can do 1000 training on disabilities. Then the people with disabilities really have no facility to go to because they do not have enough funds to make facilities running... So, demonstrating that, quarreling a little bit, negotiating...I managed to distribute the funds as I wanted. – IP management
It is during the proposal development, review and negotiation process that local authorities (SmoH and CHD) were engaged in the priority-setting process. The impact of this engagement is observed in the disputes that occurred in certain IP proposal negotiations and indicates a level of engagement from certain local authorities. However, the extent to which this was consistent across states and counties is unclear. Full engagement is challenged by limited capacity, high turnover rates in SMoHs and CHDs, and limited channels of communication between national and state authorities with regards to policy changes and developments. Disagreements during proposal development, review, and negotiation from local authorities were often fueled by a lack of involvement, knowledge, and understanding of national level decisions with regards to national policy and the HPF program.
... I had to allocate a certain percentage [to the BHI and] when I try to explain this to the SMoH... they told me, “You are crazy or what? You are cutting health facilities for Boma health workers?” and I said “This is the priority of your government and the donors, what should I do?” -- IP management
Implicit priority-setting decisions by IPs continue into implementation. Implicit decisions were made by IPs due to physical, cultural, monetary and supply-related constraints to service provision, leading to variation in service provision across lots. Figure 3a-h shows the percentage of clinics per lot providing selected services from the HPF service package. While little variation was observed for antenatal and immunization services, variation was found for family planning, skilled birth attendant, SGBV, MHPSS, and disability services. Key informants explained that this variation results from a lack of skilled health professionals. Access to health workers varies across the country, and it is especially difficult to secure an adequate workforce in areas where conflict is more concentrated. It is up to the IPs in collaboration with local field staff and local health authorities to mitigate these challenges. An IP team member explained,
South Sudan.. overall, has a lot of challenges with qualified health personnel... A lot of the PHCUs [are] just run by community health workers. And in some situations, some of the PHCCs used to…and I'm sure some of them still are run by community health workers... So I think that poses a considerable challenge in trying to get the right level of service at some of these locations. – IP management
Service provision was also influenced by the IPs ability to mobilize resources to fill gaps in HPF funding. Health clusters are in place to track funding per technical area and facilitate this process. While IPs are encouraged to create synergies to access other funding sources and commodity streams, it is up to the IP to determine these gaps and access other sources of funding. This was described by HPF and IP team members,
[We] encourage IPs to create synergies with other programs and donors. Especially for UNICEF and WHO and UNFPA...But in general we don't have expectations in terms of how they find those other HPF services. – HPF management
It’s usually the initiative of the partners… We look at the data that comes out of the health facilities and we realize there is actually a need for the services in this area. And so based on that we usually can know who we can reach out to at the national level,..for instance, we've been having quite a long protracted discussion with the UNDP and the MoH to initiate ART services.— IP management
 From HPF’s Request for Proposals. Internally Circulated Document. Unpublished. 2018.
 DFID was replaced by the Foreign, Commonwealth & Development Office in September 2020, just after data collection. As this study is retrospective, this paper will continue to refer to FCDO as DFID.
 From DFID’s HPF3 Business Case. Internally Circulated Document. Unpublished. 2018.