COLLAPSE. A call to action. What the end of polio funding could mean for South Sudan s immunisation systems and what we can do about it JULY 2018

Transcription

1 A call to action JULY 2018 COLLAPSE What the end of polio funding could mean for South Sudan s immunisation systems and what we can do about it A call to action a

2 The authors would like to thank Penelope Campbell, Kuotong Rogers and Jennifer Banda (UNICEF South Sudan); Dr Maleghemi Sylvester (WHO South Sudan); and Dennis King and Shalini Rozario (UNICEF Headquarters) for their support throughout the production of this document. We would also like to thank the stakeholders who gave us their time to be interviewed: Dr. Samson Baba (Ministry of Health, Republic of South Sudan); The Honorable Catherine Peter Laa (National Parliament, Republic of South Sudan); Dr Mathew Tut Moses, Solomon Anguei and Dr Zecho Gatkek (Ministry of Health South Sudan); Victoria Graham and Dr Basilica Modi (USAID, South Sudan); Dan Pike, Morris Ama and Georgina Krause (DFID South Sudan); Alice Gilbert (DFID Headquarters); Grace Lee (Embassy of Canada, South Sudan); Sonja Nieuwenhuis and Dr Camene Odenyo (Health Pooled Fund, South Sudan); Takanobu Nakahara (Embassy of Japan, South Sudan); Rachel Seruyange and Anthony Laku (WHO South Sudan); Carl Hasselblad (McKing Consulting for Bill and Melinda Gates Foundation); Dr Margaret Hercules (CDC); Dr Mokaya Evans (CDC/AFENET); Peter Lado Jaden Aggrey (World Bank, South Sudan); Chali Selisho (UNDP South Sudan); Dr Lydie Maoungou Minguiel, Samuel Patti, Gopinath Durairajan, and Jean Luc Kagayo (UNICEF South Sudan); and Afework Assefa (UNICEF ESARO). All mistakes are the responsibility of the authors. Authors Jessica Koehs and Matthew Gibbs on behalf of DevSmart Group LLC - July 2018 Photographs: UNICEF/Rich Design by Inís Communication b Collapse

3 COLLAPSE What the end of polio funding could mean for South Sudan s immunisation systems and what we can do about it A call to action JULY 2018

4 Contents Acronyms and definitions i Executive summary 1 1. Introduction Country context The ramp down of GPEI in fragile states What has the Polio Programme brought to South Sudan? 9 What will the impact of the Polio Programme ramp down be? 14 Looking beyond the Polio Programme at the critical functions What are the critical functions and why are they critical? What are the risks if these functions do not continue? What does this mean for the health system in South Sudan? What does this mean for the health of the population at large? Options to absorb critical functions identified by the Government of South Sudan and partners 21 Option 1: The Boma Health Initiative 21 Option 2: Integrated Disease Surveillance and Response 22 Option 3: Routine immunisation within primary healthcare 22 Option 4: Mixed distribution of assets within the entire health system with focus on the three health priority areas Barriers to leveraging the resources to support these options Political and economic barriers Programmatic barriers The last option Preventing collapse by maintaining the bare minimum for surveillance, routine immunisation, community mobilisation and outbreak response 25 Call to action 27

5 Acronyms and definitions AFENET African Epidemiology Network of CDC AFP acute flaccid paralysis BHI Boma Health Initiative BMGF Bill and Melinda Gates Foundation BPHNS Basic Package for Health and Nutrition DTP diphtheria-tetanus-pertussis vaccine DTP3 Third dose of the diphtheria-tetanus-pertussis vaccine CDC Centers for Disease Control and Prevention CGPP CORE Group Polio Project DFID United Kingdom Department for International Development ECB EPI Capacity Building Programme EPI Expanded Programme on Immunisation GAVI Vaccine Alliance GHSA Global Health Security Agenda GPEI Global Polio Eradication Initiative HMIS Health Management Information Systems HPF Health Pooled Fund (for South Sudan) HR human resources ICCM Integrated Community Case Management IDSR Integrated Disease Surveillance and Response M&E monitoring and evaluation MSF Médecins Sans Frontières MOH Ministry of Health NGO non-governmental organization NPO National Programme Officer RI routine immunisation SIA supplementary immunisation activities UNICEF United Nations Children s Fund USAID United States Agency for International Development WASH water, sanitation and hygiene WHO World Health Organization Definitions Boma Lowest-level administrative division in South Sudan, below payams Payam Second-lowest-administrative division in the Republic of South Sudan, below the county A call to action i

6 ii Collapse UNICEF

7 EXECUTIVE SUMMARY If polio eradication succeeds but poorer countries public health services collapse in the initiative s wake, it would be a major failure of global governance and stewardship. The risks to global health and to vulnerable populations are high if the polio transition process is mismanaged. The End of the Beginning: First Report of the Transition Independent Monitoring Board of the Polio Programme, July 2017 The Global Polio Eradication Initiative (GPEI) 1 is the main health programme reaching children across South Sudan, the world s youngest and most fragile state. 2 No other initiative has so successfully accessed the most vulnerable and hardest to reach communities despite armed conflict, migrating communities and natural disasters. Globally, GPEI has protected millions of children from polio since 1988 and the global incidence of polio has decreased by 99.9%. 3 South Sudan has not reported a case of wild polio virus since Transition Independent Monitoring Board, The End of the Beginning: First Report of the Transition Independent Monitoring Board of the Polio Programme (Transition Independent Monitoring Board, July 2017), pg 3 2 Messner, J.J., 2017 Fragile States Index (Washington: The Fund for Peace, 2017), pg 8 3 Our Mission, The Global Polio Eradication Initiative, accessed June 11, 2018, who-we-are/our-mission/ 4 South Sudan, The Global Polio Eradication Initiative, accessed July 5, 2018, where-we-work/south-sudan/ In South Sudan, GPEI has also helped to create the key structures for both polio vaccination and routine immunisation (RI) in the country. Thus, polio-funded assets ensure many other life-saving vaccines and services reach women and children and that outbreaks of diseases like cholera and meningitis are quickly addressed nationwide. 5 As GPEI continues to work towards global polio eradication, GPEI funding in some countries, particularly in the non-endemic ones, will gradually ramp down over the next few years. For South Sudan, this will mean declining support to critical activities, such as a national system for disease surveillance and outbreak response, immunisation campaigns, social mobilisation networks, and a cold chain network that provides potent vaccines to the most remote and isolated portions of South Sudan. In order to ensure continuation of polio essential functions beyond GPEI funding, other resources need to be mobilized. The end of the Polio Programme must be seen in the context of South Sudan as a fragile state. The situations in fragile states have prevented 5 Global Polio Eradication Initiative, Investment case, (Geneva: World Health Organization, March 2017), pg 21 A call to action 1

8 governments from investing time and resources into developing systems while donors have been focusing on humanitarian response. Unlike other more stable countries, these functions will not be absorbed by a waiting health system. On the contrary, South Sudan s fragile health system is built upon these polio structures and must find a way to maintain its key functions. While the Government of South Sudan and partners have come up with various options for transition of the polio assets, there are significant political, economic and programmatic barriers that make uptake of the options challenging at the present time. In light of this situation, implementing partners and donors who already fund many components of the health care system recommend a contingency plan, partly because there is hesitation about investing in long-term development programmes during a protracted emergency and partly because there are insufficient funds available to cover all that the options presented need to run effectively. Call to Action To avert a public health crisis, South Sudan needs to maintain, as a minimum, active surveillance, better immunisation coverage, strong resilience through social mobilisation and robust outbreak response capacity. Supporting fragile states through a longer transition period must be a political priority nationally, regionally and globally. We call upon high-level stakeholders to come together to acknowledge the special case of South Sudan and other fragile states in the context of the global GPEI ramp down and formulate plans to help these states fortify routine immunisation and supporting systems. WHAT S AT RISK? DISEASE SURVEILLANCE Active case-based surveillance would end and the quality of available data would dramatically decline. OUTBREAK RESPONSE The ability to detect outbreaks of vaccine preventable disease and to support critical frontline staff in the field will severely deteriorate. IMMUNISATION All immunisation figures for the population would further decline. All supplementary immunisation activities would stop (or be of poor quality), ending the most effective health interventions in the country. COMMUNITY MOBILISATION Social mobilisation activities promoting healthseeking behaviour would be reduced by about 50 per cent. VACCINE INTEGRITY The cold chain would be interrupted, severely limiting vaccines getting to end-users. 2 Collapse

9 RECOMMENDATIONS 1. Support routine immunisation and continue campaigns Routine immunisation processes and functions must be progressively transferred to the Ministry of Health to ensure sustainability and avoid parallel structures. Strengthening the Expanded Programme on Immunisation (EPI) needs to be a key priority. 2. Maintain funding for health-based community mobilisation Ensure continuity in fostering behaviour change in terms of health-seeking behaviour, the creation of a demand-based culture and community awareness of rights. South Sudan is fragile and communities are vulnerable, so this work is critical to building resilience and ensuring rights are recognised. 3. Maintain active surveillance Nationally, South Sudan currently runs different surveillance systems in health and in other sectors. A streamlined system would reduce gaps in disease surveillance, ensure the same quality of surveillance for all risk monitoring and improve inter-sectoral collaboration. Internationally, South Sudan should collaborate with its neighbours in information sharing, surveillance and response capacity to maintain minimum standards in the detection of and response to infectious disease threats. 4. Monitor relevant initiatives The options presented by the Government of South Sudan, like the Boma Health Initiative, should be carefully monitored so that polio assets can be transferred to them when they can successfully absorb them. 5. Reorganise current funding streams to include vital parts of the polio structure While funding for 2018 is already allocated for the Health Pooled Fund, GAVI and other major donors portfolios in South Sudan, it would behove these donors to reconsider whether more funding to cover this transition and strengthen routine immunisation, surveillance, social mobilisation and outbreak response needs to be integrated into their portfolios. 6. Initiate a Fragile State Fund for Routine Immunisation, surveillance and social mobilisation South Sudan is not the only fragile state that could put national, regional and global health at risk if the already tenuous immunisation and surveillance systems stop working. A new pooled fund structure could allow donors to support several fragile states at the same time while preventing duplication of efforts by working bilaterally with each. A call to action 3

10 1 INTRODUCTION The GPEI is the main health programme reaching children across South Sudan, the world s youngest and most fragile state. 6 It has helped to create the key structures for both polio vaccination and routine immunisation in the country. No other initiative has so successfully accessed the most vulnerable and hardest to reach children despite armed conflict, migrating communities and natural disasters. Currently, for the Republic of South Sudan polio vaccination campaigns are the best planned public health arrangements in the country, covering [over] 80 per cent of the population 7 while similar programmes cover between just two to ten per cent. 8 GPEI was established in 1988 and the global incidence of polio has decreased by 99.9% since its foundation. 9 In 2018, polio remains endemic in only three countries: Afghanistan, Nigeria and Pakistan. South Sudan has not reported a case of wild polio virus since Having nearly reached their commitment in South Sudan and other countries, GPEI partners will be ending their funding for polio eradication activities and helping countries transition polio assets to national health programmes. For South Sudan, this will mean declining support to critical activities, such as a national system for disease surveillance and outbreak response, immunisation campaigns, social mobilisation networks, and a cold chain network that provides potent vaccines to the most remote and isolated portions of the country. More than 95 per cent of funding from the GPEI goes to sixteen countries to support their eradication activities. While many of these countries will have their own difficulties with polio transition, most are more likely than South Sudan to absorb essential functions that are currently funded by GPEI. UNICEF/Hatcher-Moore 6 Messner, J.J., 2017 Fragile States Index, pg 8 7 Transition Independent Monitoring Board, The End of the Beginning, pg 8 8 Ibid. 9 Our Mission, The Global Polio Eradication Initiative website, accessed June 11, 2018, polioeradication.org/who-we-are/our-mission/ 4 Collapse

11 South Sudan is one of sixteen priority GPEI countries producing a national Polio Transition Plan. GPEI s primary goals for transition planning are to protect a polio-free world and to ensure that the investments, made to eradicate polio, contribute to future health goals after the completion of polio eradication. 10 For South Sudan, the key is for transition of GPEI assets to support broader health initiatives. 11 In South Sudan, investments from GPEI partners 12 have totalled around USD 20 million per year for almost 20 years, including pre-independence, under the Sudan programme. These investments will continue to ramp down into 2019 and beyond until funding ceases. 13 GPEI, GAVI, the Bill and Melinda Gates Foundation (BMGF), the Centres for Disease Control and Prevention (CDC) and the United States Agency for International Development (USAID) have been the major sources of guaranteed funding coming into the health system. Other resources for health are short-term due to the conflict and thus unguaranteed for medium-term planning and programming. Without GPEI resources, South Sudan will be unable to detect outbreaks of vaccine preventable disease, to deliver vaccines, or to support critical frontline staff in the field. With the eventual closure of GPEI, the possibility of collapse of the Expanded Programme on Immunisation (EPI) system is imminent: 1. Vaccine security is 100 per cent dependent on GPEI funds (cold chain storage and vaccine transportation); 2. Local technical capacity is sub optimal; Insecurity is widespread; DPT3 coverage is extremely low at 59 per cent in 2017; and 7. Measles, rubella and cholera outbreaks have occurred recently or are occurring in most states. Sources: Presentation by Dr. Makur Kariom, Undersecretary, Ministry of Health South Sudan (May ): Update on South Sudan Polio Transition Process, for the Polio Transition Independent Monitoring Board and the South Sudan EPI Joint Reporting Form (JRF) from May South Sudan s routine immunisation and other health programmes have benefited from GPEI partners investments of USD 20 million per year for almost 20 years. 10 Republic of South Sudan, Transition Plan for The Polio Eradication Initiative (Juba: Ministry of Health, June 2018), pg Ibid. 12 USAID, WHO, UNICEF, Rotary Club International, CDC, JICA and CIDA. 13 Transition Independent Monitoring Board, The End of the Beginning, pg 11 A call to action 5

12 South Sudan map Manyo Renk Melut Maban Raja Aweil North Aweil West Western Bahr el Ghazal Aweil P Northern Bahr el Ghazal Aweil Centre Wau Tambura Aweil East Aweil South Nagero Kuajok P Wau P Jur River Western Equatoria Ezo 1 Nzara Abyei region Twic Gogrial West Warrap Yambio Yambio P Gogrial East Tonj South Unity Abiemnhom Rubkona Bentiu Mayom P Tonj North Cueibet Ibba Tonj East Wulu Koch Mayendit Rumbek North Rumbek Centre Rumbek P Lakes Maridi Pariang Mvolo Guit Rumbek East Leer Panyijiar Mundri West Yei Yirol West Fangak Ayod Terekeka Mundri East Duk Yirol East Lainya Panyikang Awerial Canal/Pigi Twic East P Fashoda Malakal P Malakal Bor Nyirol Central Equatoria Juba Uror Bor South Baliet Upper Nile Torit P Jonglei Lafon Ulang Akobo Longochuk Pibor Eastern Equatoria Torit Luakpiny/Nasir Budi Maiwut Pochalla Kapoeta North Kapoeta South Kapoeta East Kajo-keji Magwi Ikotos Morobo 1.1 Country context The primary reason South Sudan has returned to the number one spot in the Fragile States Index 14 is because of conflict between supporters of President Salva Kiir and Vice President Riek Machar, reports of ethnic cleansing, and suspended elections. 15 The conflict has caused the world s worst food security crisis, 16 inducing famine in some parts of the country as recently as As with other fragile states, administrative structures in South Sudan are weak or nonexistent. Exacerbating this is the new state structure the Government put in place in The old ten states have been replaced by 33 new states, most of which do not have adequate administrative structures. Some planned government health programmes, such as the Boma Health Initiative (BHI), 17 aim to use the old state structure for ease of programming. In addition, the Government has not paid some staff for several months, such as teachers and health 14 Messner, J.J., 2017 Fragile States Index, pg 8 15 Messner, J.J., 2017 Fragile States Index, pg South Sudan - The Most Dangerous Country for Aid Workers, Editorials, Voice of America, September 11, 2017, south-sudan-the-most-dangerous-country-for-aidworkers/ html 17 See section 5 for more information on the Boma Health Initiative. care professionals. Budget allocations for the social sector are shrinking, 18 while the defence budget has increased. 19 South Sudan s Health System Structure by Geographic Area 650 Payams: 2532 Bomas: 80 Counties: State Ministries of Health National Ministry of Health in 10 original states County Health Departments (80% run by non-governmental organizations) No permanent health structures or systems yet No permanent health structures or systems yet 18 UNICEF, National Budget Brief Fiscal Year 2017/18, Republic of South Sudan (Juba: UNICEF South Sudan, November 2017), pg 7 19 According to the World Bank, military spending has increased from 4.1 per cent in 2010 to 12.8 per cent in 2015 (as percentage of GDP). Military expenditures, Stockholm International Peace Research Institution Yearbook: Armaments, Disarmament and International Security, accessed 11 June 2018, worldbank.org/indicator/ms.mil.xpnd.gd.zs?end=201 6&locations=SS&start= Collapse

13 South Sudan stands to benefit from inheriting the bulk of Sudan s oil wealth, 20 but today the country rates 181st out of 188 countries on the UN Human Development Index 21 and over 80 per cent of the population of approximately 13 million lives on less than 1 USD per day. 22 The absolute poverty rate is estimated to be 50 per cent of the total population. 23 Accurate estimates on the current literacy rates or how many children are enrolled in and attend school are difficult to ascertain as diverse estimates exists. Literacy is predicted to be lower than 20 per cent and school enrolment 31 per cent. Girls have lower literacy and enrolment rates than boys. 24 With regard to health financing in the country, the Government of South Sudan spends less than one per cent of its Gross Domestic Product on health 25 and the country has some of the worst health indicators in the world. The maternal mortality ratio is the world s fifth highest 26, at 789 per 100,000 live births and neonatal and underfive mortality rates are also extreme at 39.3 and 99.6 per 1000 live births respectively (2014). 27 Complicating matters, 80 per cent of health facilities in South Sudan depend on nongovernmental organizations (NGOs) to provide primary health care services at the county level, including immunisation. 28 Thus, health care at the community level is underdeveloped with communities often unaware of the benefits of immunisation, or how or where to access services. 29 Today, only about a third of health facilities have functioning immunisation services due to lack of appropriate staffing, equipment, and planning 30 and many facilities were looted during periods of unrest. Cold chain equipment, necessary for protecting the integrity of vaccines, was damaged in more than 100 facilities between 2015 and Staff shortages at all levels have led to immunisation, and wider health care services being outsourced to NGOs, with unskilled staff only receiving training on the job, making it difficult to maintain community trust. Staff are largely paid through per diems or performance based incentives rather than by regular salaries, resulting in poor motivation and high staff attrition, with many positions left unfilled. At national level, EPI managerial skills are weak making programme planning, coordination, monitoring, supervision and reporting difficult. Transition Independent Monitoring Board, The End of the Beginning: First Report of the Transition Independent Monitoring Board of the Polio Programme, July BBC South Sudan Profile, 27 April 2016 (accessed 11 July, 2018): world-africa Human Development Index, Human Development Reports, UNDP, accessed 11 June 2018, org/en/countries/profiles/ssd 22 UNDP. About South Sudan (accessed July 11, 2018): countryinfo.html 23 ibid. 24 South Sudan Poverty Profile, World Bank (2015) (accessed July 11, 2018): microdata.worldbank.org/ index.php/catalog/2778/download/39504 Poverty Profile. 25 Transition Independent Monitoring Board, The End of the Beginning, pg 8 26 Maternal Mortality Rate Maternal and Newborn Health, UNICEF, accessed 11 June 2018, unicef.org/topic/maternal-health/maternal-mortality/ 27 WHO, Country Cooperation Strategy at a Glance: South Sudan, (Juba: WHO, May 2018), pg 1 28 Republic of South Sudan, Transition Plan for The Polio Eradication Initiative, pg 7 29 UNICEF. Draft Programme Strategy Note (May 2017) 30 Ibid. 31 Ibid. UNICEF/Hatcher-Moore A call to action 7

14 South Sudan is experiencing low immunisation rates, at 44 per cent in 2016, and has ongoing measles and rubella outbreaks in most states. 32 Compromised security and lack of access has also led to diphtheria-tetanuspertussis (DTP) coverage falling nationally from 72 per cent in 2012 to 26 per cent in Frequent outbreaks of measles, cholera, whooping cough and Kalazar 34 are also having a disturbing impact on public health. Since December 2013, more than 3.4 million people have been displaced: almost 2.5 million refugees 35 crossing into Uganda, Kenya, Ethiopia and Sudan and 1.9 million internally displaced persons. 36 The people movement has added to tensions over land ownership and occupancy, which is becoming increasingly fragmented along ethnic lines. In addition to the significant insecurity faced by millions of people across the country, South Sudan is regarded as one of the most dangerous countries in the world for aid workers. Since the conflict began in December 2013, 101 aid workers have been killed. 37 According to the United Nations, nearly 630 incidents hindering humanitarian access occurred between January and July of The ramp down of GPEI in fragile states More than 95 per cent of GPEI funding goes to sixteen countries to support their eradication activities. While many of these countries will have their own difficulties with polio transition, efforts to finance and absorb essential functions currently funded by GPEI are especially complex in some countries. Countries dealing with long running conflict that brings insecurity economic uncertainty and stunted development - like South Sudan, Somalia, Chad and the Democratic Republic of the Congo - are among those that may face more extreme challenges. 39 As noted by the Transition Independent Monitoring Board, the reason that they [these countries] have the GPEI staff and resources in the first place is because they were not considered capable of eradicating polio on their own. 40 In this connection, these states are dealing with transition differently than other countries and the risks they face are more hazardous to health systems. States are fragile when state structures lack political will and/or capacity to provide the basic functions needed for poverty reduction, development and to safeguard the security and human rights of their population. 32 Transition Independent Monitoring Board, The End of the Beginning, 8; The Government of South Sudan s Joint Reporting Form Ministry of Health, Health Management Information System data (2016) 34 WHO, Weekly Bulletin on Outbreaks and Other Emergencies: Week 52, 31 December South Sudan Emergency, UNHCR, updated January 2018, html 36 UNICEF, South Sudan Mid-Year Humanitarian Situation Report (Juba: UNICEF, July 20, 2017) pg 1 37 UNOCHA, Humanitarian Bulletin, Issue 5, (Juba: UNCHA, May 23, 2018), pg 2 38 South Sudan - The Most Dangerous Country for Aid Workers, Editorials, Voice of America, September 11, 2017, Source: OECD DAC, 2007 (Mcloughlin, Claire, Topic Guide on Fragile States, Governance and Social Development Resource Centre, International Development Department, University of Birmingham, August 2009, page 8) 39 Transition Independent Monitoring Board, The End of the Beginning, pg Ibid. 8 Collapse

15 2 WHAT HAS THE POLIO PROGRAMME BROUGHT TO SOUTH SUDAN? Over the past three decades, the GPEI has built significant infrastructure in immunisation campaigns, disease surveillance, social mobilisation, and vaccine delivery; developed in-depth knowledge and expertise; and learned valuable lessons about reaching the most vulnerable and hardto-reach populations on earth. 42 South Sudan has achieved something remarkable: it has all but eradicated polio. This is no mean feat for a country that has been involved in conflict for most of the period of the GPEI. Since 1988, GPEI has protected millions of children from polio, saving them from a debilitating illness that would affect them for their entire lives. Even though the health system has been compromised and parts of the country are frequently inaccessible, campaigns ensured that polio vaccination rates remain high. The country has not had an outbreak of wild poliovirus since But that s not all. 41 Funding from donors like CDC, USAID, BMGF and Rotary International through GPEI is the backbone of the country s communicable disease surveillance system; vaccine cold chain system; laboratory networks; routine and supplementary immunisation programmes; and human resource networks for health in the areas of coordination, surveillance, social mobilisation, and disease outbreak responses. Thus, polio-funded assets ensure many other life-saving vaccines and services reach women and children and that outbreaks of diseases like cholera and meningitis are quickly addressed nationwide. 42 Surveillance: The Polio Programme, with support from GPEI and other donors and technical guidance from WHO and UNICEF, introduced an active acute flaccid paralysis (AFP) surveillance system in South Sudan. This system has helped to ensure South Sudan has remained poliofree. At both state and county levels there is active surveillance in a number of sites, including internally displaced persons sites. Even in Greater Unity, Upper Nile and Jonglei, partners funded by the Bill and Melinda Gates Foundation continue to conduct active surveillance, despite the ongoing conflict. In 2014, there was an outbreak of vaccine-derived poliovirus, but it was detected by the surveillance system, showing just how effective active surveillance can be in South Sudan with its limited infrastructure and health system. Another example of this was when Rift Valley fever of 2017 was detected and the initial investigation was conducted by the AFP surveillance network. Surveillance extends to other vaccine preventable diseases, which has led to many suspected outbreaks of measles being notified, investigated and responded to through the polio infrastructure, including collection of samples. 41 Republic of South Sudan, Transition Plan for The Polio Eradication Initiative, pg 4 42 Global Polio Eradication Initiative, Investment case, pg 21 A call to action 9

16 OUTBREAK RESPONSE POLIO SURVEILLANCE MENINGITIS SURVEILLANCE MEASLES SURVEILLANCE IMMUNISED RATE VIT A SOCIAL MOBILISATION CAMPAIGNS COLD CHAIN GPEI DONOR SOCIAL MOBILISATION DONOR IMMUNISATION SYSTEM COLLAPSE 10 Collapse

17 Many health interventions depend on Polio Programme systems and structures WASH ROUTINE IMMUNISATION MEASLES, MENINGITIS, TETANUS NUTRITION POLIO Health systems modelling: In South Sudan, the Polio Programme has demonstrated an effective systems-approach, which other priorities have been able to leverage. The polio network cuts across the county level, in which it has about 95 per cent presence. 43 Other programmes, such as water, sanitation and hygiene (WASH) and nutrition also leverage across this network. In addition, with limited government capacity to support staff, a number of health workers are motivated during the polio campaigns with performance based incentives. Improved immunity and routine immunisation: The Polio Programme has helped to strengthen RI in the country, relying heavily on supplementary immunisation activities (SIAs) to achieve a basic level of coverage in the country. Vitamin A and deworming as well as measles, meningitis, and tetanus vaccinations are administered using the structure of the Polio Programme, including microplanning, funds management, capacity building and logistics. That is, a lot of the assets currently being used for RI come from the Polio Programme. Thus, not only has stronger immunity to polio been achieved, but immunity to other diseases too which is helping to control the rates of childhood diseases in the country. Social mobilisation: A major value-added of the Polio Programme has been the proliferation of social mobilisation as a key intervention and platform for public health. Engaging the community is a central pillar in polio eradication efforts around the world and critical to the success of eradication efforts. Social mobilisation started as a health promotion strategy, sharing information to facilitate achievement of the goals of the Polio Programme and encouraging parents to immunise their children. Over time, social mobilisation has grown into a strategy that seeks to empower beneficiaries of health programmes to become active stakeholders in public health. Communities are knowledgeable about basic lifesaving services and are empowered to demand services that will contribute to the health and wellbeing of their children and communities. As a strategy, it now reaches into other programmes. For example, UNICEF s Communication for Development was initially developed for the Polio Programme and is now utilised as a crosssectoral strategy for health, nutrition, WASH, and education around the world. Moreover, for UNICEF in South Sudan, social mobilisation funding is already transitioning: only 50 per cent of it is reliant on funding from the GPEI. 43 WHO team, South Sudan, Interview by Matthew Gibbs, DevSmart, Juba, April 2018 A call to action 11

18 3.2 Reaching the hardest-to-reach children Greater Unity Upper Nile Jonglei GPEI Logistics and laboratory testing: Vaccine security is 100 per cent dependent on GPEI funding 44 and the Polio Programme has shown just what can be achieved with good logistics. For example, the conflict has meant that some communities in Greater Unity, Upper Nile, and Jonglei states have been hard to access communities, but during campaigns the Polio Programme used microplanning and community social mobilisation to access and vaccinate these hard to reach populations. The Nutrition Programme uses the polio network twice a year to reach children under-five across the country to boost their immunity and growth with Vitamin A supplementation and deworming. There have also been times when the Global Fund for AIDS, Tuberculosis and Malaria has used campaigns a critical component of the Polio Programme 44 Global Polio Eradication Initiative, Update on South Sudan Polio Transition Process, Presentation delivered by Dr. Makur Kariom Undersecretary Ministry of Health, Republic of South Sudan (London: GPEI, May 2017) slide 12 to distribute bed nets to prevent malaria. The Polio Programme essentially established the cold chain in the country, which goes down to county level, extended to the end-user, the child, during polio National Immunisation Days. Without the Polio Programme, the Expanded Programme on Immunisation (EPI) in the country would face chronic shortfalls. Infrastructure, particularly roads and electricity, in South Sudan is very limited, so the Polio Programme brings the basics to the table vehicles and fuel for generators, transport and chartered flights when no other access is possible. Furthermore, since South Sudan does not have a national laboratory for testing suspected cases of polio, the Polio Programme pays for the quick transfer of specimens to laboratories outside the country for examination within the Global Polio Laboratory Network Abegunde, Dele, The Business case for integrating polio assets into priority health services in South Sudan (Juba: WHO, May 2018), pg Collapse

19 The funding gaps for just cold chain logistic transport and cold chain logistic fuel between 2018 and 2022 will be USD 3,000,000 and USD 4,999,038 respectively if new sources of funding are not identified. Source: Republic of South Sudan, Transition Plan for The Polio Eradication Initiative, Juba, South Sudan, June Outbreak response: Disease outbreak response capacity in South Sudan is heavily dependent on the polio infrastructure and instructions passed from the state to lower levels. The EPI Officers at the state level and Field Assistants at the county level, including Polio Field Assistants and community informants follow these instructions when investigating community alerts, supporting sample collection and packaging and shipping specimens. These same people increase active surveillance site visits, link communities with health facilities, provide sensitisation for health facility staff, and implement recommended public health surveillance interventions in response to confirmed outbreaks. 46 In addition to surveillance response, one of the major tasks the polio staff is responsible for is conducting supplemental immunisation this includes preparation, training, implementation and monitoring each campaign s quality. Thus, the polio structure supports the health system to respond to any outbreak with an effective and timely response mechanism. Training and capacity development: The Polio Programme established and equipped a team capable of detecting and eliminating poliovirus and running the country s most successful health initiative. Today, the Polio Eradication Initiative in South Sudan is composed of a disciplined workforce that utilises performance standards and accountably structures to effectively immunise, detect, and respond. For example, the workers are expected to visit priority facilities as per surveillance priority standards. Every week, every two weeks and every month they visit high, medium and low priority sites respectively using open data kits to collect and submit information and record geo-coordinates. For active surveillance, each officer has to be in the field for at least 14 days each a month to visit 9 15 health facilities. To reach this level of efficiency, the Polio Programme invested millions of dollars into staff training, manuals and tools, which has significantly strengthened the health system. Each of these areas have helped to drive the process of eradicating polio, but they share something else in common: they have introduced elements to the health system that are critical to its functioning. They have helped to demonstrate that a functional immunisation system is the bedrock of a sound health system. 46 Ministry of Health, Republic of South Sudan, Polio Simulation Exercise, Polio Transition Planning (Juba: Ministry of Health, July 2017), pg 14 A call to action 13

20 3 WHAT WILL THE IMPACT OF THE POLIO PROGRAMME RAMP DOWN BE? Parts of the health system will shut down due to lack of funding. The Polio Programme support to routine immunisation will stop. Currently, RI in South Sudan is sub-optimal. A key global indicator of immunisation programme performance is third dose coverage of DTP vaccine (DTP3) by age 12 months. Global coverage in 2016 was 86 per cent 47, but 26 per cent in South Sudan. This level of coverage will not result in strong herd immunity (see graphic on page 15). The elimination of polio and high levels of polio immunisation in South Sudan has been the result of campaigns SIAs, including National Immunisation Days administering oral polio vaccines. Moreover, many of the counties in conflict affected states campaigns are the only chance for children to get vaccination including routine vaccination. In 2017, there were four campaigns to supplement RI; in 2018 and 2019, there will be one national and two subnational campaigns. As GPEI funding continues to ramp down in 2019, there will be less funding provided for polio functions and polio vaccination campaigns, and there is a very real concern that EPI will come close to collapse. UNICEF has been trying to expand the existing cold chain in support of the EPI and the GPEI has already made a big contribution. The cold chain system will be at risk of breaking down when the GPEI funding expires. Maintenance is expensive, for vehicles, generators and regional cold chain stores for vaccines. Fuel is a very important element here. Currently, the EPI is trying to adjust the budget for fuel and transportation to make it cheaper and more efficient. Added to the mix is GAVI the global Vaccine Alliance which is providing some support to introduce solar energy into South Sudan s cold chain at the county level. Progressive solarisation is reducing the fuel bill. However, the state and national levels still rely on fuel and GAVI (whose contribution is already quite significant) may not be able to cover all of the gap. In addition, some solar refrigerators have been stolen or misappropriated during recent conflict. Replacement of this equipment becomes complicated by the due diligence processes of donors and implementing agencies and ongoing assessment of the unpredictable situation. Active surveillance will no longer be adequately practiced in the country. Currently, surveillance for polio, mainly run by WHO, CoreGroup and McKing Consultancy/BMGF, is almost a parallel structure to other surveillance activities conducted by the Ministry of Health. WHO is helping to strengthen the Integrated Disease Surveillance and Response (IDSR) system in South Sudan, but there is considerable work still to be done. The Polio Programme has invested a lot in surveillance county supervisors, national officers and staff at the lowest levels of implementation have all been adequately trained to conduct surveillance activities including AFP. Other diseases interventions and surveillance activities have piggy-backed on the polio network and infrastructure, including measles, so if no support is forthcoming, surveillance activity quality across the board will be seriously affected. Data analysis will be compromised and all partners will have even less access to quality data. This data is not just important to understand immunisation rates, but to understand how effective Primary Health Care units are working. 47 Overview, Newsroom Fact Sheet on Immunization Coverage, WHO, accessed 11 June immunization-coverage 14 Collapse

21 HERD IMMUNITY Susceptible (indirectly protected) Immunised Contagious Contagious disease spreads through the population No one is immunised Contagious disease spreads through some of the population Some of the population gets immunised Spread of contagious disease is contained Most of the population gets immunised A call to action 15

22 UNICEF/Hatcher-Moore Another issue is the surveillance infrastructure. Good surveillance is about speed. While the Ministry of Health will have the motorbikes and other vehicles to support surveillance, concerns about their maintenance following the end of GPEI funding give rise to worries about the collection of data, even if staff could be maintained to conduct active surveillance. The ramp down of the Polio Programme will be felt at the community level. Polio funding is still financing approximately 50 per cent of the current number of social mobilisers some 5,000, 2,397 of whom are part of the Integrated Community Mobilisation Network. 48 Without them, there will be less information reaching communities, which will have a knock-on effect in terms of health-seeking behaviour. This will not just affect the immunisation work in the future, but the other interventions that now benefit from the social mobilisation strategies. The health system needs community involvement and a diminished network will have a significant impact. In a fragile country, the empowerment of community members is critical to building resilience to current and future shocks. The brain drain will begin. When the polio money goes, the personnel involved in surveillance, vaccination, and social mobilisation will suddenly not be a resource. At the implementation level, trained social mobilisers and vaccinators will no longer be financed to work. The technical experts in the immunisation sector are mostly recruited by polio, so there will be diminished capacity to plan and run immunisation programmes. The data surveillance system will suffer for lack of active surveillance people at the lower levels. International workers with expertise will move on to another country that has positions for their skills, while national workers could be recruited to other organisations, go to work abroad or simply withdraw from the public health scene in South Sudan. Capacity gains built up over time will be lost. 48 UNICEF, Polio Transition Snapshot, South Sudan (Juba: UNICEF, April 2018) pg 4 16 Collapse

23 4 LOOKING BEYOND THE POLIO PROGRAMME AT THE CRITICAL FUNCTIONS WHO, UNICEF and the Ministry of Health in South Sudan have initiated a process reviewing the end of the GPEI funding and transitioning assets into other programmes. This process identified and prioritised key assets that emerged from the Polio Programme that will not be supported when funding ceases and that the health system needs in order to function. However, the transition instigated by the ramp down of GPEI funding is not about preserving the assets of the Polio Programme. It is about the functions carried out by these assets and how they have been used. Going further, it is about understanding which ones are critical to maintaining a bare minimum of presence and services and helping to ensure these functions continue. The Polio Programme currently pays for at least 703 staff in South Sudan that would be lost without assertive planning and attention The impact would be felt in routine immunisation activities, vaccine cold chain, logistics, polio and other disease surveillance, training, and outbreak response. Transition Independent Monitoring Board, The End of the Beginning: First Report of the Transition Independent Monitoring Board of the Polio Programme, July 2017 and updated numbers (703 staff) from the South Sudan Polio Transition Plan, June The questions moving forward as polio funding ramps down are the following: What functions will still be required by the health system to ensure a basic level of information and services continue from the community level up? What is at risk if the functions are not absorbed by the health system? How can these functions continue? 4.1 What are the critical functions and why are they critical? The following functions are some of the most critical to maintain after polio ramp down in South Sudan: 1. Active surveillance The AFP surveillance network encompasses 1,882 surveillance sites across the country. This includes personnel at the national, county, payam and community level including more than 3,000 community informants 49 making it the most comprehensive surveillance system in the country. In addition, the surveillance for polio is currently the only active surveillance system (case-based) in the country and most disease surveillance activities are the platform for the AFP surveillance as well as for measles, neonatal tetanus, yellow fever, meningitis and other diseases. 49 Republic of South Sudan, Transition Plan for The Polio Eradication Initiative, pg 12 A call to action 17

24 2. Social mobilisation The social mobilisation network established to support the SIAs includes eleven NGOs with 4,500 social mobilisers. 50 This Integrated Community Mobilisation Network mobilises communities towards key healthy behaviours around health, education, WASH, child protection, and nutrition. This community mobilisation network operates all year round Immunisation supply chain management While GAVI continues to generously support the cold chain, GPEI funding has been critical to its smooth running, including provision of fuel and distribution of vaccines and EPI supply, mainly done by air. 4. Outbreak response capacity As a vertical programme, the outbreak response was designed only for polio, but it has become essential: polio-funded officers have always contributed to outbreak response. This goes hand-in-hand with active surveillance and social mobilisation. The network from the community upwards needs to be in place to protect public health in South Sudan. Without the Polio Programme, the health system does not have an effective mechanism for outbreak response. A note on human resources: Human resources are necessary to sustain these vital functions. While the focus of the investment case is on the functions, these functions are implemented by highly skilled personnel on salaries or incentives who are vital to sustaining presence and services across the country. 4.2 What are the risks if these functions do not continue? Disease has no borders and requires no visa. Dr. Baba Samson, Special Adviser to the Minister of Health, Republic of South Sudan Heavily dependent on polio funding, South Sudan s fragile health system is at risk of collapse without new funding commitments from donors to ensure the essential functions discussed above are maintained for routine immunisation, surveillance, and other basic health services. Other risks include limited technical capacity for transition, lack of awareness about the transition process and understanding of the imminent changes, and insufficient governance structures. Annual cost for polio personnel: USD 9.8 million 70 per cent of immunisation staff are funded by polio resources. An estimated 70 per cent of polio funding in South Sudan is normally shared with routine immunisation activities covering staff salaries, vaccine logistics and cold chain systems. 52 In 2017, while donor funding for polio was USD 25.7 million, approximately USD 18.2 million supported RI. 53 Thus USD 18.2 million will be the deficit that will confront RI in South Sudan when GPEI phases out if new funding is not allocated to cover these core functions. 54 Stakeholders are concerned that the ramp down in funding will result in increased rates of child morbidity and mortality due to the impact 50 Republic of South Sudan, Transition Plan for The Polio Eradication Initiative, pg Ibid. 52 Abegunde, Dele, The Business case for integrating polio assets into priority health services in South Sudan, pg Ibid. 54 Ibid. 18 Collapse

25 UNICEF/Hatcher-Moore on the immunization programme and broader health system. In terms of human resources, if trained staff members are let go at the end of the transition period, it is possible they will not be available if funds come at a later date to cover the minimal immunisation and surveillance needs that every country must have to prevent and protect its population, neighbouring countries and the world from disease outbreak. In summary, what are the risks? Active case-based surveillance would end and the quality of available data monitoring the health of the population and disease outbreak would dramatically reduce; All immunisation figures for the population would be expected to further decline; The cold chain would be interrupted, severely limiting vaccines getting to end-users; Social mobilisation activities promoting healthseeking behaviour would be reduced by about 50 per cent; Sorely needed inter-sectoral collaboration would be threatened; and All SIAs would stop (or be of poor quality), ending the most effective health interventions in the country. 4.3 What does this mean for the health system in South Sudan? Without sustaining the functions from the Polio Programme, the health system is in danger of collapse. GPEI, CDC, BMGF and USAID polio resources have been the only sources of guaranteed funding coming into the health system. Other resources for health are shortterm due to the conflict and thus unguaranteed for medium-term planning and programming. Thus, without these resources, there is a risk that vaccines will not be delivered and staff will lose support in the field. Outbreak response will be limited as this has been led by the polio team, which is in place at the county and payam The loss of polio s USD 20 million per year will place South Sudan s entire health system at risk. A call to action 19