Input:
**The World Bank**
South Sudan Health Sector Transformation Project (HSTP) (P181385)

including protection and coordinating government and external support for refugees. The CRA is present in all
refugee-hosting areas, even as capacity limitations impede its ability to fulfill its designated responsibilities.

**B. Sectoral and Institutional Context**

**Health Sector Outcomes**

9. **South Sudan faces significant challenges that adversely affect its human capital with one of the lowest** **Human**


Input:
**Capital Index (HCI)** **[8]** **scores at 0.31** (2020) [9] In the country, 31 out of every 100 children are stunted, increasing the
risk of physical and cognitive impairment, which can ultimately affect the adult survival rate. South Sudan’s health
outcomes rank among the poorest in the world. As of 2021, life expectancy at birth is one of the lowest in the
world, estimated at 54.98 years, and the under-five mortality rate was 98.69 per 1,000 live births from 2017 to
2021. [10] The country has the highest neonatal mortality globally at 39.63 per 1,000 live births. [11] About 71 percent
of the population residing over 5 km from the nearest health facility. South Sudan has the highest maternal
mortality ratio globally at 1,223 per 100,000 live births. [12] Notably, only 38 percent of facilities offering
Comprehensive Emergency Obstetric and Newborn Care (CEmONC) [13] are partially functional and caesarian
sections are only available in major urban areas, accounting for only 1 percent of all deliveries, much lower than
the expected rate of necessary caesarian sections at around 10–15 percent.

10. **Cultural norms and a preference for larger families dampen the demand for reproductive and maternal health**

---
[8] World Bank. Human Capital Index, 2020.
[9] The HCI uses two primary health indicators: the stunting rate in children under the age of 5; and the adult survival rate.
[10] World Bank. World Development Indicators. https://databank.worldbank.org/id/fef9176d?Report_Name=Macroeconomics-Workshop.
[11] World Bank. Mortality Rate – Neonatal: South Sudan. https://data.worldbank.org/indicator/SH.DYN.NMRT?locations=SS.
[12] World Bank. Maternal Mortality Ratio. https://data.worldbank.org/indicator/SH.STA.MMRT?locations=SS.
[13] World Bank. Empowering Girls and Women in South Sudan. 2022.


Input:
**The World Bank**
South Sudan Health Sector Transformation Project (HSTP) (P181385)

estimated at 49 percent for the first dose of the measles vaccine, [19] while a 95 percent coverage rate is needed to
substantially reduce transmission. [20] Additionally, the 2017 EPI coverage survey estimated that only 18.9 percent
of children are fully immunized, contributing to the high levels of vaccine preventable diseases. [21]

**Health System and Service Delivery Challenges**

13. **Substantial supply- and demand-side health service delivery challenges persist across all health services.** Supply
side issues include limited physical infrastructure, supply stock-outs, severe health service delivery capacity gaps,
and a long history of suboptimal health service delivery. While historically, the focus has been on supply-side
challenges, demand-side issues require equal attention. The Boma [22] Health Initiative (BHI), [23] is a community
health worker program, targeting these issues by improving community-level interventions and bridging the gap
between health service supply and demand.

14. **Health and health service delivery in South Sudan are intertwined with climate change and the country’s**

---
[19] World Health Organization. Measles – South Sudan. 10 February 10, 2023. https://www.who.int/emergencies/disease-outbreaknews/item/2023-DON440#:~:text=South%20Sudan%20is%20one%20of,were%20estimated%20to%20be%2049%25.
[20] Gavi. South Sudan launches major push on measles vaccination. 2023. https://www.gavi.org/news/media-room/south-sudan-launches-majorpush-measles-vaccination.
[21] Draft South Sudan Health Sector Strategic Plan 2023-2027.
[22] A boma is the lowest-level administrative division in South Sudan. Bomas vary in size and typically contain many individual villages.
[23] BHI is a national scale community health program that aims to strengthen the health system in South Sudan.


Input:
**The World Bank**
South Sudan Health Sector Transformation Project (HSTP) (P181385)

reforms under the HSTP. This includes: (i) a US$10 million budgetary allocation as a direct co-financing into HSTP;
and (ii) an additional US$10 million provided under the food shock window of the IMF program with South Sudan
that has been disbursed to MoH to procure pharmaceuticals, medical consumables, and equipment. The World
Bank will provide to the Government through an independent Third-Party Monitoring (TPM) a report outlining the
execution and utilization of the funds supported by the IMF program. The MoFP and MoH will provide the required
access and documentation to facilitate the TPM validation.

**C. Relevance to Higher Level Objectives**

18. **The proposed South Sudan Health Sector Transformation Project (HSTP) is aligned with the World Bank’s goals**


Input:
**and regional and global strategies and is poised to contribute to IDA20 policy commitments.** Specifically, the
HSTP contributes to the World Bank’s vision to create a world free of poverty on a livable planet, the World Bank
Evolution, and the Eastern and Southern African regional priorities by investing in improved water and sanitation
and energy efficiency in health facilities, strengthening national and state level capacity for climate and health
emergency preparedness and response, and critical nutrition interventions for children and pregnant women. The
IDA20 commitments place special priority on improving overall human capital focus on improving pandemic
prevention and preparedness support building resilient health systems that have the capacity to prevent, detect,
and respond to disease outbreaks and other health emergencies. The project is also fully aligned with the 2023
Dar es Salaam declaration on human capital.

19. **The project is consistent with the World Bank Group Country Engagement Note (CEN) for South Sudan for**


Input:
**FY2021—2023 (Report No. 158008-SS).** The project is aligned with the first and second focus areas of the CEN: (a)
lay groundwork for institution building; and (b) continue support for basic public service delivery. In addition, the
project is in line with the Fragility, Conflict and Violence (FCV) Strategy Pillar 2 on remaining engaged during
conflict and crisis situations, with a direct link to its first high priority area of investing in human capital, as well as
Pillar 4, which centers on mitigating the spillovers of FCV, given that the project will facilitate provision of vaccines
to refugees and IDPs in South Sudan.

20. **The project is fully aligned with South Sudan Health Sector Strategic Plan (HSSP 2023—2027)** which aims to

improve the health status of people by effective delivery of a basic package of health and nutrition services
(BPHNS) and highlights partnership with donors to support key health sector programs as one of its strategic
objectives. The upcoming National Immunization Strategy will be part of the HSSP.

21. **The project is consistent with South Sudan’s Second Nationally Determined Contribution (NDC) and National**


Input:
**Adaptation Plan (NAP), both issued in 2021.** [26] The NDC details specific health goals while the NAP identifies health
as a priority sector for climate adaptation in South Sudan. Both documents outline activities supported by and
embedded in the project including strengthening surveillance and early outbreak warning systems for climatesensitive diseases and climate and health emergencies, building community capacity for climate emergency
preparedness and response, and developing climate resilient health systems.

22. **The project complements both World Bank and development partner investments in health systems’**

**strengthening, disease control and surveillance, interventions to change individual and institutional behavior,**

**and citizen engagement** . The project also supports the attainment of Universal Health Coverage and of the
Sustainable Development Goals, and the promotion of a One Health approach.

---
[26] South Sudan’s Health Sector Strategic Plan (HSSP) 2023-2027, with which the project is aligned and is considered the Long-Term Strategy (LTS)


Input:
**third parties** demonstrated by; (a) the Government of South Sudan’s requests to the World Bank dated August
14, 2018 and January 27, 2020 to provide financing directly to organizations to carry out operations for the benefit
of the people in South Sudan, due to capacity constraints of the Government to effectively manage and implement
operations; (b) the World Bank’s value proposition and strategic focus on laying the foundations for institutional
building in areas such as financial management (FM), procurement, and environmental and social risk
management and building the humanitarian development nexus through sustaining the provision of health
services while investing in core aspects of the health system; (c) the planned institutional capacity development
at the Ministry of Health (MoH) to support a gradual transition towards government-led project management
modality through customized capacity building activities in the core areas of effective project management; and
(d) contributing to sustainability of the project activities through supporting community-based approach of health
service delivery, and strengthening disease surveillance and information systems, allowing the country to be more
responsive to the emerging diseases and more resilient to public health threats.

**II.** **PROJECT DESCRIPTION**


Input:
Sudan requested the World Bank, in letters dated August 14, 2018, and January 27, 2020, to provide financing
directly to organizations to carry out operations for the benefit of the people in South Sudan, due to capacity
constraints of the Government to effectively manage and implement operations. The project seeks to build the
MoH’s institutional capacity to pave the way for the future World Bank-financed projects in South Sudan to
transition toward a fully government-led implementation modality where the MoH’s role in service delivery will
be to contract and manage service providers.

**A. Project Development Objective**

**PDO Statement**

The Project Development Objective (PDO) is to expand access to a basic package of health and nutrition services,

improve health sector stewardship, and strengthen the health system.

**PDO-Level Indicators**

- Percentage of bomas covered by the Boma Health Initiative

`o` Percentage of bomas covered by the Boma Health Initiative in refugee areas

`o` Percentage of bomas covered by the Boma Health Initiative in host communities’ areas

Page 14 of 68


Input:
health service delivery and coordination. [29] In collaboration and through the leadership of the MoH, SMoHs, and
CHDs, UNICEF will be responsible for (a) oversight and coordination of health services and DHIS2 data collection
and entry systems; (b) supervision and quality assurance of IPs and health facilities in line with national plans and
guidelines; (c) coordinating and conducting in-service training; (d) through an integrated approach, developing
the capacity of SMoHs to plan, supervise, and oversee service delivery and the DHIS2 system; and (e) integrated
pharmaceutical procurement, quantification, and forecasting. Contracted IPs will be responsible for: (a) delivering
quality health services; (b) quality improvement activities; (c) supervision of health facilities (d) recording of HMIS
data, provision of HMIS data to CHDs, and support for entry of DHIS2 data into DHIS2 and data use; (e) in-service
training complementing UNICEF’s training activities; (f) health facility stock management, recording, and rational
use; (g) through an integrated approach, developing the capacity of CHDs to plan, supervise, and oversee service
delivery and the DHIS2 system; and (h) sustain the support of the innovation activities under CERHSSP and expand
using the digital health technology to address service delivery and supply chain issues.

---
[29] Subcomponent 1.1 will finance costs related to: (a) health service delivery at health facilities and outreach activities; (b) operational costs of health facilities including


Input:
**equivalent IDA [including US$0.63 million WHR] and US$1.57 million Trust Funds [US$0.17 million SDTF and**

**US$1.40 million MDTF]).** This subcomponent will focus on developing systems and procedures for the national
HMIS, with an emphasis on supporting the collection of routine data through DHIS2, to standardize data collection,
entry and cleaning, as well as instituting data quality improvement practices. This will enhance targeting and data
tracking for refugees and provide regularly updated information to understand the evolving needs on the ground
that will aid further in the decision-making process. The subcomponent will: (a) finance procurement of
information communication technology equipment at the national level and train staff on data entry and use; (b)
train trainers to develop health facility staff data entry, management, and use capacity; (c) create interoperability
and integration between data systems and ensure data sharing, storage and backup; (d) develop, print, and
disseminate Standard Operating Procedures for HMIS data entry, cleaning, quality improvement, and use at all
levels; (e) conduct data review meetings and generate data use tools; (f) establish and operate the National and
State level HMIS and Monitoring and Evaluation (M&E) Technical Working Groups; (g) conduct data quality
improvement activities at the facility and national level; (h) operationalize a national and state level research
committee, building on existing structure; (i) conduct an annual health sector review meeting; and (j) maintain
and institutionalize the Health Service Functionality (HSF) Database.

Health Service Functionality (HSF) Database


Input:
**The World Bank**
South Sudan Health Sector Transformation Project (HSTP) (P181385)

will ensure that independent and credible data on health service delivery and coverage and commodities are
generated and that the data are usable and used to enable the Government, the World Bank, and development
partners to verify that resources are reaching the intended beneficiaries and minimize potential harm. The
monitoring entities’ roles will include working with the PMU, UNICEF, the World Bank, and IPs to explain results,
providing guidance on improved methods, proposing context-appropriate solutions, and conducting ex-post fact
verification of results provided by project reporting mechanisms.

41. **Subcomponent 3.1:** **Third Party Monitoring (Competitively selected TPM agencies; US$13.75 million: US$6.15**


Input:
**million equivalent IDA [WHR] and US$7.6 million Trust Funds [US$0.8 million SDTF and US$6.8 million MDTF]).**
The project will finance TPM of delivery of basic health services under Subcomponent 1.1 and will build on
arrangements through the COVID-19 Emergency Response and Health System Preparedness Project (CERHSPPP176480), incorporating lessons learned from the project. TPM will provide critical assessment and survey data,
in complement to routine data through DHIS2, in support of the country’s overall HMIS. The TPM arrangements
will incorporate quarterly health facility functionality assessments and data quality verification; biannual health
service quality assessments, patient feedback, and BHI performance visits; and baseline and endline household
coverage and citizen engagement surveys. The TPM agent will be selected for the full project period through a
competitive process, with close attention to their capacity to scale up nationwide. To facilitate nationwide scaleup, multiple agencies may be recruited with an anticipated geographic division of labor using standardized data
collection, entry, analysis, and reporting tools nationwide. TPM arrangements are outlined in detail in Annex 2.
Along with monitoring and survey activities, the TPM will develop Government capacity for the design of data
collection tools, data use, and oversight of health service monitoring. [31]

---
[31] Geocoded technology will be used to track TPM data collection activities and facilitate near-real-time reporting of field data. All data will be


Input:
42. **Subcomponent 3.2: Data Analysis and Visualization Platform (Competitively selected TPM Agency; US$0.73**

**million: US$0.30 million equivalent IDA [US$0.0 million IDA Grant and US$0.30 million WHR] and US$0.43**

**million Trust Funds [US$0.05 million SDTF and US$0.38 million MDTF]).** To facilitate data sharing and use, the
subcomponent will develop a data visualization and use platform (software) focusing on visual representations of
TPM and routine data, inclusive of BHI data. Linking of platforms, including DHIS2 and the HSF platform will be
integral to the work. The data visualization platform will include visualization of Results Framework data and other
core indicators from the HSSP, linking TPM and DHIS2 data using maps, charts, and graphs and will incorporate
HSF data along with the overlay of health and meteorologic data to better understand the impact of climatic
patterns on health. The platform will include analysis of health service delivery in refugee and host community
areas to facilitate improved health service delivery among the critical underserved populations. The development
of an integrated, institutionalized, and sustainable platform which will strengthen MoH systems will be
emphasized. Annex 2 provides further details on the platform.

43. **Subcomponent 3.3: Contract and Program Management Capacity Development (PMU; US$3.44 million: US$1.54**


Input:
**The World Bank**
South Sudan Health Sector Transformation Project (HSTP) (P181385)

outputs such as the number of beneficiaries receiving basic package of health and nutrition services including
among refugees and host communities, the expansion of BHI, increased of number of health facilities that have
received pharmaceutical supplies ahead of the distribution period, functional laboratories, and enhanced health
sector coordination. In turn, these are expected to lead to the following outcomes: improved access to basic
package of health services, strengthened health systems, and improved government stewardship capacity. In the
long-term, the impact of the project will be improved health outcomes nationwide.

**Figure 1. Theory of Change**

**E. Rationale for Bank Involvement and Role of Partners**

48. **The value added of supporting the delivery of a basic package of health services through a World Bank**

**supported operation is high, given the World Bank’s ability to provide higher-level technical oversight and**


Input:
**The World Bank**
South Sudan Health Sector Transformation Project (HSTP) (P181385)

stage in integrating health financing and harmonizing health service delivery nationwide in South Sudan, through
the IDA co-financing arrangements (standalone trust funds) to cover health service provision across the country,
which complements government resources. Pooling health sector resources through the IDA co-financed by donor
funds will: (a) improve efficient use of limited available resources by consolidating management and monitoring
mechanisms in the country; (b) reduce fragmentation and simplify the Government’s coordination with health
sector partners; (c) help transition towards better governance of the sector through strong accountability
mechanisms; (d) ensure a streamlined package of services is delivered in a consistent manner throughout the
country through unified planning, budgeting, and implementation processes; a€(e) allow for lessons learned
through current and previous health service delivery modalities, such as the need for robust management and
supervisory systems, strong monitoring, and consistent supply chain systems.

50. **und pooling mechanism is also an opportunity to strengthen the Government’s role as a steward of the**


Input:
**The World Bank**
South Sudan Health Sector Transformation Project (HSTP) (P181385)

a progressive role in project management based on the capacity acquired. In addition, the PMU will contract, with
World Bank guidance, technical assistance for capacity-building activities based on a needs’ assessment. The
current COVID-19 Emergency Response and Health System Preparedness Project (CERHSPP-P176480) is financing
customized institutional capacity development at the MoH; a PMU of 15 qualified members is in place at the MoH
and started engaging in oversight of core aspects of project activities. A new PMU will be established through an
open and competitive recruitment process to be carried out by the MoH with close support from the World Bank.
The current PMU team will provide good candidates for the new PMU. A PIM will be prepared, describing the
main activities to be carried out by the PMU and implementation modalities.

61. **Two steering committees will be established.** A High-level Steering Committee (HSC) will provide strategic


Input:
to (a) benefit from UNHCR’s expertise as the lead UN agency working on refugee issues; (b) capitalize on UNHCR’s
existing citizen engagement platforms to ensure the target groups are heard; and (c) identify ways to complement
ongoing health activities that UNHCR and its partners are implementing in these areas. In view of their lead role
on refugee protection, the project will also closely coordinate with CRA officials in refugee-hosting areas to ensure
refugees are equitably included in WHR-financed activities, as well as seek to foster collaboration between local
government health officials and CRA on this effort. Further, the OSC will liaise and frequently meet with the South
Sudan Humanitarian Cluster, a forum that involves all humanitarian players in the country.

**B. Results Monitoring and Evaluation Arrangements**

63. **Monitoring and tracking of project outputs will rely on different sources of information and monitoring**


Input:
**Health System Preparedness Project (CERHSPP-P176480)** and will aim at measuring actual service delivery
outcomes. UNICEF and WHO will provide detailed technical reports biannually with narrative updates on the
overall project implementation and results as well as reporting on the project’s Results Framework indicators. In
addition, quarterly matrices will be provided which will contain updated progress of Results Framework indicators
as well as social and environmental risk management.

65. The project will identify refugees and host communities’ beneficiaries by building on a targeting mechanism that

has been designed under the ongoing COVID-19 Emergency Response and Health System Preparedness Project
(CERHSPP-P176480) which uses a combination of geographic targeting and community-based targeting, with

Page 25 of 68


Input:
**The World Bank**
South Sudan Health Sector Transformation Project (HSTP) (P181385)

some filters mainly related to the presence of children below 12 years and pregnant women. The project will rely
on the refugee household data collected by UNHCR. The targeting methodology will be tested to ensure its
applicability to refugees and adapted as needed. Moreover, these activities will be complemented by a strong
communications campaign designed in partnership with humanitarian agencies to ensure that the project is seen
as fair to both refugees and host communities.

**C. Sustainability**

66. **The project contributes to sustainability in two ways.** First, in line with the CEN, the project focuses on building


Input:
71. **Mitigation goal and risk reduction measures.** Most activities in the project are on the universally aligned list for

climate change mitigation. Minor rehabilitation activities under Subcomponent 1.4 will ensure at least 20 percent
more energy efficiency than standard practice, aligning with EDGE level 1 building criteria. An energy efficiency
consultant will be hired to conduct an energy efficiency audit and ensure these measures are incorporated into
health service delivery. Subcomponent 1.4 will also finance solar power for sustainable health facility
electrification.

**Technical**

72. The proposed HSTP will strengthen MoH capacity in management of health services and will contribute to the

sustainability of the program. The project has been specifically designed to ensure that the South Sudanese
population continue to have access to critical health care services. To guide the design of the operation, several
key principles were used in formulating the project activities:


Input:
**The World Bank**
South Sudan Health Sector Transformation Project (HSTP) (P181385)

(b) Support the delivery of an integrated package of services building on the experience of the ongoing IDA
funded health operations. There are predefined guidelines and protocols for integrated service delivery and
facility-based health planning suited to South Sudan that are consistent with the current capacities in the country.
These standards ensure that (i) delivery through facilities is focused on basic health and nutrition services and
ensure optimum use of the limited resources, (ii) routine outreach and community-based services are planned to
complement delivery through fixed services, and (iii) mobile teams respond to the needs of disadvantaged groups
in areas lacking functional fixed facility or refugees and host community areas.

**B. Fiduciary**

**(i)** **Financial Management**

73. An FM assessment was carried out covering planning and budgeting, accounting, internal control including

internal audit, financial reporting, funds flow, and external audit arrangements.

74. The objective of the FM assessment was to determine whether the MoH maintains adequate FM arrangements


Input:
**The World Bank**
South Sudan Health Sector Transformation Project (HSTP) (P181385)

International Court of Justice regarding the claims of South Sudan, Sudan, Uganda and Kenya, no objection to the
project has been raised.

**D. Environmental and Social**

81. The project’s overall environmental and social (ES) risk classification is rated high. Nine of the ten ESS (except ESS

9) of the World Bank Environmental and Social Framework are relevant to the project. Description of the
environmental, social, health, and safety risks and impacts related to the project and the proportionate mitigation
measures is summarized as follows.

82. **Environmental risks** . The nationwide provision of basic health services of Component 1 poses several


Input:
83. **Social risks** : The project social risks are classified as High. The project could face multiple potential social risks as it

will be implemented nationwide where prevalence of poverty, drought, security challenges, and many more
complex social issues under the FCV context of South Sudan are severe. Investments and support to service
providers, including in the health sector, increases the risks of service providers becoming targets of attacks,
pillaging, and acts of violence by armed groups. Cases of health facilities and hospitals being raided have been
documented in South Sudan and experienced during implementation of the parent and previous health projects.
These include risks resulting from (a) inter/intra-communal tensions, including between refugees and host
communities, over implementation issues, (b) assets and staff becoming targets of violent groups, and (c) GBV and
SEA/SH risks that are prevalent and heightened in conflict-affected areas. The SEA/SH risk of the project is
considered High. Pervasive incidences of GBV in South Sudan are a significant contextual challenge, exacerbated by
a context of pervasive insecurity in the country. More specifically, Component 1 includes activities which may
potentially exacerbate existing inequalities or cause social exclusions in health service access, especially for
vulnerable and conflict-affected communities. The project activities including the technical assistance activities
involve limited potential social risks associated with labor, labor conditions, safety and security of project workers,
exclusion of beneficiaries during targeting, and delivery of capacity development trainings, compromising the service
delivery quality, and challenges of ensuring the quality and reliability of the data generated, particularly in areas
with limited human resources and infrastructure.


Input:
**The World Bank**
South Sudan Health Sector Transformation Project (HSTP) (P181385)

uncertainty. There is also a significant risk that frequent changes in political leadership and appointees may
undermine government ownership and cause project delays. To mitigate this risk, the World Bank will continue to
engage at multiple levels within the MoH and MoFP and with key health sector stakeholders to ensure broad buyin and ownership. The project will also support regular coordination meetings and ensure flexibility so that
adjustments can be made during implementation. Political risks related to refugee issues are minimal, as the
Government and South Sudanese have adopted–in policy and practice–a progressive policy towards refugees.

92. **Macroeconomic risks are High.** South Sudan has one of the least diversified economies in the world, a result of


Input:
93. **Sector strategies and policies risks are Substantial.** It is critical to recognize that after over five decades of

continuous assistance and presence in South Sudan, international actors and the aid they provide are now an
integral part of the local political economy. The continued change in the MoH leadership over the last few years
continued to disrupt the development of sectoral strategies. The provision of basic health services, however, is a
priority for the ministry. Maintaining a strong focus on procurement of necessary supplies and equipment and
training of health and non-health workers at targeted areas are key mitigation measures.

94. **Technical design of the project risk is High** . The targeting of refugees and host communities increases the

complexity of delivering health services. Experiences from humanitarian organizations provide valuable lessons
about how to ensure neutrality and impartiality in the delivery of these services. Various mechanisms are proposed,
both within agreements with the implementation agencies and across project components. In addition, robust
mechanisms for results monitoring and verification will provide an additional oversight in ensuring that the package
of services has reached the intended targeted populations of refugees and host communities.


Input:
**The World Bank**
South Sudan Health Sector Transformation Project (HSTP) (P181385)

96. **Fiduciary risk is Substantial** . The FM assessment identified capacity gaps within the MoH and deficiencies in the

internal control systems. The external audit for the project previously implemented by the MoH identified
weaknesses, some of which remain unresolved. There will also be hands on support and close monitoring by the
World Bank. to mitigate incomplete public procurement framework, lack of a functional procurement units and
oversight functions at the MoH and general weak PFM governance. As a mitigation measure, the fiduciary
arrangements for the project will be handled by a PMU to be set up within the ministry. The FM activities at the
PMU will be overseen by a consultant, supported by a project accountant hired for the project and complemented
by finance staff deployed by the MoH to strengthen capacity within the ministry., The World Bank will also provide
HEIS to support the establishment of the PMU and contracting of UNICEF and WHO, using advance procurement of
major activities to fast-track implementation of project, including preparation of a Procurement Manual and hiring
of procurement specialist as an effectiveness condition among other conditions.


Input:
**The World Bank**
South Sudan Health Sector Transformation Project (HSTP) (P181385)

information by unauthorized personnel, (b) gaps in regulation on data privacy and protections, and (c) breaches to
cybersecurity. There are regulations protecting personal information, including health-related data. Electronic and
paper-based data collection and reporting forms that contain personal information are stored in a manner that
prevents unauthorized access to sensitive and confidential information. The project will provide support for
software and hardware investments that further mitigate the risk of breaches to cybersecurity.

Page 35 of 68


Input:
**The World Bank**
South Sudan Health Sector Transformation Project (HSTP)(P181385)

**VII.** **RESULTS FRAMEWORK AND MONITORING**

|Baseline|Period 1|Period 2|Closing Period|
|---|---|---|---|
|**Expand access to a basic package of health and nutrition services**|**Expand access to a basic package of health and nutrition services**|**Expand access to a basic package of health and nutrition services**|**Expand access to a basic package of health and nutrition services**|
|**Percentage of Bomas covered by the Boma Health Initiative (Percentage)**|**Percentage of Bomas covered by the Boma Health Initiative (Percentage)**|**Percentage of Bomas covered by the Boma Health Initiative (Percentage)**|**Percentage of Bomas covered by the Boma Health Initiative (Percentage)**|
|Sep/2023|Jul/2025|Jul/2026|Jul/2027|
|16|20|25|32|
|➢Percentage of Bomas covered by the Boma Health Initiative in refugee areas. (Percentage)|➢Percentage of Bomas covered by the Boma Health Initiative in refugee areas. (Percentage)|➢Percentage of Bomas covered by the Boma Health Initiative in refugee areas. (Percentage)|➢Percentage of Bomas covered by the Boma Health Initiative in refugee areas. (Percentage)|
|Sep/2023|Jul/2025|Jul/2026|Jul/2027|
|16|20|25|32|
|➢Percentage of Bomas covered by the Boma Health Initiative in host communities' areas. (Percentage)|➢Percentage of Bomas covered by the Boma Health Initiative in host communities' areas. (Percentage)|➢Percentage of Bomas covered by the Boma Health Initiative in host communities' areas. (Percentage)|➢Percentage of Bomas covered by the Boma Health Initiative in host communities' areas. (Percentage)|
|Sep/2023|Jul/2026|Jul/2025|May/2027|
|16|20|25|32|
|**Improve health sector stewardship**|**Improve health sector stewardship**|**Improve health sector stewardship**|**Improve health sector stewardship**|
|**Percentage of MoH budget executed (Percentage)**|**Percentage of MoH budget executed (Percentage)**|**Percentage of MoH budget executed (Percentage)**|**Percentage of MoH budget executed (Percentage)**|
|Sep/2023|Jul/2025|Jul/2026|Jul/2027|
|30|50|75|99|
|**Strengthen the health system**|**Strengthen the health system**|**Strengthen the health system**|**Strengthen the health system**|
|**General service availability score (Percentage)**|**General service availability score (Percentage)**|**General service availability score (Percentage)**|**General service availability score (Percentage)**|
|Sep/2023|Jul/2025|Jul/2026|Jul/2027|
|30.4|35|40|46|
|➢General service availability score for refugees (Percentage)|➢General service availability score for refugees (Percentage)|➢General service availability score for refugees (Percentage)|➢General service availability score for refugees (Percentage)|
|Sep/2023|Jul/2025|Jul/2026|Jul/2027|
|30.4|35|40|46|
|➢General service availability score for HC (Percentage)|➢General service availability score for HC (Percentage)|➢General service availability score for HC (Percentage)|➢General service availability score for HC (Percentage)|
|Sep/2023|Jul/2025|Jul/2026|Jul/2027|
|30.4|35|40|46|


Input:
**The World Bank**
South Sudan Health Sector Transformation Project (HSTP)(P181385)

|Baseline|Period 1|Period 2|Closing Period|
|---|---|---|---|
|**Component 1: Provision of Basic Health Services Nationwide**|**Component 1: Provision of Basic Health Services Nationwide**|**Component 1: Provision of Basic Health Services Nationwide**|**Component 1: Provision of Basic Health Services Nationwide**|
|**Percentage of Gender-Based Violence Services provided (Percentage)**|**Percentage of Gender-Based Violence Services provided (Percentage)**|**Percentage of Gender-Based Violence Services provided (Percentage)**|**Percentage of Gender-Based Violence Services provided (Percentage)**|
|Sep/2023|Jul/2025|Jul/2026|Jul/2027|
|0|10|20|45|
|**Percentage of women receiving four ANC visits (Percentage)**|**Percentage of women receiving four ANC visits (Percentage)**|**Percentage of women receiving four ANC visits (Percentage)**|**Percentage of women receiving four ANC visits (Percentage)**|
|Sep/2023|Jul/2025|Jul/2026|Jul/2027|
|20|30|40|52|
|➢Percentage of refugee women receiving four ANC visits (Percentage)|➢Percentage of refugee women receiving four ANC visits (Percentage)|➢Percentage of refugee women receiving four ANC visits (Percentage)|➢Percentage of refugee women receiving four ANC visits (Percentage)|
|Sep/2023|Jul/2025|Jul/2026|Jul/2027|
|20|30|40|52|
|➢Percentage of HC women receiving four ANC visits (Percentage)|➢Percentage of HC women receiving four ANC visits (Percentage)|➢Percentage of HC women receiving four ANC visits (Percentage)|➢Percentage of HC women receiving four ANC visits (Percentage)|
|Sep/2023|Jul/2025|Jul/2026|Jul/2027|
|20|30|40|52|
|**Coverage of birth registration notification (Percentage)**|**Coverage of birth registration notification (Percentage)**|**Coverage of birth registration notification (Percentage)**|**Coverage of birth registration notification (Percentage)**|
|Sep/2023|Jul/2025|Jul/2026|Jul/2027|
|0.4|4.0|8.0|10|
|**Coverage of maternal death review (Percentage)**|**Coverage of maternal death review (Percentage)**|**Coverage of maternal death review (Percentage)**|**Coverage of maternal death review (Percentage)**|
|Sep/2023|Jul/2025|Jul/2026|Jul/2027|
|0|25|35|55|
|**Number of health facilities with climate friendly minor rehabilitation and water and sanitation improvements completed (Number)**|**Number of health facilities with climate friendly minor rehabilitation and water and sanitation improvements completed (Number)**|**Number of health facilities with climate friendly minor rehabilitation and water and sanitation improvements completed (Number)**|**Number of health facilities with climate friendly minor rehabilitation and water and sanitation improvements completed (Number)**|
|Sep/2023|Jul/2025|Jul/2026|Jul/2027|
|0|50|100|200|
|**Percentage of deliveries attended by skilled health personnel (Percentage)**|**Percentage of deliveries attended by skilled health personnel (Percentage)**|**Percentage of deliveries attended by skilled health personnel (Percentage)**|**Percentage of deliveries attended by skilled health personnel (Percentage)**|
|Sep/2023|Jul/2025|Jul/2026|Jul/2027|
|19|25|35|43|
|➢Percentage of refugee deliveries attended by skilled health personnel (Percentage)|➢Percentage of refugee deliveries attended by skilled health personnel (Percentage)|➢Percentage of refugee deliveries attended by skilled health personnel (Percentage)|➢Percentage of refugee deliveries attended by skilled health personnel (Percentage)|
|Sep/2023|Jul/2025|Jul/2026|Jul/2027|
|19|25|35|43|
|➢Percentage of HC deliveries attended by skilled health personnel (Percentage)|➢Percentage of HC deliveries attended by skilled health personnel (Percentage)|➢Percentage of HC deliveries attended by skilled health personnel (Percentage)|➢Percentage of HC deliveries attended by skilled health personnel (Percentage)|
|Sep/2023|Jul/2025|Jul/2026|Jul/2027|


Input:
**The World Bank**
South Sudan Health Sector Transformation Project (HSTP)(P181385)

|Sep/2023|Jul/2025|Jul/2026|Jul/2027|
|---|---|---|---|
|0|1,300,000|3,700,000|5,940,000|
|➢Number of health, nutrition and population services provided to refugees (Number)|➢Number of health, nutrition and population services provided to refugees (Number)|➢Number of health, nutrition and population services provided to refugees (Number)|➢Number of health, nutrition and population services provided to refugees (Number)|
|Sep/2023|Jul/2025|Jul/2026|Jul/2027|
|0|300|700|940,000|
|➢Number of health, nutrition, and population services provided to HC (Number)|➢Number of health, nutrition, and population services provided to HC (Number)|➢Number of health, nutrition, and population services provided to HC (Number)|➢Number of health, nutrition, and population services provided to HC (Number)|
|Sep/2023|Jul/2025|Jul/2026|Jul/2027|
|0|1,000,000|3,000,000|5,000,000|
|**Component 2: Health Systems Strengthening**|**Component 2: Health Systems Strengthening**|**Component 2: Health Systems Strengthening**|**Component 2: Health Systems Strengthening**|
|**Percentage of SMoH/CHDs with work plans aligned to the HSSP (Percentage)**|**Percentage of SMoH/CHDs with work plans aligned to the HSSP (Percentage)**|**Percentage of SMoH/CHDs with work plans aligned to the HSSP (Percentage)**|**Percentage of SMoH/CHDs with work plans aligned to the HSSP (Percentage)**|
|Sep/2023|Jul/2025|Jul/2026|Jul/2027|
|0|30|60|70|
|**Proportion of health alerts investigated in 48 hrs (Percentage)**|**Proportion of health alerts investigated in 48 hrs (Percentage)**|**Proportion of health alerts investigated in 48 hrs (Percentage)**|**Proportion of health alerts investigated in 48 hrs (Percentage)**|
|Sep/2023|Jul/2025|Jul/2026|Jul/2027|
|81|84|86|88|
|**Percentage of disease outbreaks in refugee areas that are adequately addressed as per WHO guidelines (Percentage) (Percentage)**|**Percentage of disease outbreaks in refugee areas that are adequately addressed as per WHO guidelines (Percentage) (Percentage)**|**Percentage of disease outbreaks in refugee areas that are adequately addressed as per WHO guidelines (Percentage) (Percentage)**|**Percentage of disease outbreaks in refugee areas that are adequately addressed as per WHO guidelines (Percentage) (Percentage)**|
|Sep/2023|Jul/2025|Jul/2026|Jul/2027|
|0|100|100|100|
|**Component 3: Monitoring and Evaluation and Project Management**|**Component 3: Monitoring and Evaluation and Project Management**|**Component 3: Monitoring and Evaluation and Project Management**|**Component 3: Monitoring and Evaluation and Project Management**|
|**Percentage of health facilities receiving quarterly supervision visits (disaggregated by visits by CHDs, SMoH, and IPs) (Percentage)**|**Percentage of health facilities receiving quarterly supervision visits (disaggregated by visits by CHDs, SMoH, and IPs) (Percentage)**|**Percentage of health facilities receiving quarterly supervision visits (disaggregated by visits by CHDs, SMoH, and IPs) (Percentage)**|**Percentage of health facilities receiving quarterly supervision visits (disaggregated by visits by CHDs, SMoH, and IPs) (Percentage)**|
|Sep/2023|Jul/2025|Jul/2026|Jul/2027|
|0.00|30|60|85|
|➢Percentage of refugee health facilities receiving quarterly supervision visits (Percentage)|➢Percentage of refugee health facilities receiving quarterly supervision visits (Percentage)|➢Percentage of refugee health facilities receiving quarterly supervision visits (Percentage)|➢Percentage of refugee health facilities receiving quarterly supervision visits (Percentage)|
|Sep/2023|Jul/2025|Jul/2026|Jul/2027|
|0|20|40|75|
|➢Percentage of HC health facilities receiving quarterly supervision visits (Percentage)|➢Percentage of HC health facilities receiving quarterly supervision visits (Percentage)|➢Percentage of HC health facilities receiving quarterly supervision visits (Percentage)|➢Percentage of HC health facilities receiving quarterly supervision visits (Percentage)|
|Sep/2023|Jul/2025|Jul/2026|Jul/2027|
|0|20|50|75|
|**Percentage of complaints to Grievance Redress Mechanisms satisfactorily addressed in a timely manner (Percentage)**|**Percentage of complaints to Grievance Redress Mechanisms satisfactorily addressed in a timely manner (Percentage)**|**Percentage of complaints to Grievance Redress Mechanisms satisfactorily addressed in a timely manner (Percentage)**|**Percentage of complaints to Grievance Redress Mechanisms satisfactorily addressed in a timely manner (Percentage)**|
|Sep/2023|Jul/2025|Jul/2026|Jul/2027|
|0|35|50|70|
|**Completeness of reporting by facilities (Percentage)**|**Completeness of reporting by facilities (Percentage)**|**Completeness of reporting by facilities (Percentage)**|**Completeness of reporting by facilities (Percentage)**|
|Sep/2023|Jul/2025|Jul/2026|Jul/2027|
|41|60|70|80|


Input:
**The World Bank**
South Sudan Health Sector Transformation Project (HSTP)(P181385)

**Percentage of states that conducted quarterly coordination meetings with a review of data and documented with minutes including action items and follow-up (Percentage)**

|Sep/2023|Jul/2025|Jul/2026|Jul/2027|
|---|---|---|---|
|0|30|50|70|
|**Component 4: Contingent Emergency Response Component**|**Component 4: Contingent Emergency Response Component**|**Component 4: Contingent Emergency Response Component**|**Component 4: Contingent Emergency Response Component**|

Page 41 of 68


Input:
**The World Bank**
South Sudan Health Sector Transformation Project (HSTP) (P181385)

**Monitoring & Evaluation Plan: PDO Indicators by PDO Outcomes**

|Expand access to basic package of health and nutrition services|Col2|
|---|---|
|**BHI Coverage (Percentage)**|**BHI Coverage (Percentage)**|
|Description|The proportion of functional BHI as per the standard (based on the population)|
|Frequency|Quarterly|
|Data source|Quarterly Health Facility Assessment|
|Methodology for Data
Collection|Quarterly Health Facility Assessment report|
|Responsibility for Data
Collection|Third Party Monitor / PMU Responsible for Monitoring; Measures subcomponent 1.1 Under UNICEF|
|**BHI Coverage for refugees (Percentage) BHI**|**BHI Coverage for refugees (Percentage) BHI**|
|Description|The proportion of functional BHI as per the standard (based on the population)|
|Frequency|Quarterly|
|Data source|Quarterly Health Facility Assessment|
|Methodology for Data
Collection|Quarterly Health Facility Assessment report|
|Responsibility for Data
Collection|Third Party Monitor / PMU Responsible for Monitoring; Measures sub-component 1.1 Under UNICEF|
|**BHI Coverage for HC (Percentage) Number of health facilities providing at least 75 percent of the basic package of health services to host**
**communities (Number)**|**BHI Coverage for HC (Percentage) Number of health facilities providing at least 75 percent of the basic package of health services to host**
**communities (Number)**|
|Description|The proportion of functional BHI as per the standard (based on the population)|
|Frequency|Quarterly|
|Data source|Quarterly Health Facility Assessment|
|Methodology for Data
Collection|Quarterly Health Facility Assessment report|
|Responsibility for Data
Collection|Third Party Monitor / PMU Responsible for Monitoring; Measures subcomponent 1.1 Under UNICEF|
|**Percentage of MoH budget implemented (Budget execution rate) (Percentage)**|**Percentage of MoH budget implemented (Budget execution rate) (Percentage)**|
|Description|The proportion of Health budget expenditure to allocation|
|Frequency|Quarterly|
|Data source|MoH budgetary data|
|Methodology for Data
Collection|PMU and WB|
|Responsibility for Data
Collection|PMU and WB|
|**Percentage of general service availability score (Percentage)**|**Percentage of general service availability score (Percentage)**|
|Description|Service availability is described by an index using the three areas of tracer indicators (infrastructure, workforce, and
utilization). This is made possible by expressing the indicators as a percentage score un-weighted average of the
three areas|
|Frequency|Quarterly|
|Data source|Quarterly Health Facility Assessment|
|Methodology for Data
Collection|TPM report|
|Responsibility for Data
Collection|TPM / PMU|
|**Percentage of general service availability score in host communities’ areas (Percentage)**|**Percentage of general service availability score in host communities’ areas (Percentage)**|
|Description|Service availability is described by an index using the three areas of tracer indicators (infrastructure, workforce, and
utilization). This is made possible by expressing the indicators as a percentage score un-weighted average of the
three areas|


Input:
**The World Bank**
South Sudan Health Sector Transformation Project (HSTP) (P181385)

|Frequency|Quarterly|
|---|---|
|Data source|Quarterly Health Facility Assessment|
|Methodology for Data
Collection|TPM report|
|Responsibility for Data
Collection|TPM / PMU|
|**Percentage of general service availability score for refugees.**|**Percentage of general service availability score for refugees.**|
|Description|Service availability is described by an index using the three areas of tracer indicators (infrastructure, workforce, and
utilization). This is made possible by expressing the indicators as a percentage score un-weighted average of the
three areas|
|Frequency|Quarterly|
|Data source|Quarterly Health Facility Assessment|
|Methodology for Data
Collection|TPM report|
|Responsibility for Data
Collection|TPM / PMU|

**Monitoring & Evaluation Plan: Intermediate Results Indicators by Components**


Input:
|Component 1: Provision of Basic Health Services Nationwide|Col2|
|---|---|
|**Percentage of Gender-Based Violence Services provided (Percentage) **|**Percentage of Gender-Based Violence Services provided (Percentage) **|
|Description|Percentage of SGBV survivors who treated for assault + SGBV cases provided with emergency contraceptives +
SGBV cases referred out + SGBV survivors given PEP + Clinical management of rape + OPD Rape and GBV services|
|Frequency|Quarterly|
|Data source|DHIS|
|Methodology for Data
Collection|DHIS2|
|Responsibility for Data
Collection|MoH and UNICEF; Measures subcomponents 1.1 and 1.2 Under UNICEF|
|**BHI training material revised to include refugee sensitive health interventions (Yes/No) **|**BHI training material revised to include refugee sensitive health interventions (Yes/No) **|
|Description|BHI training materials for boma health workers revised to include refugee sensitive health interventions|
|Frequency|Quarterly|
|Data source|TPM Report|
|Methodology for Data
Collection|TPM|
|Responsibility for Data
Collection|TPM / PMU; Measures subcomponents 1.1 and 1.2 Under UNICEF|
|**Percentage of women receiving four ANC visits (Percentage)**|**Percentage of women receiving four ANC visits (Percentage)**|
|Description|Percentage of women at childbearing age with a live birth in a given time period who received antenatal care,
four times or more times from any provider.|
|Frequency|Quarterly|
|Data source|DHIS2|
|Methodology for Data
Collection|DHIS2|
|Responsibility for Data
Collection|MoH and UNICEF; Measures subcomponent 1.1 Under UNICEF|
|**Percentage of refugee women receiving four ANC visits (Percentage)**|**Percentage of refugee women receiving four ANC visits (Percentage)**|
|Description|Percentage of refugee women at childbearing age with a live birth in a given time period who received antenatal
care, four times or more times from any provider.|


Input:
**The World Bank**
South Sudan Health Sector Transformation Project (HSTP) (P181385)

|Frequency|Quarterly|
|---|---|
|Data source|DHIS2|
|Methodology for Data
Collection|DHIS2|
|Responsibility for Data
Collection|MoH and UNICEF; Measures subcomponent 1.1 Under UNICEF|
|**Percentage of HC women receiving four ANC visits (Percentage)**|**Percentage of HC women receiving four ANC visits (Percentage)**|
|Description|Percentage of HC women at childbearing age with a live birth in a given time period who received antenatal
care, four times or more times from any provider.|
|Frequency|Quarterly|
|Data source|DHIS2|
|Methodology for Data
Collection|DHIS2|
|Responsibility for Data
Collection|MoH and UNICEF; Measures subcomponent 1.1 Under UNICEF|
|**Number of health facilities with climate friendly minor rehabilitation and water and sanitation improvements completed (Number)**|**Number of health facilities with climate friendly minor rehabilitation and water and sanitation improvements completed (Number)**|
|Description|Number of health facilities with a.) climate friendly rehabilitation measures as defined by a set list of measures
that go beyond standard practice to reduce flooding, heavy rain, and heat risk to health facilities; and/or b.)
water and sanitation improvements as defined as improvements in the availability of safe water (drilling of
boreholes, piping of water, safe rainwater catchment) and sanitation (pit latrines to ESF specifications; flushable
toilets)|
|Frequency|Quarterly|
|Data source|UNICEF/TPM report|
|Methodology for Data
Collection|UNICEF/TPM|
|Responsibility for Data
Collection|UNICEF/TPM|
|**Percentage of deliveries attended by skilled health personnel (Number)**|**Percentage of deliveries attended by skilled health personnel (Number)**|
|Description|Percentage of live births attended by skilled health personnel during a specified time period.|
|Frequency|Quarterly|
|Data source|DHIS2|
|Methodology for Data
Collection|DHIS2|
|Responsibility for Data
Collection|MoH and UNICEF; Measures subcomponent 1.1 Under UNICEF|
|**Percentage of refugee deliveries attended by skilled health personnel (Number)**|**Percentage of refugee deliveries attended by skilled health personnel (Number)**|
|Description|Percentage of refugee live births attended by skilled health personnel during a specified time period.|
|Frequency|Quarterly|
|Data source|DHIS2|
|Methodology for Data
Collection|DHIS2|
|Responsibility for Data
Collection|MoH and UNICEF; Measures subcomponent 1.1 Under UNICEF|
|**Percentage of HC deliveries attended by skilled health personnel (Number)**|**Percentage of HC deliveries attended by skilled health personnel (Number)**|
|Description|Percentage of HC live births attended by skilled health personnel during a specified time period.|
|Frequency|Quarterly|
|Data source|DHIS2|
|Methodology for Data
Collection|DHIS2|
|Responsibility for Data
Collection|MoH and UNICEF; Measures subcomponent 1.1 Under UNICEF|


Input:
**The World Bank**
South Sudan Health Sector Transformation Project (HSTP) (P181385)

|Percentage of children under one year of age who have received 1st & 3rd dose of pentavalent vaccine (Percentage)|Col2|
|---|---|
|Description|Proportion of surviving infants who have received 1st & 3rd dose of the combined diphtheria, tetanus toxoid,
pertussis, Hepatitis B and Homophiles influenza type b vaccine|
|Frequency|Quarterly|
|Data source|DHIS2|
|Methodology for Data
Collection|DHIS2|
|Responsibility for Data
Collection|MoH and UNICEF; Measures subcomponent 1.1 Under UNICEF|
|**Percentage of refugee children under one year of age who have received 1st & 3rd dose of pentavalent vaccine (Percentage)**|**Percentage of refugee children under one year of age who have received 1st & 3rd dose of pentavalent vaccine (Percentage)**|
|Description|Proportion of surviving infants who have received 1st & 3rd dose of the combined diphtheria, tetanus toxoid,
pertussis, Hepatitis B and Homophiles influenza type b vaccine|
|Frequency|Quarterly|
|Data source|DHIS2|
|Methodology for Data
Collection|DHIS2|
|Responsibility for Data
Collection|MoH and UNICEF; Measures subcomponent 1.1 Under UNICEF|
|**Percentage of HC children under one year of age who have received 1st & 3rd dose of pentavalent vaccine (Percentage)**|**Percentage of HC children under one year of age who have received 1st & 3rd dose of pentavalent vaccine (Percentage)**|
|Description|Proportion of surviving infants who have received 1st dose of the combined diphtheria, tetanus toxoid, pertussis,
Hepatitis B and Homophiles influenza type b vaccine|
|Frequency|Quarterly|
|Data source|DHIS2|
|Methodology for Data
Collection|DHIS2|
|Responsibility for Data
Collection|MoH and UNICEF; Measures subcomponent 1.1 Under UNICEF|
|**Percentage of facilities reporting stock out of tracer medicines (Percentage)**|**Percentage of facilities reporting stock out of tracer medicines (Percentage)**|
|Description|This indicator measures whether facilities experienced a stockout of one or more tracer medicines and
laboratory reagents at any point during the reporting period being assessed. The result is expressed as a
percentage of the total number of facilities.|
|Frequency|Quarterly|
|Data source|Pharmaceutical agency/ Quarterly Health Facility Assessment|
|Methodology for Data
Collection|Pharmaceutical agency, to be verified quarterly by TPM|
|Responsibility for Data
Collection|TPM; PMU; pharmaceutical agency|
|**Percentage of refugee facilities reporting stock out of tracer medicines (Percentage)**|**Percentage of refugee facilities reporting stock out of tracer medicines (Percentage)**|
|Description|This indicator measures whether refugee facilities experienced a stockout of one or more tracer medicines and
laboratory reagents at any point during the reporting period being assessed. The result is expressed as a
percentage of the total number of facilities.|
|Frequency|Quarterly|
|Data source|Pharmaceutical agency/ Quarterly Health Facility Assessment|
|Methodology for Data
Collection|Pharmaceutical agency, to be verified quarterly by TPM|
|Responsibility for Data
Collection|TPM; PMU; pharmaceutical agency|
|**Percentage of HC facilities reporting stock out of tracer medicines (Percentage)**|**Percentage of HC facilities reporting stock out of tracer medicines (Percentage)**|
|Description|This indicator measures whether HC facilities experienced a stockout of one or more tracer medicines and
laboratory reagents at any point during the reporting period being assessed. The result is expressed as a
percentage of the total number of facilities.|


Input:
**The World Bank**
South Sudan Health Sector Transformation Project (HSTP) (P181385)

|Frequency|Quarterly|
|---|---|
|Data source|Pharmaceutical agency/ Quarterly Health Facility Assessment|
|Methodology for Data
Collection|Pharmaceutical agency, to be verified quarterly by TPM|
|Responsibility for Data
Collection|TPM; PMU; pharmaceutical agency|
|**Number of health, nutrition, and population (HNP) services provided to refugees (Number)**|**Number of health, nutrition, and population (HNP) services provided to refugees (Number)**|
|Description|Number of health and nutrition services provided to refugees from health facilities and outreach services, this
includes reproductive and maternal health service, immunization and child health, nutrition, OPD consultation,
NCD, NTD, TB, HIV testing and treatment services, disaggregated by age and sex)|
|Frequency|biannual|
|Data source|Survey|
|Methodology for Data
Collection|Survey report|
|Responsibility for Data
Collection|MoH and UNICEF; Measures subcomponent 1.1 Under UNICEF|
|**Number of health, nutrition, and population (HNP) services provided to HC (Number)**|**Number of health, nutrition, and population (HNP) services provided to HC (Number)**|
|Description|Number of health and nutrition services provided to HC from health facilities and outreach services, this includes
reproductive and maternal health service, immunization and child health, nutrition, OPD consultation, NCD,
NTD, TB, HIV testing and treatment services, disaggregated by age and sex)|
|Frequency|biannual|
|Data source|Survey|
|Methodology for Data
Collection|Survey report|
|Responsibility for Data
Collection|MoH and UNICEF; Measures subcomponent 1.1 Under UNICEF|
|**Percentage of children aged <59 months receiving Vitamin A supplements twice a year**|**Percentage of children aged <59 months receiving Vitamin A supplements twice a year**|
|Description|Percentage of children aged 6–59 months who received two age-appropriate doses of vitamin A in the past 12
months.|
|Frequency|Quarterly|
|Data source|DHIS2|
|Methodology for Data
Collection|DHIS2|
|Responsibility for Data
Collection|MoH and UNICEF; Measures subcomponent 1.1 Under UNICEF|
|**Percentage of refugee children aged <59 months receiving Vitamin A supplements twice a year**|**Percentage of refugee children aged <59 months receiving Vitamin A supplements twice a year**|
|Description|Percentage of children aged 6–59 months who received two age-appropriate doses of vitamin A in the past 12
months.|
|Frequency|Quarterly|
|Data source|DHIS2|
|Methodology for Data
Collection|DHIS2|
|Responsibility for Data
Collection|MoH and UNICEF; Measures subcomponent 1.1 Under UNICEF|
|**Percentage of HC children aged <59 months receiving Vitamin A supplements twice a year**|**Percentage of HC children aged <59 months receiving Vitamin A supplements twice a year**|
|Description|Percentage of children aged 6–59 months who received two age-appropriate doses of vitamin A in the past 12
months.|
|Frequency|Quarterly|
|Data source|DHIS2|
|Methodology for Data
Collection|DHIS2|


Input:
**The World Bank**
South Sudan Health Sector Transformation Project (HSTP) (P181385)

|Responsibility for Data
Collection|MoH and UNICEF; Measures subcomponent 1.1 Under UNICEF|
|---|---|
|**Percentage of Children under 5 years who are wasted**|**Percentage of Children under 5 years who are wasted**|
|Description|Percentage of wasted (moderate and severe) children aged 0–59 months (moderate = weight-for-height below -
2 standard deviations of the WHO Child Growth Standards median; severe = weight-for-height below -3 standard
deviations of the WHO Child Growth Standards median).|
|Frequency|Annually|
|Data source|Survey|
|Methodology for Data
Collection|Survey|
|Responsibility for Data
Collection|Third Party Monitor / PMU|
|**Percentage of refugee children under 5 years who are wasted**|**Percentage of refugee children under 5 years who are wasted**|
|Description|Percentage of wasted (moderate and severe) refugee children aged 0–59 months (moderate = weight-for-height
below -2 standard deviations of the WHO Child Growth Standards median; severe = weight-for-height below -3
standard deviations of the WHO Child Growth Standards median).|
|Frequency|Annually|
|Data source|Survey|
|Methodology for Data
Collection|Survey|
|Responsibility for Data
Collection|Third Party Monitor / PMU|
|**Percentage of HC children under 5 years who are wasted**|**Percentage of HC children under 5 years who are wasted**|
|Description|Percentage of wasted (moderate and severe) HC children aged 0–59 months (moderate = weight-for-height
below -2 standard deviations of the WHO Child Growth Standards median; severe = weight-for-height below -3
standard deviations of the WHO Child Growth Standards median).|
|Frequency|Annually|
|Data source|Survey|
|Methodology for Data
Collection|Survey|
|Responsibility for Data
Collection|Third Party Monitor / PMU|
|**Percentage of Measles (MCV1) immunization coverage**|**Percentage of Measles (MCV1) immunization coverage**|
|Description|Proportion of surviving infants who have received first dose measles (MCV1) vaccine before their first birthday|
|Frequency|Annually|
|Data source|Survey|
|Methodology for Data
Collection|Survey|
|Responsibility for Data
Collection|Third Party Monitor / PMU|
|**Under ive years’ mortality rate (per 1000 live births)**|**Under ive years’ mortality rate (per 1000 live births)**|
|Description|The probability of a child born in a specific year or period dying before reaching the age of 5 years, if subject to
age-specific mortality rates of that period, expressed per 1000 live births|
|Frequency|Annually|
|Data source|Survey|
|Methodology for Data
Collection|Survey|
|Responsibility for Data
Collection|Third Party Monitor / PMU|
|**Under ive years’ mortality rate (per 1000 live births) for HC**|**Under ive years’ mortality rate (per 1000 live births) for HC**|
|Description|The probability of a child born in a specific year or period dying before reaching the age of 5 years, if subject to|


Input:
**The World Bank**
South Sudan Health Sector Transformation Project (HSTP) (P181385)

|Col1|age-specific mortality rates of that period, expressed per 1000 live births|
|---|---|
|Frequency|Annually|
|Data source|Survey|
|Methodology for Data
Collection|Survey|
|Responsibility for Data
Collection|Third Party Monitor / PMU|
|**Under ive years’ mortality rate (per 1000 live births) for refugees**|**Under ive years’ mortality rate (per 1000 live births) for refugees**|
|Description|The probability of a child born in a specific year or period dying before reaching the age of 5 years, if subject to
age-specific mortality rates of that period, expressed per 1000 live births|
|Frequency|Annually|
|Data source|Survey|
|Methodology for Data
Collection|Survey|
|Responsibility for Data
Collection|Third Party Monitor / PMU|
|** ntermittent prevention o malaria during pregnancy (  p≥3)**|** ntermittent prevention o malaria during pregnancy (  p≥3)**|
|Description|Percentage of women who received three or more doses of intermittent preventive treatment during antenatal
care visits during their last pregnancy|
|Frequency|Quarterly|
|Data source|DHIS2|
|Methodology for Data
Collection|DHIS2|
|Responsibility for Data
Collection|MoH and UNICEF; Measures subcomponent 1.1 Under UNICEF|
|**Maternal mortality ratio**|**Maternal mortality ratio**|
|Description|Number of maternal deaths from any cause related to or aggravated by pregnancy or its management (excluding
accidental or incidental causes) during pregnancy and childbirth or within 42 days of termination of pregnancy,
irrespective of the duration and site of the pregnancy, expressed per 100 000 live births, for a specified time
period.|
|Frequency|Annually|
|Data source|Survey|
|Methodology for Data
Collection|Survey|
|Responsibility for Data
Collection|Third Party Monitor / PMU|
|**Maternal mortality ratio for refugees**|**Maternal mortality ratio for refugees**|
|Description|Number of maternal deaths from any cause related to or aggravated by pregnancy or its management (excluding
accidental or incidental causes) during pregnancy and childbirth or within 42 days of termination of pregnancy,
irrespective of the duration and site of the pregnancy, expressed per 100 000 live births, for a specified time
period.|
|Frequency|Annually|
|Data source|Survey|
|Methodology for Data
Collection|Survey|
|Responsibility for Data
Collection|Third Party Monitor / PMU|
|**Maternal mortality ratio for HC**|**Maternal mortality ratio for HC**|
|Description|Number of maternal deaths from any cause related to or aggravated by pregnancy or its management (excluding
accidental or incidental causes) during pregnancy and childbirth or within 42 days of termination of pregnancy,
irrespective of the duration and site of the pregnancy, expressed per 100 000 live births, for a specified time
period.|


Input:
**The World Bank**
South Sudan Health Sector Transformation Project (HSTP) (P181385)

|Frequency|Annually|
|---|---|
|Data source|Survey|
|Methodology for Data
Collection|Survey|
|Responsibility for Data
Collection|Third Party Monitor / PMU|
|**Contraceptive prevalence rate (any method)**|**Contraceptive prevalence rate (any method)**|
|Description|Percentage of women aged 15− 9 years, married or in union, who are currently using, or whose sexual partner is
using, at least one method of contraception, regardless of the method used.|
|Frequency|Annually|
|Data source|Survey|
|Methodology for Data
Collection|Survey|
|Responsibility for Data
Collection|Third Party Monitor / PMU|
|**The proportion of patients with suspected malaria who received a parasitologic test (RDT/Microscopy)**|**The proportion of patients with suspected malaria who received a parasitologic test (RDT/Microscopy)**|
|Description|Percentage of suspected malaria cases that received parasitological diagnosis either by microscopy or RDT|
|Frequency|Quarterly|
|Data source|DHIS2|
|Methodology for Data
Collection|DHIS2|
|Responsibility for Data
Collection|MoH / UNICEF; Measures subcomponent 1.1 Under UNICEF|
|**Proportion of health facilities that have a core set of relevant basic medicines and commodities available and affordable**|**Proportion of health facilities that have a core set of relevant basic medicines and commodities available and affordable**|
|Description|Proportion of health facilities that have a core set of relevant essential medicines available and affordable on a
sustainable basis. Availability: will be calculated based on currently existing data on average proportion of
medicines available in health facilities per country.|
|Frequency|Quarterly|
|Data source|Quarterly Health Facility Assessment|
|Methodology for Data
Collection|TPM report|
|Responsibility for Data
Collection|TPM / PMU|
|**Component 2: Health Systems Strengthening**|**Component 2: Health Systems Strengthening**|
|**Percentage of disease outbreaks in refugee areas that are adequately addressed as per WHO guidelines (Percentage)**|**Percentage of disease outbreaks in refugee areas that are adequately addressed as per WHO guidelines (Percentage)**|
|Description|Disease outbreaks in refugee areas that have been adequately addressed as per WHO guidelines.|
|Frequency|Quarterly|
|Data source|WHO/MoH report|
|Methodology for Data
Collection|WHO to provide data|
|Responsibility for Data
Collection|UNICEF/WHO/ PMU- Measures subcomponent 2.1 under WHO|
|**Percentage of SMoH/CHDs with work plans aligned to the HSSP**|**Percentage of SMoH/CHDs with work plans aligned to the HSSP**|
|Description|Percentage of SMoH and CHDs that develop annual operational work plans aligned to HSSP|
|Frequency|Quarterly|
|Data source|WHO report|
|Methodology for Data
Collection|WHO to provide data / TPM to verify|
|Responsibility for Data
Collection|PMU / TPM; Measures subcomponent 2.1 under WHO|
|**Proportion of health alerts investigated in 48 hrs**|**Proportion of health alerts investigated in 48 hrs**|


Input:
**The World Bank**
South Sudan Health Sector Transformation Project (HSTP) (P181385)

|Description|Proportion of an alert about a disease, condition, or event of public health
importance which may be true or invented|
|---|---|
|Frequency|Quarterly|
|Data source|WHO|
|Methodology for Data
Collection|Quarterly and biannual TPM|
|Responsibility for Data
Collection|PMU / TPM; Measures subcomponent 2.1 under WHO|
|**Birth registration notification coverage**|**Birth registration notification coverage**|
|Description|Proportion of live births notified by the health facility among the total expected live births in specific period|
|Frequency|Quarterly|
|Data source|DHIS2|
|Methodology for Data
Collection|DHIS2|
|Responsibility for Data
Collection|MoH / UNICEF|
|**Maternal death review coverage (%)**|**Maternal death review coverage (%)**|
|Description|Percentage of maternal deaths occurring in the health facility that were audited and reviewed.|
|Frequency|Quarterly|
|Data source|WHO|
|Methodology for Data
Collection|Quarterly and biannual TPM|
|Responsibility for Data
Collection|PMU / TPM; Measures subcomponent 2.1 under WHO|
|**Component 3: Monitoring and Evaluation and Project Management**|**Component 3: Monitoring and Evaluation and Project Management**|
|**Percentage of health facilities receiving quarterly supervision visits (disaggregated by visits by CHDs, and States MoH) (Percentage)**|**Percentage of health facilities receiving quarterly supervision visits (disaggregated by visits by CHDs, and States MoH) (Percentage)**|
|Description|Percentage of health facilities receiving at least one quarterly supervision visit within the quarter from either the
CHD, or the State MoH|
|Frequency|Quarterly|
|Data source|MoH; TPM|
|Methodology for Data
Collection|MoH to provide data; TPM to verify|
|Responsibility for Data
Collection|MoH / TPM|
|**Percentage of health facilities receiving quarterly supervision visits (Percentage)**|**Percentage of health facilities receiving quarterly supervision visits (Percentage)**|
|Description|Percentage of health facilities receiving at least one quarterly supervision visit within the quarter|
|Frequency|Quarterly|
|Data source|MoH; TPM|
|Methodology for Data
Collection|MoH to provide data; TPM to verify|
|Responsibility for Data
Collection|MoH / TPM|
|**Percentage of refugee health facilities receiving quarterly supervision visits (Percentage)**|**Percentage of refugee health facilities receiving quarterly supervision visits (Percentage)**|
|Description|Percentage of refugee health facilities receiving at least one quarterly supervision visit within the quarter|
|Frequency|Quarterly|
|Data source|MoH; TPM|
|Methodology for Data
Collection|MoH to provide data; TPM to verify|
|Responsibility for Data
Collection|MoH / TPM|
|**Percentage of HC health facilities receiving quarterly supervision visits (Percentage)**|**Percentage of HC health facilities receiving quarterly supervision visits (Percentage)**|


Input:
**The World Bank**
South Sudan Health Sector Transformation Project (HSTP) (P181385)

|Description|Percentage of HC health facilities receiving at least one quarterly supervision visit within the quarter|
|---|---|
|Frequency|Quarterly|
|Data source|MoH; TPM|
|Methodology for Data
Collection|MoH to provide data; TPM to verify|
|Responsibility for Data
Collection|MoH / TPM|
|**Percentage of health facilities receiving quarterly supervision visits from the CHD (Percentage)**|**Percentage of health facilities receiving quarterly supervision visits from the CHD (Percentage)**|
|Description|Percentage of health facilities receiving at least one quarterly supervision visit within the quarter from the CHD|
|Frequency|Quarterly|
|Data source|MoH; TPM|
|Methodology for Data
Collection|MoH to provide data; TPM to verify|
|Responsibility for Data
Collection|MoH / TPM|
|**Percentage of health facilities receiving quarterly supervision visits from State MoH (Percentage)**|**Percentage of health facilities receiving quarterly supervision visits from State MoH (Percentage)**|
|Description|Percentage of health facilities receiving at least one quarterly supervision visit within the quarter from the State
MoH|
|Frequency|Quarterly|
|Data source|MoH; TPM|
|Methodology for Data
Collection|MoH to provide data; TPM to verify|
|Responsibility for Data
Collection|MoH / TPM|
|**Percentage of complaints to Grievance Redress Mechanisms satisfactorily addressed in a timely manner**|**Percentage of complaints to Grievance Redress Mechanisms satisfactorily addressed in a timely manner**|
|Description|Percentage of complaints submitted to the GRM addressed according to the protocol and within agreed time
period.|
|Frequency|Quarterly|
|Data source|UNICEF|
|Methodology for Data
Collection|UNICEF to provide data / TPM to verify|
|Responsibility for Data
Collection|UNICEF; PMU|
|**Percentage of completeness of reporting by facilities**|**Percentage of completeness of reporting by facilities**|
|Description|Percentage of facilities that submit complete reports within the required deadline.|
|Frequency|Quarterly|
|Data source|DHIS2|
|Methodology for Data
Collection|DHIS2|
|Responsibility for Data
Collection|MoH/ PMU|
|**Percentage of states that conducted quarterly coordination meetings with a review of data and documented with minutes including**
**action items and follow-up**|**Percentage of states that conducted quarterly coordination meetings with a review of data and documented with minutes including**
**action items and follow-up**|
|Description|Percentage of State’s quarterly health service delivery coordination meetings for the health sector held with a
review of data included in the meeting and documented with minutes which include action items and follow-up
on action items. Meetings are to be held quarterly in each state. Four meetings are expected each year per
state. CHDs and implementing partners will be participated in the review|
|Frequency|Quarterly|
|Data source|MoH/ WHO|
|Methodology for Data
Collection|WHO to provide data / TPM to verify|


Input:
**The World Bank**
South Sudan Health Sector Transformation Project (HSTP) (P181385)

Responsibility for Data
Collection

WHO; PMU

Page 52 of 68


Input:
**The World Bank**
South Sudan Health Sector Transformation Project (HSTP) (P181385)

**ANNEX 1: Implementation Arrangements and Support Plan**

**Introduction**

1. South Sudan’s health system is systemically underdeveloped, characterized by poor access to health services,

significant shortage of skilled health workers, and difficult operating environment leading to extremely alarming
health outcomes. Under five mortality is 96.2 per 1,000 live births, infant mortality is 62.4 per 1,000 births, and
maternal mortality is estimated at 1,150 per 100,000 births. [33] Poor health outcomes are underlined by weak health
service delivery including only 40 percent of births assisted by a skilled provider and 11.5 percent of children between
12 and 23 months of age receiving routine vaccinations. [34]

2. Fragmentation is a defining features of South Sudan’s health system. Since 2013, health service delivery in South

---
[33] WDI, 2019
[34] LGAS, 2020; Routine vaccinations: three doses of Diphtheria, Pertussis, and Tetanus (DPT3)


Input:
**The World Bank**
South Sudan Health Sector Transformation Project (HSTP) (P181385)

- NGOs sub-contracted by the management organization will deliver the identified package of health services
nationwide as per the required standards.

- TPM agency/ies will conduct household and health facility surveys along with surveys to solicit community and
patient feedback. The TPM agency/ies will submit quarterly monitoring reports directly to the PMU, the World
Bank, and UNICEF.

- An HSC to provide technical strategic direction and guidance on the sectoral challenges and future steps including
service delivery, health financing, HRH, data, and medicines and medical supplies. The HSC will meet on a biannual basis and may invite any party to join the meetings.

- An OSC to provide technical guidance on the management and oversight of project implementation, challenges
and achieved results of the program. The OSC will meet on a quarterly basis and may invite any party to join the
meetings.

**Figure 1.1. Structure and Governance**

5. Below are the proposed ToRs for the Project Management Unit (PMU), HSC, and the OSC.

6. The PMU will be responsible for managing health service contracting and the day-to-day engagement and


Input:
**The World Bank**
South Sudan Health Sector Transformation Project (HSTP) (P181385)

**Figure 1.2. PMU Structure**

# **UNDERSECRETSRY** Overall leadership & strategic directions under Steering Committees guidance **PMU MANAGER** Oversee management, coordination, implementation, progress towards desired results, and provide necessary technical expertise

**FIELD OFFICERS**

**High-Level Steering Committee Mandate and Functions**

7. The HSC will pursue the following ToRs.

(a) The HSC is mandated to provide strategic direction and guidance on the sectoral challenges and future steps on

service delivery and other health system pillars.
(b) The HSC will oversee and monitor the implementation of the project-approved plans and different processes

including health facilities hand-over plan, plan to expand coverage of health facilities, BHI expansion plan, MoH
capacity-building plan, government and partners’ commitments, and any reprogramming amendments.
(c) Review and approve applications to join project funding and/or activities by other potential interested parties.
(d) The committee will review project data to monitor progress towards achieving desired results, identify needed

actions, and follow-up on actions during meetings.
(e) The committee will ensure the existence and enforcement of effective coordination and communication between


Input:
**The World Bank**
South Sudan Health Sector Transformation Project (HSTP) (P181385)

- Communicate decisions of the committees among and between all members and into any relevant entities
and personnel.

- Follow up on committees’ decisions and recommendations.

- Maintain a log of the committees’ decisions that reflects the confirmed minutes.

- Support and contribute to the committees’ communications, representation, and M&E.

**Steering Committees Logistics**

12. Unless agreed otherwise, the MoH or the World Bank will host the meetings in their offices in Juba. The secretariat

shall ensure offering options for virtual joining for those unbale to attend physically.

**Table 1.3: Roles and responsibilities for each entity and health service contracting arrangements.**


Input:
**The World Bank**
South Sudan Health Sector Transformation Project (HSTP) (P181385)

|Pharmaceutical
Procurement
and Logistics
agency|Competitively selected
agency|• Procure pharmaceuticals
• Conduct last mile delivery to health facilities|
|---|---|---|
|World Health
Organization|WHO|• Conduct state and federal level MoH capacity building activities
• Conduct health systems strengthening activities|
|Third Party
Monitor(s)|TPM agency/ies
contracted by the PMU|• Conduct quarterly verification visits
• Conduct household and health facility surveys to monitor health service
delivery and health outcomes
• Conduct community satisfaction surveys
• Monitor health facility functionality
• Prepare analysis, presentations, and bulletins presenting monitoring results
and findings
• Capacity building for state and district level staff (on-the-job training on M&E
activities).|

Flow of Funds, Fiduciary Safeguards, and Monitoring Arrangements

13. **The proposed program will build on the World Bank experience with similar structures in South Sudan in other**

**sectors.** The funds for the project interventions and procurement of supplies will flow directly from the World Bank
to UNICEF and WHO, while the fund required for PMU salaries and operating expenses will flow from the World Bank
to the project designated account managed by the Government.

**Figure 1.3. Flow of Funds**

14. **Reporting and monitoring** : The PMU, UNICEF, and WHO will submit to the World Bank quarterly financial and

household and health facility surveys
community satisfaction surveys


Input:
**The World Bank**
South Sudan Health Sector Transformation Project (HSTP) (P181385)

undergoes scheduled internal audits by the organization's own Office for Internal Audit and Investigation. UNICEF is
also subject to multi-country programs external audit when the focus of that audit is also of relevance to UNICEF’s
South Sudan country office program. Both the final internal and external audits are made public and accessible to any
interested party. On the other hand, findings from the HACT linked programmatic visits, spot checks, and special audits
are for internal use of UNICEF for program improvement and strengthening, confidential, not for the public, and not
shared.

16. **PIM.** The PIM will be the key document based on which the project will be implemented. The PIM will be prepared


Input:
**The World Bank**
South Sudan Health Sector Transformation Project (HSTP) (P181385)

**ANNEX 2: Third Party Monitoring and Data Visualization**

1. TPM is critical for an objective understanding of project progress and to collect data to improve service delivery. Along


Input:
with monitoring and survey activities, the TPM will develop Government capacity for the design of data collection
tools, data use, and oversight of health service monitoring. To support high-quality data collected in a conflictsensitive manner, ToR for health service delivery TPM will be developed to ensure robust supervision as well as data
review to assess and address data quality. Comprehensive ToRs have proven critical to high-quality TPM arrangements
in FCV settings. All TPM will pay close attention to ensuring all language groups in the country are incorporated in
monitoring through translated tools and representative selection of enumerators. Set data entry, reporting, and
presentation formats will be established and used by the TPM. The TPM will be expected to produce quarterly reports
and presentations for national and state level use as well as quarterly reports for IPs detailing results at the facility
level. The TPM will present findings to the State and Federal Level as well as IPs, CHDs, development partners, UNICEF,
and The World Bank. Under this arrangement, TPM will be contracted by the PMU with input and oversight from the
World Bank. TPM arrangements will include the following:


Input:
**(a)** **Quarterly TPM visits.** All data collection methods will be administered during the same visits, at the frequency

indicated. A phased approach will be used to support the expansion of TPM in the country, with initial sampling
for quarterly and bi-annual assessments moving to a bi-annual census of health facilities once monitoring capacity
is established, anticipated in Year 2. Quarterly TPM visits will incorporate the following:
(i) **Quarterly health facility functionality assessments.** At baseline and endline, the assessments will
incorporate a sample of operational health facilities not supported by the project to generate
comprehensive information on health service delivery nationwide and the added value of the project.
Measures on disability access will be included in the assessments.
(ii) Quarterly data quality verification to provide measures of partner data quality and reporting accuracy.
(iii) Bi-annual health service quality assessment to capture the quality of key health services, focusing on health
service process and structural quality. On an annual basis the health service quality assessment will include
direct observation of health service process quality measures at hospitals and health centers.
(iv) Bi-annual patient feedback using exit surveys.
(v) Bi-annual visits to a sample of BHTs to measure service outputs and quality.


Input:
**(b)** **Periodic TPM data collection:**

(i) Biennial household coverage surveys as baseline/endline surveys in the project’s three-year timeframe. [35]
(ii) Citizen engagement survey collected at the household level, with the coverage survey every other year.

2. **Data Analysis and Visualization Platform.** The platform will emphasize development of an integrated,

institutionalized, and sustainable system. The platform will include analysis of health service delivery in refugee and
host community areas. The platform will include the following:
(a) Interactive data visualization platform presenting Results Framework and core indicators. The platform will use

data from DHIS2 and the TPM and will include BHI data. It will be updated at least on a quarterly basis.
(b) Presentation of data in data visualization platform in the form of static and interactive maps, charts and graphs,

tailored to project monitoring needs and partner priorities.
(c) Incorporation of HSF data within the data visualization platform through a link or page within the platform.
(d) Overlay of disease and health service delivery data with meteorologic data to better understand seasonal patterns

in service delivery and infectious disease data.

---
[35] Given the planned project length of three years, this is a baseline and an endline survey. Potential timeframe changes would include interim surveys, which are

Biennial household coverage surveys
Citizen engagement survey


Input:
**The World Bank**
South Sudan Health Sector Transformation Project (HSTP) (P181385)

**ANNEX 4: Refugees and Host Communities**

1. **The HSTP will provide services to the population of South Sudan through IDA and expected donor financed MDTF**

**and SDTF funding.** Within the scope of the project there is a special focus to continue to address the pressing health
and nutrition needs of refugees and host communities. It includes the following measures:

- **Maintain the provision of health and nutrition services to refugees and host communities** that are currently
covered under the COVID-19 Emergency Response and Health System Preparedness Project (CERHSPP-P176480)
(with funds available to cover until July 2024) in Upper Nile, Jonglei and Unity States. In addition, the project
includes: (a) scaling up disease surveillance and early detection activities; (b) strengthening the rapid response
teams; (c) increasing the operational support costs to facilities to improve access to enhanced water and sanitation
services, electricity, and fuel; and (d) providing minor repair works in various facilities. The HSTP aims to address
rapidly increasing and evolving needs of refugees and host-communities.


Input:
- **Expand the provision of the high-impact package of basic health and nutrition services nationwide.** The project
expands the provision of services across the country in addition to Maban and Jamjang (which benefited from
previous resources accessed through WHR). This includes Western Equatoria State (Ezo and Yambio Counties),
Central Equatoria (Juba and Yei Counties) and Jonglei State (Pochalla County) which are among the largest refugeehosting counties in South Sudan. The support provided takes the form of a gradual replacement of support by
humanitarian agencies (including UNHCR and ICRC) which are pulling back their support from at least 50 health
facilities to cater to other humanitarian priorities (especially Sudan).

- **Ensure better strengthened elements of the health care systems that will directly affect maternal and child**

**mortality rates through WHO implemented activities.** The project will support the functionality of state and
district level blood banks and reference laboratories. This will allow enhanced access to those services and directly
decreasing preventable causes of death. In addition, the project will support the expansion of surveillance systems
for early disease detection that would enable timely response to disease outbreaks which is highly relevant to
refuges and host communities’ population.


Input:
**The World Bank**
South Sudan Health Sector Transformation Project (HSTP) (P181385)

|Focus on demand side activities to generate adequate
demand for services is necessary given the contextual
challenges and the low literacy rate among the
population.|• Enhanced focus on health literacy and
updating communication messaging and
materials in local languages.|
|---|---|
|Moving from facility based to community/outreach
mode of service delivery is important to consider given
the difficult context (flooding, movement, and
transportation cost).|•
Expansion in BHI program|
|The support offered by the humanitarian actors is not
sustainable.
As
of
September
2023,
different
humanitarian actors are in discussion with the to vacate
50 health care facilities catering for the refugees and
their host communities owing to other competing
global priorities, for example, conflict areas in Sudan.
Those facilities will require urgent substitute support to
prevent any interruption in services.
|•
Transition plan established for the handover
process. This will be monitored by MoH, World
Bank and donor partners.|
|Close
coordination
between
IPs,
donors
and
humanitarian agencies is of critical importance to
ensure one plan and one strategy for service provision
efforts. The refugee community has witnessed
disproportionally higher levels of disease outbreaks
over the past year. This has required intensified efforts,
and increased demand for costly surveillance,
diagnostic and curative services by the IPs. Several
measles, hemorrhagic fever, and schistosomiasis
outbreaks were frequently recorded.
|•
All project partners (MoH, World Bank,
donors, UNICEF and WHO) will coordinate
through the two established coordinating
bodies, namely: high and technical steering
committees.
•
Technical steering committee will meet and
coordinate with the Humanitarian Cluster in
South Sudan on a regular basis.
•
Coordination links in county and state level
with other humanitarian partners.|
|Refugees and their host communities are usually
subject to inadequate access to food and water,
sanitation, and other basic services, increasing their risk
of communicable diseases, particularly measles and
foodborne and waterborne illnesses. They are also at a
higher risk of accidental injuries, hypothermia, burns,
unwanted
pregnancy
and
delivery-related
complications, and various noncommunicable diseases.
This stresses the need for more responsive health care
services that are capable of early detection and
management of those cases.
|•
Enhanced surveillance and early response
•
Introduction
of
ambulance
evacuation
services to nearest hospitals.
•
Improved access to laboratory and blood bank
services.|
|Health illiteracy is a widespread issue among refugees,
and only about 40 percent have sufficient knowledge to
effectively navigate health care systems. The barriers
are important for individuals with disabilities, affecting
30% of this subgroup. In addition, nearly 50% of women
and girls in the refugee population struggle to access
sexual and gender-based violence protection services.|•
Expansion of BHI program
•
Enhanced health and nutrition education
materials.
•
Introduction of Sexual and Reproductive
Health Services in the Package (SRH).
•
Introduction of GBV services.|


Input:
**The World Bank**
South Sudan Health Sector Transformation Project (HSTP) (P181385)

**Growing Humanitarian Needs in Refugee and Host Communities**

4. Since gaining eligibility to the WHR under IDA19, the Government of South Sudan has made important progress in


Input:
**The World Bank**
South Sudan Health Sector Transformation Project (HSTP) (P181385)

partners are struggling to keep up with growing needs in in these areas and failing to meet the need could lead to
health and sanitation risks.

7. **The current refugee population estimates are as follows:**

**Table 5.1 Refugee and Asylum-Seeker Population in South Sudan**

_Source_ : UNHCR, September 2023

8. The projected refugee population estimates for 2024 and 2025 are as follows – based on UNHCR data analysis:

**Table 5.2 Projected Refugee Population Estimates**

|Col1|2023|Col3|2024|Col5|2025|Col7|
|---|---|---|---|---|---|---|
||Total|Assisted|Total|Assisted|Total|Assisted|
|Refugees|366,028|366,028|446,625|446,625|456,496|456,496|
|Asylum-Seekers|4,908|4,908|6,799|6,799|7,397|7,397|
|Internally Displaced Persons|2,267,236|500,000|2,027,331|540,000|2,392,236|650,000|
|Returned Refugees|555,000|555,000|870,000|870,000|1,250,000|1,250,000|
|TOTAL|3,193,172|1,425,936|3,350,755|1,863,424|4,106,129|2,363,893|

**Consultation with UNHCR**

9. The World Bank is working closely with UNHCR and the MoH to ensure South Sudan’s refugee protection framework

remains adequate, including through periodic assessments. UNHCR has provided the World Bank with an overall
positive assessment of South Sudan’s protection framework while highlighting a set of protection-related challenges.
In addition to the legal framework in place, the Government has maintained its policy of granting refugees access to
its territory and installing practical arrangements for their initial reception and registration.

**Transition to UNICEF**

10. **UNICEF, through World Bank support, has developed an operational model where support was complementary to**


Input:
**UNHCR activities through day-to-day coordination.** This coordination included areas such as human resources,
warehousing, pharmaceutical supply, nutrition programs and vaccination. This has allowed UNICEF to gather a
firsthand operational knowledge of the specific needs and pre-requisites of those specific communities within the
context of South Sudan. It is worth noting that other donor agencies, for example, FCDO are also providing their
support to communities hosting refugees through UNICEF.

11. **UNICEF has started its preparatory work to facilitate its coverage of the anticipated expansion of activities to the**

**refugees and host community areas**, this includes: (a) the development of a strategic framework (in partnership with

Page 66 of 68


Input:
**The World Bank**
South Sudan Health Sector Transformation Project (HSTP) (P181385)

UNHCR and MOH) to address the needs of those specific areas; (b) development of a detailed and timed transition
plan towards the gradual onboarding of the additional 50 facilities that will be handed over by the humanitarian
agencies, the transition will is planned to start on January 2024 and to be completed by June 2024; (c) advanced
procurement of medical supplies and pharmaceuticals is underway based on a commitment letter issued by the World
Bank on May 2023 under the anticipated HSTP to avoid any gaps in service continuity; (d) early selection of IPs (to be
completed by December 2023) to facilitate early and gradual onboarding of the selected partners towards a smooth
transition from the humanitarian agencies; and (e) expansion of local footprint through additional hiring of dedicated
staff to support local county health departments and implementing partners.

**Economic Analysis of Supporting Refugees and Host Communities**

12. **The Economic benefits of investing in health and nutrition services to refugees and host communities are high.** The