VZCZCXRO2255
PP RUEHGI RUEHMA RUEHROV
DE RUEHKH #1821/01 3251115
ZNR UUUUU ZZH
P 211115Z NOV 07
FM AMEMBASSY KHARTOUM
TO RUEHC/SECSTATE WASHDC PRIORITY 9245
INFO RUCNFUR/DARFUR COLLECTIVE PRIORITY
RUEHRN/USMISSION UN ROME
UNCLAS SECTION 01 OF 02 KHARTOUM 001821
SIPDIS
AIDAC
SIPDIS
STATE FOR AF/SPG, PRM, AND ALSO PASS USAID/W
USAID FOR DCHA SUDAN TEAM, DCHA/OFDA, AND AFR/SP
NAIROBI FOR USAID/DCHA/OFDA, USAID/REDSO, USAID/SFO AND FAS
GENEVA FOR NKYLOH
NSC FOR PMARCHAM AND MMAGAN
USUN FOR TMALY
BRUSSELS FOR PBROWN
E.O. 12958: N/A
TAGS: EAID PREF PGOV PHUM SOCI UN SU
SUBJECT: SOUTHERN SUDAN - LAINYA COUNTY UPDATE
REF: KHARTOUM 0766
KHARTOUM 00001821 001.2 OF 002
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Summary
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1. From November 4 to 6, program officers from USAID's Office of
U.S. Foreign Disaster Assistance (USAID/OFDA) traveled to Lainya
County in Central Equatoria State, Southern Sudan, to review the
status of the planned transition of USAID/OFDA-funded programs to
the Government of Southern Sudan (GOSS) Ministry of Health (MOH).
Lainya County, with an estimated population of 200,000 people,
experienced significant displacement during the civil war. However,
Lainya County is farther along than most other counties in Southern
Sudan in transitioning away from emergency relief aid to more
sustainable recovery and development assistance. Even with the
progress, the USAID/OFDA team found that significant obstacles to
transition still exist. End Summary.
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Background
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2. Since March 2005, the USAID/OFDA-funded ZOA Refugee Care primary
health care project in Lainya County has provided life-saving
services to more than 95,000 people at its three primary health care
centers and 11 primary health care units. The total population of
the county is more than 200,000 people. Approximately, 23 percent
of patients treated at the facilities are recent returnees. Many
internally displaced persons (IDPs) and refugees cite the
availability of quality health care as a factor in influencing their
decision to return to the county. Prior to the project, the county
did not have a health department. In addition to ZOA's health care
program, the Lainya County Health Department employs 15 professional
health staff and manages 30 community-based health workers and 30
vaccinators.
3. Further evidence of the functionality of the Lainya County Health
Department is that the Lainya County Medical Officer and the Primary
Health Care Supervisor have actively lobbied and negotiated with the
Central Equatoria State health authorities to incorporate the county
health department staff into the state public service payroll and
health budget. An agreement reached earlier in 2007 between ZOA and
the Central Equatoria State MOH, laid out plans for all 11 primary
health care units and three primary health care centers supported by
ZOA in Lainya County to be handed over to the county health
department by December 2007. While significant progress has been
made towards that goal, it is clear that several key obstacles will
likely prevent this handover from taking place on target.
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Transition: Opportunities and Obstacles
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4. In Lainya County, like most other counties in Southern Sudan, the
county health department staff are not yet paid by the government.
The staff are still paid incentives by non-governmental
organizations (NGOs), such as ZOA in Lainya. After positive
discussions between the County Health Department, ZOA and the
Central Equatoria State MOH (SMOH) in May, the SMOH agreed to carry
out the necessary steps to incorporate the ZOA-supported facilities
into the County Health Department and state MOH health system. The
SMOH conducted a full assessment of the facilities and staffing in
July 2007 and forwarded the details to the Ministry of Public
Service, which is responsible for reviewing and approving the
incorporation of staff and facilities in the GOSS budget.
5. Unfortunately, the assessment report's list of staffing needs
exceeded the state's staff ceiling imposed by the Ministry of Public
Service. The ministry's ceiling policy specifies that each state
may only employ 5,000 civil servants across all departments. At the
same time, MOH's facility standards require certain staff levels for
each facility type: 6 staff for health care units, 16 staff for
health care centers, and 107 staff for hospitals. Meeting the
required health staff levels alone would likely exceed civil servant
ceilings in most states. In addition, the MOH has not budgeted
funds for the support of county-level health staff salaries; it
simply does not have enough revenue to cover salary support at this
level. Lack of funding at the county level is a critical problem
because it directly impacts service delivery. Without adequate
support for salaries, it will be very difficult for any county to
attract and retain qualified health personnel or train new staff,
KHARTOUM 00001821 002.2 OF 002
even in counties as relatively well positioned for handover as
Lainya. The dual obstacles of staff ceilings and lack of salary
support are significant barriers to handing facilities over to the
MOH in Lainya County in the near term.
6. USAID/OFDA staff met with the Deputy Director at the Central
Equatoria SMOH after returning from Lainya County. While the SMOH
and County Health Department are still optimistic that the planned
handover will happen by the end of the year, they admit significant
barriers exist. The SMOH cites revenue flow as a major problem.
The SMOH budget for 2007 was submitted in January and approved in
August, yet no funds have been allocated from the central to the
state level. According to the SMOH, the central MOH claims that the
funds are not there and that the GOSS' share of oil revenues has not
met projected levels. Instead, the central government has
instructed states to raise their own revenues via taxation.
However, relying on taxation seems unrealistic given the lack of
systems to collect taxes and manage budgets, even in places where a
realistic tax base exists such as Juba.
7. Despite obstacles, it is clear that the presence of a truly
dedicated and energetic County Health Department, County Medical
Officer (CMO), and strong NGO partner (ZOA) has made a great
difference in the progress of planning for an eventual handover of
health facilities to the MOH. The selection of the CMO has led to
impressive progress towards handover in the past six months. For
example, the CMO traveled to Juba and spent one month negotiating
with SMOH and GOSS MOH to get the promised three-month drug supply
for his facilities. Despite this effort, the CMO managed to obtain
supplies for only half of the facilities and had to rely on ZOA for
transportation back to the county. The dedication of the CMO has
increased the confidence of the county staff and opened vital
communication links between the county health department and the
Central Equatoria State health and public service authorities. The
Lainya County Health Department plans to further engage the Central
Equatoria State authorities in other key health areas such as the
provision of pharmaceuticals.
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Conclusions
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8. Lainya County benefits from its proximity to Juba and the
presence of such a strong cadre of stakeholders actively engaged in
supporting and improving the health care system. Still, obstacles
to sustainable handover exist and need to be overcome, such as the
lack of support for county-level salaries and a dysfunctional system
for developing the human resource base. Many other counties in
Southern Sudan more remote than Lainya County get less support from
GOSS and state structures, and do not have a functioning county
health department. Donors must coordinate and engage the GOSS MOH
to address these obstacles and provide ongoing support to fill
critical gaps in health sector coverage over the coming year.
FERNANDEZ